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10639651-DS-24
| 10,639,651 | 23,406,707 |
DS
| 24 |
2139-07-16 00:00:00
|
2139-07-16 15:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Much of the record is through ED notes and review of OMR. Mr.
___ himself is altered and is not aware of his surroundings or
able to contribute to the history.
Mr. ___ is a ___ year old male with a pmh of CAD, CHF, IDDM,
chronic pain syndrome and morbid obesity who presented after
falling.
Per Wife:
Fell three times yesterday, never witnessed. Wife was not home
first two times, and third time she was sleeping. He fell
getting out of bed the third time. Became confused over the past
day approximately 5am. Not completely normal prior though she
has difficulty explaining how. He has a "memory problem." He has
a history of depression (major) and anxiety. He has been
hospitalized in the past for major depression. He has been
having hallucinations recently. He "saw a spider in the
Emergency Department."
He manages his own medications. His wife is unsure of what he
has been taking. Intermittently takes sertraline, not
consistently.
Per ED record, history obtained through wife, patient "fell 3
times today, all unwitnessed. The third fall was out of bed and
he was not able to get up. He has also seemed confused today. He
has had short periods of confusion in the past but never this
severe. He does not know why he is falling. He denies headache,
neck pain, back pain, chest pain, shortness of breath, abdominal
pain. According to his wife he has had intermittent chest pain,
shortness of breath and abdominal pain for the last few days. He
has a stress echo on ___ scheduled."
He was seen by his PCP ___ ___ for chest pain which was not
consistent with ischemia. He was scheduled for a stress test and
an EKG showed a q wave in III but otherwise without signs of
ischemia.
In the ED: initial vitals: 99.8 100 185/95 16 99%. Transfer
vitals: 97.7 74 ___ 99% RA. His tox was negative. CXR
without acute process. CT head and c-spine: prelim no acute
process. Trop x1 negative. He was given 2L fluids. K was 8.6,
hemolyzed. Repeat 6.0. He was given 10u insulin and an amp of
dextrose. Also given aspirin.
ROS: + for pain, though unable to localize. He is otherwise
unable to reliably give a review of systems due to his mental
status.
Past Medical History:
Diabetes type II, Insulin Dependent
PVD
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
Chronic pain syndrome
Social History:
___
Family History:
Per OMR
Father had heart disease, died at ___. Mother died of a blood
clot in her neck.
1 sister = asthma
Physical ___:
Adission Exam:
VS: 99.9 181/94 110 20 94% on RA
PAIN: "all over"
GEN: Chronically ill, dishevelled, obese
HEENT: Dry MM
NECK: Supple, large
CV: tachycardic, distant, no appreciable murmurs
RESP: CTAB anteriorly, unwilling to comply with full lung exam
GI: Soft, NT, ND, NABS
GU: No foley
DERM: No noticeable rash on limited exam
NEURO: Alert, oriented to self, not date, or place. He is
talking to himself as I enter the room, when asked says he's
talking to his wife. He denies visual or auditory
hallucinations. He has limited attention. No cranial nerve
deficits in limited exam. Moving all 4 extremitities. No
asterixis. Pill rolling tremor of his L>R thumb, some
cogwheeling in the upper extremities and increased tone -
difficult to determine if this is resistance to exam or true
increased tone.
Discharge Exam:
VS: 98.9 98.3 155/81 72 20 97%RA (CPAP also)
Gen: Wearing CPAP mask, Odd affect and behaviors, perseverating
on some things but tangential otherwise, variety of somatic
complaints though affect discongruent with concerns.
HEENT: MMM, mild scleral anicteric today
CV: Normal rate, regular rhythm
Resp: CTAB
GI: Soft, NT, ND, NABS
Skin: No apparent rash on limited exam, brusies over elbows and
knees
Vascular: cool feet, but palpable 2+ DP pulses
Pertinent Results:
Admission Labs:
___ 07:40AM BLOOD WBC-9.6 RBC-4.92 Hgb-13.9* Hct-40.3
MCV-82 MCH-28.1 MCHC-34.4 RDW-14.6 Plt ___
___ 07:40AM BLOOD Neuts-88.6* Lymphs-5.5* Monos-5.0 Eos-0.8
Baso-0.1
___ 07:40AM BLOOD ___ PTT-22.5* ___
___ 07:40AM BLOOD Glucose-166* UreaN-15 Creat-1.7* Na-126*
K-8.6* Cl-92* HCO3-23 AnGap-20
___ 07:40AM BLOOD Calcium-8.2* Phos-2.5* Mg-1.7
___ 07:41AM BLOOD Lactate-3.5* Na-134 K-6.0* Cl-94*
calHCO3-26
Interval labs:
___ 01:37PM BLOOD Glucose-97 UreaN-14 Creat-1.3* Na-135
K-4.4 Cl-97 HCO3-28 AnGap-14
___ 02:14PM BLOOD Lactate-2.2* K-4.1
Discharge Labs
___ 06:17AM BLOOD WBC-3.3* RBC-4.51* Hgb-13.1* Hct-37.1*
MCV-82 MCH-29.1 MCHC-35.4* RDW-15.0 Plt Ct-92*
___:17AM BLOOD Neuts-55.9 ___ Monos-10.8
Eos-4.2* Baso-0.7
___ 06:17AM BLOOD Glucose-339* UreaN-19 Creat-1.1 Na-133
K-4.7 Cl-99 HCO3-27 AnGap-12
___ 06:17AM BLOOD ALT-34 AST-58* AlkPhos-68 TotBili-1.5
___ 06:17AM BLOOD Calcium-9.2 Phos-3.7 Mg-1.7
Other Labs:
___ 01:37PM BLOOD VitB12-___ Folate-12.5
___ 01:37PM BLOOD TSH-0.75
CXR:
FINDINGS:
The patient is status post sternotomy. The cardiac, mediastinal
and hilar contours appear unchanged including mild cardiomegaly.
The lung volumes are low. There is no pleural effusion or
pneumothorax. The lungs appear clear.
IMPRESSION:
No evidence of acute cardiopulmonary.
CT Head: Prelim
No evidence of intracranial injury. Small superficial hematoma
overlying the occiput.
CT C-spine: Prelim
No evidence of fracture or dislocation. Spondylosis.
EKG: Sinus with rate in the ___. IVCD, Q wave in III, t-wave
flattening inferiorly, no signs of acute ischemia.
RUQ ultrasound
FINDINGS:
Exam is somewhat limited by patient body habitus.
LIVER: The liver is diffusely echogenic. The contour of the
liver is smooth. There is no focal liver mass. Main portal vein
is patent with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD
measures 7mm.
GALLBLADDER: There are gallstones layering within the
gallbladder. There is no gallbladder wall thickening or
pericholecystic fluid.
PANCREAS: The pancreas is not visualized due to overlying bowel
gas and body habitus.
SPLEEN: Normal echogenicity, measuring 15.6 cm.
KIDNEYS: The right kidney measures 10.4 cm. The left kidney
measures 12.2 cm. Normal cortical echogenicity and
corticomedullary differentiation is seen bilaterally. There is
no evidence of masses, stones or hydronephrosis in the kidneys.
RETROPERITONEUM: The aorta and IVC are not well visualized.
IMPRESSION:
1. Echogenic liver compatible with hepatic steatosis. However,
diffuse liver disease such as steatohepatitis or advanced
cirrhosis/fibrosis can't be excluded. There is no intrahepatic
biliary dilatation.
2. Cholelithiasis.
3. Splenomegaly.
Brief Hospital Course:
___ yo M with history of HTN, DM, depression and likely
psychiatric or cognitive comorbidity who presented from home
with falls and encephalopathy found to have sepsis and hepatitis
from unknown etiology now resolved.
# Metabolic encephalopathy: Possibly due to medication
withdrawal, acute delirium on chronic cognitive impairment,
medication effect/side effects, infection, acute renal failure
and manifestations of psychiatric/neurologic conditions. He has
cogwheeling, intermittent involuntary low amplitude tremor of
his upper extremities and increased tone on exam, also with
visual hallucinations in the past as well as tactile and
auditory per his wife, all of which are concerning for
withdrawal or psychiatric manifestations of depression or
neurologic disease (___). He is on several
mood altering medications which may have caused his presenting
symptoms, most concerning of which is his benzodiazepine. Given
his tachycardia and hypertension, he was treated empirically
with clonazepam and a foley for urinary retention. His mental
status and renal function improved rapidly. Metabolic work-up
with B12, folate, TSH, and RPR was normal or negative. He was
febrile to 102.4, in an isolated fever. He was treated with
Unasyn, which was discontinued after 48 hours of negative
culture data and defervescence and remained afebrile and with
ongoing clinical improvement off antibiotics for >48hours.
# Sepsis: Tachcyardia and fever on admission without clear
source. No positive bacterial evidence or focal findings to
invoke bacterial process. CXR negative, cultures negative.
Treated empirically with Unasyn for 48 hours until cultures
returned negative and discontinued with ongoing clinical
improvement while off ABx for >48 hours. In setting of
thrombocytopenia, elevated LFTs, fever and absence of positive
cultures a viral process seems most likely etiology.
# Acute renal failure: He had a creatinine of 1.7 on admission
with hyperkalemia to 6.0. Improved to 1.3 and 4.1 with
hydration/insulin. He also had an elevated CK in the setting of
his falls. He was hydrated, monitored on tele and his
hyperkalemia and ARF resolved.
# Thrombocytopenia: Has had chronic thrombocytopenia dating back
to ___ however baseline appears to be low 100s. Acute
exacerbation of thrombocytopenia potentially BM suppression
related to sepsis and/or viral process. No evidence of bleeding,
during admit and platelet uptrended with resolution in symptoms.
Microangiopathic hemolysis work up negative.
# Hepatitis:
# Cirrhosis: Presumed cirrhosis. Thrombocytopenia, elevated
bilirubin, mildly elevated INR and splenomegaly in setting of
RUQ US showing steatosis all seem consistent with potential
cirrhosis. No ascites on ultrasound or asterixis during
admission. Presented with acute hepatitis on admission with
cholestatic patter which was though most likely sepsis related
though potentially viral as well, US did not reveal evidence of
obstruction. Hepatitis serologies checked and are pending on
discharge
# DM: Chronic insulin dependent DM II, poorly controlled and
complicated. Often refused Lantus during admission and received
pre-meal insulin though did not routinely eat after insulin
given so had two episodes of hypoglycemia. Did not adjust
insulin regimen as ___ otherwise well controlled when regimen
administered as ordered.
# Depression
# Insomnia
# Anxiety:
He is on several medications. Reportedly takes clonazepam and
nortriptylline regularly, though he does not take sertraline
regularly. He was treated with clonzepam and nortriptylline,
Sertraline were held and discontinued since patient is not
taking. Will likely need neurocoginitive evaluation as an
outpatient for evaluation of possible tactile and visual
misperceptions/hallucinations and memory complaints
# Chronic pain: On oxycontin, Vicodin, gabapentin. His vicodin
has been being decreased in the outpatient setting and was held
while in house, discontinued on discharge due to lack of
requirement in house. His oxycontin was continued.
# OT / ___ and OT both evaluated patient including basic
cognitive eval. Patient exhibited "mild impairments in language,
attention and memory... however baseline. Pt was able to
complete safety portion of OTAPS with good results. Pt is
observed to make inappropriate, nonsensical comments occasional
thorughout the session but appears to be more personality
based." Patient likely at baseline and recommended DC with home
OT eval and maximum services. Set up with ___, ___ and OT on
discharge.
Transitional Issues: Communicated to PCP on day of discharge
- Hepatitis serologies pending on DC
- Outpatient Hepatology referral
- Home with ___, ___
- Outpatient neurocoginitive evaluation
- Repeat CBC and LFTs to monitor WBC/PLT and TBili trend
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 1 mg PO TID
2. Ezetimibe 10 mg PO DAILY
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Gabapentin 600 mg PO TID
5. Gabapentin 1200 mg PO HS
6. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO BID
7. Hydrocodone-Acetaminophen (5mg-325mg) 0.5 TAB PO DAILY
8. Hydrocortisone Cream 1% 1 Appl TP 2X/WEEK (MO,TH)
9. Glargine 100 Units Bedtime
Humalog 25 Units Breakfast
Humalog 25 Units Lunch
Humalog 25 Units Dinner
Insulin SC Sliding Scale using HUM InsulinMax Dose Override
Reason: Home dose
10. Lidocaine 5% Patch 1 PTCH TD QAM
11. Lisinopril 40 mg PO DAILY
12. Meclizine ___ mg PO BID
13. MetFORMIN (Glucophage) 500 mg PO BID
14. Metoprolol Tartrate 100 mg PO BID
15. Miconazole Powder 2% 1 Appl TP BID:PRN itch
16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
17. Nortriptyline 100 mg PO HS
18. Omeprazole 20 mg PO BID
19. OxyCODONE SR (OxyconTIN) 30 mg PO Q8H
20. Ranitidine 150 mg PO BID
21. Sertraline 25 mg PO DAILY
22. Simvastatin 40 mg PO DAILY
23. Acetaminophen 325 mg PO Q8H:PRN pain
24. Aspirin 81 mg PO DAILY
25. Cetirizine 10 mg PO TID
26. Ferrous Sulfate 325 mg PO BID
Discharge Medications:
1. Acetaminophen 325 mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
3. ClonazePAM 1 mg PO TID
4. Gabapentin 600 mg PO TID
5. Glargine 100 Units Bedtime
Humalog 25 Units Breakfast
Humalog 25 Units Lunch
Humalog 25 Units Dinner
Insulin SC Sliding Scale using HUM InsulinMax Dose Override
Reason: Home dose
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. Metoprolol Tartrate 100 mg PO BID
8. Miconazole Powder 2% 1 Appl TP BID:PRN itch
9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
10. Omeprazole 20 mg PO BID
11. OxyCODONE SR (OxyconTIN) 30 mg PO Q8H
12. Ranitidine 150 mg PO BID
13. Simvastatin 40 mg PO DAILY
14. Ferrous Sulfate 325 mg PO BID
15. Fluticasone Propionate NASAL 2 SPRY NU DAILY
16. Gabapentin 1200 mg PO HS
17. Hydrocortisone Cream 1% 1 Appl TP 2X/WEEK (MO,TH)
18. Lisinopril 40 mg PO DAILY
19. MetFORMIN (Glucophage) 500 mg PO BID
20. Cetirizine 10 mg PO TID
21. Ezetimibe 10 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
___:
Benzo withdrawal
Metabolic encephalopathy
Acute renal failure
Thrombocytopenia
Diabetes type II
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to ___ after multiple falls and altered
mental status. You were treated for a fever, urinary retention,
and withdrawal from clonazepam. Your condition rapidly improved,
and no source of infection was found so antibiotics were
discontinued. ___ and OT evaluated you and recommended discharge
home with home OT and safety evaluation.
You should also have full neurocognitive evaluation completed as
an outpatient.
You should have repeat labs checked this week.
Followup Instructions:
___
|
10639651-DS-27
| 10,639,651 | 28,778,862 |
DS
| 27 |
2140-09-14 00:00:00
|
2140-09-16 12:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Confusion, ___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is ___ with PMH of diabetes type II, CAD s/p CABG in
___, HTN, HLD, chronic pain, newly diagnosed NASH who presents
with altered mental status (per wife) and lethargy. Notably, he
was admitted two weeks ago with an SBO that resolved with
medical management. Patient feels that nothing was wrong and
came in due to wife's concern, who felt that he has been
behaving strangely at home. Per wife, patient has been staying
up all night doing unusual tasks, such as home ___. and has
also fallen asleep during random times during the day. He
acknowledges that he hasn't slept much in the last several days.
No recent medication changes. He does not know of any hx of
liver disease, has no physician for this, and doesn't take any
meds for this. Re focal symptoms, he has pain across the backs
of his shoulders and in both arms x3d; unlike the pain from his
prior heart attacks. Denies ETOH. Has a fairly aggressive
regimen of oxycodone. He also complains of R eye pain after an
eye exam. They note his legs are more swollen.
In the ED, initial vitals were: 97.3 88 147/76 18 99% RA.
He was alert and oriented to person, and could state the
president, recent holidays, and ___ backwards.
Exam notable for lethargy, but he was oriented. he was tremulous
without asterixis; neuro and pupillary exam nonfocal. Heart
lungs unremarkable. No obvious wounds or skin lesions.
Labs notable for unremarkable CBC, INR 1.0, AST 71, ALT 30, AP
38, Positive serum tricyclics, positive urine opiates and
oxycodone, lactate 2.7, creatinine 2.6, K 6.8, urinalysis
significant for 25 hyaline casts.
Imaging notable for ___: negative for DVT's, R leg Xray
significant for ?soft tissue swelling, CXR No acute
cardiopulmonary process.
Patient was given 500 cc NS, Hydrocodone-Acetominophen ___,
ASA 81 mg, Clonazepam 1 mg, metoprolol tartrate 100 mg,
omeprazole 20 mg, Ranitidine, simvastatin, gabapentin, insulin
15 units plus 8 units.
Patient was seen by Transplant surgery who recommended no acute
surgical issue, no indication for transplant surgery
intervention or admission.
Decision was made to admit for ET, but they declined admission -
med bed for anemia, ___.
Vitals on transfer were 97.7 67 112/64 18 97% RA.
On the floor, he (and his wife) feel that he is mentating
normally.
Review of systems:
(+) Per HPI, otherwise negative
Past Medical History:
Diabetes type II, Insulin Dependent
PVD
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
Chronic pain syndrome
admit in ___ with confusion, ?cirrhosis?
Social History:
___
Family History:
Per OMR
Father had heart disease, died at ___. Mother died of a blood
clot in her neck.
1 sister = asthma
Physical ___:
Admission:
VS: 97.4 129/73 70 20 99 RA
Gen: Disheveled, alert & oriented, NAD
HEENT: Eyes anicteric. PERRL, EOMI
CV: RRR, normal S1 & S2, no M/R/G
Pulm: CTAB, no W/R/R
Abd: obese, soft, nontender, nondistended, +BS
GU: Deferred
Ext: Warm & well perfused, trace b/l lower extremity edema
Skin: No rashes noted
Neuro: Alert and oriented x3. CN II - XII intact. No focal
deficits. ?mild asterixis.
Psych: Normal affect.
Discharge:
VS: 97.5 ___ 128-137/87-62 18 94%RA
Gen: Disheveled, alert & oriented, NAD. lying in bed with CPAP
mask in place
HEENT: Eyes anicteric. PERRL, EOMI
CV: RRR, normal S1 & S2, no M/R/G
Pulm: CTAB, no W/R/R
Abd: obese, soft, nontender, nondistended, +BS
GU: Deferred
Ext: Warm & well perfused, trace b/l lower extremity edema
Skin: No rashes noted
Neuro: Alert and oriented x3. CN II - XII intact. No focal
deficits. ?mild asterixis.
Psych: Normal affect.
Pertinent Results:
Admission:
___ 09:45PM LACTATE-1.8
___ 07:50PM GLUCOSE-262* UREA N-27* CREAT-1.4*#
SODIUM-134 POTASSIUM-4.8 CHLORIDE-98 TOTAL CO2-26 ANION GAP-15
___ 07:50PM ALT(SGPT)-22 AST(SGOT)-28 ALK PHOS-41 TOT
BILI-1.2
___ 07:50PM CALCIUM-9.0 PHOSPHATE-3.1 MAGNESIUM-1.4*
IRON-126
___ 07:50PM calTIBC-282 FERRITIN-161 TRF-217
___ 07:50PM WBC-4.9 RBC-4.19* HGB-11.9* HCT-34.1* MCV-81*
MCH-28.4 MCHC-34.9 RDW-13.0 RDWSD-37.7
___ 07:50PM PLT COUNT-104*
___ 07:50PM ___ PTT-29.8 ___
___ 06:50AM URINE HOURS-RANDOM CREAT-161 SODIUM-30
POTASSIUM-20 CHLORIDE-20
___ 06:50AM URINE HOURS-RANDOM
___ 06:50AM URINE OSMOLAL-337
___:50AM URINE GR HOLD-HOLD
___ 06:50AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG oxycodn-POS mthdone-NEG
___ 06:50AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 06:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5
LEUK-NEG
___ 06:50AM URINE RBC-2 WBC-4 BACTERIA-NONE YEAST-NONE
EPI-<1 TRANS EPI-<1
___ 06:50AM URINE HYALINE-25*
___ 06:50AM URINE MUCOUS-RARE
___ 02:27AM COMMENTS-GREEN TOP
___ 02:27AM LACTATE-2.7* K+-4.6
___ 02:00AM GLUCOSE-265* UREA N-30* CREAT-2.6*#
SODIUM-133 POTASSIUM-6.8* CHLORIDE-94* TOTAL CO2-26 ANION GAP-20
___ 02:00AM estGFR-Using this
___ 02:00AM ALT(SGPT)-30 AST(SGOT)-71* ALK PHOS-38* TOT
BILI-0.7
___ 02:00AM LIPASE-25
___ 02:00AM cTropnT-0.01
___ 02:00AM proBNP-169
___ 02:00AM ALBUMIN-4.2 CALCIUM-9.5 PHOSPHATE-4.6*#
MAGNESIUM-1.6
___ 02:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-POS
___ 02:00AM WBC-7.2 RBC-4.57* HGB-12.8* HCT-37.9* MCV-83
MCH-28.0 MCHC-33.8 RDW-13.3 RDWSD-39.3
___ 02:00AM NEUTS-55.4 ___ MONOS-8.6 EOS-2.5
BASOS-0.7 IM ___ AbsNeut-4.00# AbsLymp-2.34 AbsMono-0.62
AbsEos-0.18 AbsBaso-0.05
___ 02:00AM PLT COUNT-134*
___ 02:00AM ___ PTT-28.9 ___
Discharge
___ 11:20AM BLOOD WBC-4.4 RBC-4.17* Hgb-11.7* Hct-34.3*
MCV-82 MCH-28.1 MCHC-34.1 RDW-13.0 RDWSD-38.3 Plt ___
___ 11:20AM BLOOD Plt ___
___ 11:20AM BLOOD Glucose-160* UreaN-24* Creat-1.2 Na-138
K-5.1 Cl-101 HCO3-27 AnGap-15
___ 11:20AM BLOOD Calcium-9.2 Phos-2.5* Mg-1.7
Imaging:
# Liver U/S (___): IMPRESSION:
1. Echogenic liver consistent with steatosis. Other forms of
liver disease and more advanced liver disease including
steatohepatitis or significant hepatic fibrosis/cirrhosis cannot
be excluded on this study.
2. Patent main portal vein.
3. Air within the gallbladder lumen, unchanged since prior CT
study. Cholelithiasis without evidence of acute cholecystitis.
4. Splenomegaly at 16.3 cm.
+ EKG: Slightly enlarged T waves but no true peaking.
Renal Ultrasound ___ The right kidney measures 13.4 cm. The
left kidney measures 11.3 cm. There is no hydronephrosis,
stones, or masses bilaterally. Normal cortical echogenicity and
corticomedullary differentiation are seen bilaterally.
The bladder is moderately well distended and normal in
appearance.
Brief Hospital Course:
Brief Hospital Course:
===================================
___ year old male with PMH of NASH, diabetes type II, CAD s/p
CABG in ___, HTN, HLD, chronic pain who presents with ___ in
the setting of lethargy/encephalopathy.
Active Issues:
===================================
___: His creatinine improved from 2.6 on admission to 1.2 by
discharge after 2 L IV fluids, indicating likely prerenal
etiology (FeNa <2). Patient reports inconsistent po intake at
home and was encouraged to maintain po intake with consistent
water drinking when at home.
#Encephalopathy: His wife initially felt that he was confused at
home but by the time he was admitted to the floor he was back to
his baseline. Most likely this was acute toxic metabolic
encephalopathy due to multiple deliriogenic medications. We
decreased his Oxycontin dosing to BID and decreased his
Gabapentin dose as well, which we recommend to be continued as
an outpatient. We did not feel strongly that he had hepatic
encephalopathy as his liver function tests and markers of liver
function such as INR were not impaired and he had no asterixis
on exam. He was counseled extensively and encouraged to taper
off his sedating medications and follow up with his
psychiatrist. His psychiatrist was contacted and a voicemail
message was left with these concerns.
#Anemia: He also presented with anemia with Hgb around 12 which
is significantly lower than his baseline of 15. As he was
asymptomatic, had no signs of bleeding, and H/H remained stable,
we felt that this could be worked up with outpatient
colonoscopy.
Transitional Issues:
========================================
-Please continue to wean off sedating medications.
-Recommend outpatient colonoscopy and further anemia work-up.
-Please check creatinine within one week of discharge to trend
creatinine.
-We recommended decreasing oxycontin to q12hr and cut gabapentin
dose in half. Please continue to try to decrease deliriogenic
meds.
-Psychiatry follow-up for ongoing titration of his medications
# CODE: Full
# CONTACT: Wife, ___ (HCP): ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Cepastat (Phenol) Lozenge 2 LOZ PO Q4H:PRN throat pain,
breath
3. ClonazePAM 1 mg PO TID
4. Fluticasone Propionate NASAL 2 SPRY NU BID
5. Gabapentin 600 mg PO QAM
6. Gabapentin 600 mg PO NOON
7. Gabapentin 1200 mg PO QHS
8. Lidocaine 5% Patch 1 PTCH TD QPM
9. Lisinopril 40 mg PO DAILY
10. Loratadine 10 mg PO DAILY
11. MetFORMIN (Glucophage) 500 mg PO BID
12. Metoprolol Tartrate 100 mg PO BID
13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
14. Nortriptyline 100 mg PO QHS
15. Omeprazole 20 mg PO BID
16. OxyCODONE SR (OxyconTIN) 30 mg PO Q8H
17. Ranitidine 150 mg PO BID
18. Sertraline 25 mg PO DAILY
19. Simvastatin 40 mg PO QPM
20. Glargine 100 Units Bedtime
Humalog 25 Units Breakfast
Humalog 25 Units Lunch
Humalog 25 Units DinnerMax Dose Override Reason: stabilized at
home
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. ClonazePAM 1 mg PO TID
3. Fluticasone Propionate NASAL 2 SPRY NU BID
4. Gabapentin 300 mg PO BID
5. Gabapentin 600 mg PO HS
6. Glargine 100 Units Bedtime
Humalog 25 Units Breakfast
Humalog 25 Units Lunch
Humalog 25 Units DinnerMax Dose Override Reason: stabilized at
home
7. Lidocaine 5% Patch 1 PTCH TD QPM
8. Metoprolol Tartrate 100 mg PO BID
9. Nortriptyline 100 mg PO QHS
10. Omeprazole 20 mg PO BID
11. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
12. Ranitidine 150 mg PO BID
13. Sertraline 25 mg PO DAILY
14. Simvastatin 40 mg PO QPM
15. Cepastat (Phenol) Lozenge 2 LOZ PO Q4H:PRN throat pain,
breath
16. Lisinopril 40 mg PO DAILY
17. Loratadine 10 mg PO DAILY
18. MetFORMIN (Glucophage) 500 mg PO BID
19. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
20. Lactulose 30 mL PO TID
Please hold for diarrhea
RX *lactulose 20 gram/30 mL 30 mL by mouth TID PRN Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: prerenal ___, acute toxic metabolic encephalopathy due
to medications
Secondary: CAD, DM, anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ due to lethargy and confusion as well
as an injury to your kidney. We felt that your confusion was
probably due to the many medications you are on that can cause
confusion like clonazepam, gabapentin, oxycodone, and
amitryptiline. We reduced the dose of a few of these medications
and we urge you to follow our recommendations in order to
prevent future confusion. Your kidney function improved
throughout your stay here. We feel that your kidney function was
worsened briefly due to dehydration. You need to drink fluids
and eat food consistently throughout the day to prevent this.
You should follow up with your PCP. We wish you all the best.
Sincerely,
Your care team at ___
Followup Instructions:
___
|
10639651-DS-28
| 10,639,651 | 24,583,769 |
DS
| 28 |
2142-09-24 00:00:00
|
2142-09-24 18:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / amlodipine
Attending: ___.
Chief Complaint:
COUGH, S/P FALL
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with IDDM, CAD s/p
CABG in ___, HTN, HLD, chronic pain, NASH, chronic opioid use
who presented as a transfer from ___ for
altered mental status, concern for overdose and hypoglycemia.
Patient gets regular care at ___ per WebOMR. His wife
requested
transfer to ___ for further care. Patient and his wife both
poor historians. Wife indicates that patient may have taken more
medication for his pain because of a recent change in his pain
management regimen. Patient is unable to provide further
history.
In the ED, initial VS were: 97.6 47 128/78 22 98% Nasal Cannula
Exam notable for: myotonic jerks, patient screams out in pain
-wife states that he does this when he is in pain
Labs showed: WBC 9.0, H/H 13.0/38.3, PLT K 4.2, CR 1.4, UA small
blood, Glucose of 150 and few bacteria, LACTATE 2.0, INR 1.2.
UTox was positive for benzos, opiates, amphetamines and
oxycodone. Serum tox was positive for tricyclics.
No imaging was ordered.
No consults were requested.
Patient received:
___ 09:40IVCalcium Gluconate
___ 09:40IVGlucagon 2 mg
___ 09:40IVNaloxone .4 mg
___ 10:00IVFNS
___ 10:15IVLORazepam 2 ___
___ 10:23IVLORazepam 2 ___
___ 10:38IVLORazepam 2 ___
___ 10:44IVLORazepam 2 ___
___ 10:51IVLORazepam 2 ___
___ 11:07IVLORazepam 2 mg
___ 11:27IVCalcium Gluconate 1 gm
___ 12:00IVFNS 1000 mL
___ 15:20IVDextrose 50% 12.5 gm
___ 17:15IVDextrose 50%
___ 18:22SCInsulin
___ 18:24IVDextrose 50% 12.5 gm
___ 23:02SCInsulin
___ 23:06IVDextrose 50% 12.5 gm
___ 23:25IVFNS 1000 mL
___ (1000 mL ordered)
Transfer VS were: 97.7 86 184/82 15 95% 2L NC.
On arrival to the floor, the patient thinks it is "possible" he
took too much metoprolol. He also reports taking more of
oxycodone or cloazepam due to his ongoing pain, he isn't sure
which or how much he took. He denies chest pain, shortness of
breath, abdominal pain or fevers. He reports worsened abdominal
distension.
Past Medical History:
IDDM
PVD
NASH CIRRHOSIS
CAD s/p 3v CABG (___)
HYPERTENSION
HL
OSA on CPAP
GERD
ARTHRITIS (diffuse and severe, including chest and arms)
CHRONIC PAIN SYNDROME
Social History:
___
Family History:
Per OMR
Father had heart disease, died at ___. Mother died of a blood
clot in her neck.
1 sister = asthma
Physical ___:
ADMISSION PHYSICAL EXAM
=======================
VS: Per WebOMR (not collected as of admission)
GENERAL: obese older man in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera
NECK: supple
HEART: RRR, S1/S2, no murmurs appreciated
LUNGS: clear anteriorly
ABDOMEN: distended but non-tender, no rebound/guarding
EXT: wrist with blood stains over IV site
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no rashes
DISCHARGE PHYSICAL EXAM
========================
24 HR Data (last updated ___ @ 830)
Temp: 98.5 (Tm 98.5), BP: 167/93 (129-198/73-121), HR: 73
(67-89), RR: 18 (___), O2 sat: 96% (92-98), O2 delivery: Cpap
GEN: Patient is lying comfortably in bed. Nontoxic appearing. He
is oriented to person, place, and time.
CV: RRR no murmurs rubs or gallops
LUNGS: clear to auscultation bilaterally
ABD: obese, nontender to palpation
EXT: b/l trace edema and venous stasis changes
NEURO: PERRL, EOM intact, did not follow instructions to
complete
rest of CN exam.
SKIN: Erythema and moist skin in the skin fold on the left
groin.
Pertinent Results:
ADMISSION LABS
===============
___ 09:35AM BLOOD WBC-9.0 RBC-4.65 Hgb-13.0* Hct-38.3*
MCV-82 MCH-28.0 MCHC-33.9 RDW-13.2 RDWSD-38.8 Plt ___
___ 09:35AM BLOOD Neuts-72.1* Lymphs-16.2* Monos-9.0
Eos-1.6 Baso-0.3 Im ___ AbsNeut-6.52*# AbsLymp-1.46
AbsMono-0.81* AbsEos-0.14 AbsBaso-0.03
___ 10:59AM BLOOD ___ PTT-30.1 ___
___ 09:35AM BLOOD Glucose-99 UreaN-15 Creat-1.4* Na-140
K-4.2 Cl-101 HCO3-25 AnGap-14
___ 09:35AM BLOOD ALT-13 AST-22 AlkPhos-50 TotBili-1.5
___ 09:35AM BLOOD Albumin-4.2 Calcium-8.9 Phos-3.6 Mg-1.9
___ 09:35AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-POS*
___ 01:33AM URINE Blood-SM* Nitrite-NEG Protein-30*
Glucose-150* Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
___ 01:33AM URINE bnzodzp-POS* barbitr-NEG opiates-POS*
cocaine-NEG amphetm-POS* oxycodn-POS* mthdone-NEG
DISCHARGE LABS
==============
___ 05:47AM BLOOD WBC-5.5 RBC-4.78 Hgb-13.4* Hct-39.2*
MCV-82 MCH-28.0 MCHC-34.2 RDW-13.0 RDWSD-37.9 Plt ___
___ 05:47AM BLOOD ___ PTT-29.0 ___
___ 05:47AM BLOOD Glucose-269* UreaN-22* Creat-1.3* Na-134*
K-5.0 Cl-97 HCO3-22 AnGap-15
___ 05:47AM BLOOD ALT-24 AST-39 AlkPhos-49 TotBili-2.1*
___ 05:47AM BLOOD Albumin-4.2 Calcium-9.3 Phos-3.7 Mg-1.8
IMAGING/STUDIES
==============
___ ABD US
Scans demonstrate no ascites in the upper or lower abdomen or
pelvis. Planned paracentesis was therefore canceled.
___ CT HEAD
No evidence of fracture, infarction, hemorrhage, edema, or mass.
Brief Hospital Course:
Mr. ___ is a ___ with IDDM, CAD s/p CABG in ___, HTN, HLD,
chronic pain, ___, chronic opioid use who presented as a
transfer from ___ for altered mental
status, concern for medication overdose and hypoglycemia.
#TOXIC METABOLIC ENCEPHALOPATHY
#ALTERED MENTAL STATUS IN SETTING OF POLYPHARMACY:
Patient presented with obtundation which improved w/ narcan
suggesting some component of opioid toxicity. He received 12mg
IV Lorazepam in the ED followed by a period of confusion,
tremulousness and low responsiveness. Highest suspicion that his
AMS is explained by polypharmacy with the possibility that NASH
cirrhosis predisposes him to more substantial side effects.
Hypoglycemia may also have contributed. LFTs at baseline aside
from bili being mildly elevated. No signs or symptoms of
infection. Neuro exam difficult but without focal findings. CT
head performed on ___ without acute defects. He was started on
partial doses of his home medications. Specifically, he was
continued on home oxycontin and clonazepam. The tizanidine dose
was decreased to 2mg TID initially. His lyrica, prn vicodin, and
nortriptyline were held initially and then slowly restarted. Of
note his toxicology screen was positive for amphetamines without
known medication prescription that can explain this test. His
mental status improved during his hospital stay. At discharge,
we agreed that he could resume his home medication regimen.
#HYPERTENSION:
He developed severe hypertension with SBP to 230s on the morning
on ___ with the etiology likely multifactorial in setting of
baseline HTN in addition to sympthathetic overdrive in setting
of withdrawal from multiple sedating medications. EKG without
signs of acute coronary syndrome and no laboratory evidence of
end organ failure. BP improved after starting clonidine. He was
then started on carvedilol and nifedipine with resultant
hypotension with systolic blood pressure in ___. He was given 1L
IVF with improvement in blood pressure. He was then transitioned
to carvedilol that was uptitrated to 25mg BID on discharge with
BP in systolic pressures in the 160s prior to discharge. Because
of the hypotension with nifedipine earlier in the admission,
further antihypertensives were deferred. Metoprolol was stopped.
#HYPOGLYCEMIA:
#TYPE II DIABETES MELLITUS
Patient with IDDM on large doses of insulin but presented with
persistent hypoglycemia requiring dextrose bolus X 4 and ___
NS IVF. ___ in ___ with only 8 units lantus given. He then
went over 24 hours without insulin and blood sugars remained in
the ___. He began to eat a more robust diet and the blood
sugar increased to 200. He was given 10 units lantus on the
evening of ___ with AM fingerstick at 232. With input from the
___ team, he was discharge on 20 units tresiba with
10 units novolog with meals prior to discharge with a plan to
uptitrate insulin based on his outpatient blood sugars.
#___ CIRRHOSIS: MELD 13, MRI negative for HCC in ___. Followed
in ___ liver clinic. Recent liver team assessment showed
concern for worsening ascites and patient has para scheduled on
___ in outpatient setting. Patient initially reported
worsening abdominal distention. The patient was sent down for
paracentesis on ___ but there was no ascites to tap.
#CHRONIC PAIN: Patient with debilitating arthritis on many
concurrent pain therapies. See above for pain discussion.
#CANDIDAL SKIN INFECTION:
Left groin. Miconazole in house, If not improving will give
prescription for one dose of fluconazole at discharge
CHRONIC ISSUES:
#CAD + HL: Hx of CABG in ___. Followed by ___ Cardiology.
Continued home atorvastatin
#OSA:
Continued home CPAP
#GERD:
Continued home omeprazole 20 mg capsule. Held home ranitidine
for now
TRANSITIONAL ISSUES
=================
# NEW MEDICATIONS
- Carvedilol 25 mg PO BID
# STOPPED MEDICATIONS
- Metoprolol Tartrate 100 mg PO TID
# CHANGED MEDICATIONS
- Novolog 10 Units Breakfast -- to be uptitrated prn as
outpatient
Novolog 10 Units Lunch -- to be uptitrated prn as outpatient
Novolog 10 Units Dinner -- to be uptitrated prn as outpatient
TRESIBA 20 Units Bedtime -- to be uptitrated prn as outpatient
[] Monitor blood sugars and uptitrate insulin as needed. He was
discharged with 10 units of novolog at meals and tresiba 20U QHS
with instructions to up-titrate as needed as an outpatient based
on his blood sguar
[] Monitor blood pressure and adjust antihypertensive regimen as
needed
[] Please re-order the ___ CT abdomen pelvis with triphasic
contrast to evaluate the liver as he missed his outpatient
appointment for imaging
[] suggest attempt at paracentesis again if CT shows ascites
[] Continue to adjust his home pain regimen as needed
[] Evaluate his groin rash. He was given one dose of fluconazole
on discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Lisinopril 40 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Pregabalin 75 mg PO TID
5. Ranitidine 150 mg PO BID
6. Meclizine 25 mg PO Q12H:PRN vertigo
7. ClonazePAM 1 mg PO Q8H:PRN anxiety
8. Tizanidine 4 mg PO BID:PRN pain
9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
10. OxyCODONE SR (OxyconTIN) 20 mg PO BID
11. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN
BREAKTHROUGH PAIN
12. NOVOLOG 30 Units Breakfast
NOVOLOG 30 Units Lunch
NOVOLOG 30 Units Dinner
TRESIBA 100 Units Breakfast
TRESIBA 100 Units BedtimeMax Dose Override Reason: HOME MED LIST
13. OxyCODONE SR (OxyconTIN) 30 mg PO QHS
14. Sertraline 25 mg PO DAILY
15. Nortriptyline 150 mg PO QHS
16. MetFORMIN (Glucophage) 500 mg PO BID
17. Metoprolol Tartrate 100 mg PO TID
Discharge Medications:
1. Carvedilol 25 mg PO BID
RX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
2. Fluconazole 150 mg PO ONCE Duration: 1 Dose
RX *fluconazole 150 mg 1 tablet(s) by mouth Once Disp #*1 Tablet
Refills:*0
3. Novolog 10 Units Breakfast
Novolog 10 Units Lunch
Novolog 10 Units Dinner
TRESIBA 20 Units Bedtime
4. Atorvastatin 40 mg PO QPM
5. ClonazePAM 1 mg PO Q8H:PRN anxiety
6. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN
BREAKTHROUGH PAIN
7. Lisinopril 40 mg PO DAILY
8. Meclizine 25 mg PO Q12H:PRN vertigo
9. MetFORMIN (Glucophage) 500 mg PO BID
10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
11. Nortriptyline 150 mg PO QHS
12. Omeprazole 20 mg PO DAILY
13. OxyCODONE SR (OxyconTIN) 20 mg PO BID
14. OxyCODONE SR (OxyconTIN) 30 mg PO QHS
15. Pregabalin 75 mg PO TID
16. Ranitidine 150 mg PO BID
17. Sertraline 25 mg PO DAILY
18. Tizanidine 4 mg PO BID:PRN pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Toxic metabolic encephalopathy
Hypoglycemia
Hypertension
Secondary:
Chronic pain
Diabetes type II
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 ___ with
confusion after taking multiple medications. We believe that you
over-medicated yourself at home and this caused you to be
confused. You were given lower doses of the medications and we
slowly added back your home medications.
You had low blood sugar during your stay. We are starting back
the insulin at a lower dose but you should continue to check
your blood sugars as you were as an outpatient and increase the
insulin as needed with the help of the ___. Please call your PCP
office if you have any questions.
You had very high blood pressures during your hospitalization
and were started on medications to help lower the blood
pressure.
It is very important that you take your medications as
prescribed. You should continue to work with your outpatient
doctors on ___ your medications to help with your pain
while trying to avoid the confusion that brought you into the
hospital.
It was a pleasure taking care of you. We wish you the best in
your health.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10639651-DS-29
| 10,639,651 | 29,877,191 |
DS
| 29 |
2143-06-16 00:00:00
|
2143-06-16 19:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / amlodipine
Attending: ___
Chief Complaint:
C: Hypoglycemia, Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with IDDM, CAD
s/p CABG in ___, CKD, HTN, HLD, chronic pain, NASH, chronic
opioid use here with generalized weakness, lightheadedness this
morning. Pt went to get up to go eat however was unable to do
so, slid down from his chair and was unable to get up. His wife
was also unable to get him up so they called EMS who found him
to
have a blood sugar of 60 on arrival. He states he felt better
after eating. Per EMS the household was very filthy and covered
in used needles. Patient denies hitting any part of his body or
LOC. He denies any other new sxs including f/c/n/v/d/cp/sob.
He does endorse perhaps taking too much of his metoprolol and
states that he has a difficult time seeing due to cataracts,
which may be contributing to this. He states has recently had
multiple medication changes and states it is difficult for him
to
take his medications as directed, including his insulin. Of
note
patient believes somebody is breaking into their house stealing
his medications and replacing it with other medications. His
wife expressed concerns at recent PCP appointment about his
paranoia and PCP had planned to f/u with his psychiatrist. He
had an admission at the end of last year also for medication
overdose and hypoglycemia.
In the ED, initial vitals were: 97.9 54 105/63 16 100% RA 92
Labs were notable only for creatinine of 1.6, crit 37.7, plts
118, lactate 2.2. CT abd/pelvis, CT spine, CT head were all
WNL.
EKG showed NSR. Pt was given metop, atorvastatin and pregabalin.
Pt began to feel better in the ED however was ultimately
admitted
to medicine because of concerns with safety at home and concerns
with his ability to take his medications and insulin properly.
On the floor, pt tells me that he thinks people have been
stealing oxycontin and substituting other medications for his
oxycontin and benzos. Also thinks it is happening to his wife.
He endorses vision getting worse over time however nothing
acute,
no CP, chronic SOB may be a little worse over the last week
however no significant change. Tells me he takes 150 of short
acting insulin and 200 tresiba (100 BID), however does not seem
entirely clear on how to take insulin per sliding scale. He
endorses lower abd pain x yrs due to "bile", intermittent
dysuria
x months, pain "anywhere and everywhere" feels l a bad bite or
sting from a fly, currently states he has a drilling pain in R
anticubital region. He does not think he took more insulin
than usual today and states he has been eating normally, however
does tell me that he gets food stamps and doesn't eat as much as
he would like because he wants to make sure that his wife gets
enough. He tells me that he has gained 40 lbs over the last ___
m however this is not corroborated by OMR. He has had a mild,
non-productive cough for the last week. He tells me he was
recently treated with one month of Keflex for abd cellulitis but
this has improved.
Past Medical History:
IDDM
PVD
NASH CIRRHOSIS
CAD s/p 3v CABG (___)
HYPERTENSION
HL
OSA on CPAP
GERD
ARTHRITIS (diffuse and severe, including chest and arms)
CHRONIC PAIN SYNDROME
Social History:
___
Family History:
Per OMR
Father had heart disease, died at ___. Mother died of a blood
clot in her neck.
1 sister = asthma
Physical ___:
Stable vital signs
Constitutional: obese, unkempt, alert, oriented, no acute
distress
EYES: Sclera anicteric, EOMI, PERRL
ENMT: MMM, oropharynx clear, normal hearing, normal nares
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Respiratory: clear to auscultation bilaterally, no rales,
rhonchi
GI: Soft, mild, diffuse tenderness in lower quadrants,
non-distended, bowel sounds present, no organomegaly, no rebound
or guarding
GU: No foley
EXT: Warm, well perfused, ___ L>R
NEURO: aaox3 CNII-XII and strength grossly intact
SKIN: several small <1 cm scaly skin lesions on L hand
Pertinent Results:
___ 12:55PM GLUCOSE-87 UREA N-17 CREAT-1.6* SODIUM-138
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-23 ANION GAP-15
Hba1c 7.4
___ 12:55PM cTropnT-<0.01
Brief Hospital Course:
weakness
# IDDM
# hypoglycemia
No focal weakness and no focal deficits on exam. Pt has some
difficulty articulating his insulin regimen.
Hba1c 7.4, concern about diet and low BS, diabetic education
done at the bedside.
Patient was seen by ___ and his diabetes regimen
changed to 70 daily of long acting insulin, 10 of Humalog before
meals, no ISS to simplify things. Metformin resumed.
___ are happy to see him as outpatient if PCP ___.
# HTN: 180s on manual check, however >200 on arrival to the
floor. Pt states he has missed several BP meds while in the
hospital. No sxs to suggest hypertensive emergency.
-restarted home meds
# Chronic diastolic CHF
# SOB
Does not appear to be in acute exacerbation however may be
contributing to weakness and slightly worsening SOB. Recently
seen by Dr ___ was considering adding lasix. SOB less
concerning for infection given no fever, WBC, only mild cough
- Improved after admission. Follow up with PCP.
# anxiety/depression/paranoia: outpt notes suggest that his wife
was concerned with worsening, planned for outpt psych f/u,
patient given phone number for ___ to make an appointment with
psychiatry.
-cont home clonazepam, sertraline
# ___: creatinine improved from 1.6 to 1.3 after admission.
# abd rash: pt reports that he was treated for a skin infection
on his abdomen with Keflex for a month, however this was stolen.
No e/o cellulitis currently although he does have a fungal rash
under pannus.
-miconazole prescription give on discharge
# skin lesions on hand: advised outpt follow up with PCP, ?
premalignant
about 50 minutes spent on discharge care on ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. ClonazePAM 1 mg PO Q8H:PRN anxiety
3. Lisinopril 40 mg PO DAILY
4. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
5. Nortriptyline 150 mg PO QHS
6. Omeprazole 20 mg PO DAILY
7. OxyCODONE SR (OxyconTIN) 20 mg PO TID
8. Pregabalin 100 mg PO TID
9. Sertraline 25 mg PO DAILY
10. Tizanidine 4 mg PO BID:PRN pain
11. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN
BREAKTHROUGH PAIN
12. Meclizine 25 mg PO Q12H:PRN vertigo
13. MetFORMIN (Glucophage) 500 mg PO BID
14. Ranitidine 150 mg PO BID
15. NIFEdipine (Extended Release) 30 mg PO DAILY
16. Aspirin 81 mg PO DAILY
17. Metoprolol Tartrate 100 mg PO TID
18. Lidocaine 5% Patch 1 PTCH TD QAM
19. Ranexa (ranolazine) 500 mg oral BID
20. Fluticasone Propionate NASAL 1 SPRY NU DAILY
21. Vitamin D Dose is Unknown PO Frequency is Unknown
22. alfuzosin 10 mg oral DAILY
23. tresiba 100 Units Breakfast
tresiba 100 Units BedtimeMax Dose Override Reason: pts home dose
Discharge Medications:
1. Miconazole Powder 2% 1 Appl TP TID:PRN rash
RX *miconazole nitrate [Antifungal Cream (miconazole)] 2 % apply
to skin rash area once daily Refills:*0
2. Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
tresiba 70 Units Breakfast
tresiba 00 Units BedtimeMax Dose Override Reason: pts home dose
RX *blood sugar diagnostic [OneTouch Ultra Blue Test Strip] 4
time daily Disp #*100 Strip Refills:*2
RX *blood-glucose meter [OneTouch Ultra2] 1 Disp #*1 Kit
Refills:*0
RX *insulin lispro [Humalog U-100 Insulin] 100 unit/mL AS DIR 10
Units before BKFT; 10 Units before LNCH; 10 Units before DINR;
Disp #*1 Vial Refills:*2
RX *lancets ___ Fastclix Lancet Drum] 4 times daily
Disp #*100 Each Refills:*2
RX *insulin degludec [Tresiba FlexTouch U-100] 100 unit/mL (3
mL) AS DIR 70 Units before BKFT Disp #*2 Syringe Refills:*2
3. Vitamin D 1000 UNIT PO DAILY
4. alfuzosin 10 mg oral DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. ClonazePAM 1 mg PO Q8H:PRN anxiety
8. Fluticasone Propionate NASAL 1 SPRY NU DAILY
9. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN
BREAKTHROUGH PAIN
10. Lisinopril 40 mg PO DAILY
11. Meclizine 25 mg PO Q12H:PRN vertigo
12. MetFORMIN (Glucophage) 500 mg PO BID
RX *metformin 500 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*2
13. Metoprolol Tartrate 100 mg PO TID
14. NIFEdipine (Extended Release) 30 mg PO DAILY
15. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
16. Nortriptyline 150 mg PO QHS
17. Omeprazole 20 mg PO DAILY
18. OxyCODONE SR (OxyconTIN) 20 mg PO TID
19. Pregabalin 100 mg PO TID
20. Ranexa (ranolazine) 500 mg oral BID
21. Ranitidine 150 mg PO BID
22. Sertraline 25 mg PO DAILY
23. Tizanidine 4 mg PO BID:PRN pain
24.Insulin syringes
1 cc with 6mm needle ___
Subcut injection up to 2 times daily
#150
Refill 2
25.Insulin pen needle
32G ___ 4mm nano
Use to inject insulin up to 5 times daily
#15.
Refills 2
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hypoglycemia (low blood sugar)
Hand lesion, defer to PCP regarding derm referral
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You have follow up appointment tomorrow and the day after, make
sure you keep them, in addition to your other appointments.
Watch your blood sugars closely and report to your primary care
doctor or diabetes doctor.
Follow up with psychiatry.
Followup Instructions:
___
|
10639651-DS-31
| 10,639,651 | 23,967,687 |
DS
| 31 |
2144-02-25 00:00:00
|
2144-02-26 18:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / amlodipine
Attending: ___.
Chief Complaint:
Hypotension ___ taking extra anti-hypertensives at home (BP
81/54)
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is a ___ old man with h/o CAD s/p CABG ___,
diastolic heart failure, HTN, HLD, CKD, OSA, and DM who was seen
prior to admission in ___ clinic and was referred to the ED for
hypotension w/ BP 81/54. Of note, his BPs the evening prior were
230s/90s so he took 1 extra carvedilol and 1 extra isosorbide.
Visit was initially made due to concern for gait instability.
2.5 weeks ago, patient fell and his wife caught him (she
suffered a compression fracture, he was not evaluated). He
states that one of his legs felt like it became paralyzed and
fell because of that. Did not feel like a cramp. Leg paralysis
sensation lasted for about half an hour. He states that the leg
paralysis was
associated with really bad pain. Self resolved after 30 minutes.
No weakness anymore.
Wife has been concerned that he is more unstable on his feet and
seems to be falling asleep unexpectedly at times. Had a phone
call with ___ resident on ___ where ___ was noted to have said
he feels completely fine and denied: headache, confusion, sob,
chest pain.
Had noticed some BRBPR over last two months. He states that it
is only there when he wipes too hard. And when he says blood on
the toilet paper, he means only a drop or a small steak of red
blood. No blood in the toilet bowl. No fevers.
In the ED,
- Initial vitals were: 98.5 85 102/62 18 96% RA
- Exam was notable for: obese, meandering answers, mild RUQ
tenderness, no edema
- Labs were notable for:
--wnl WBC H/H 11.1/33.3 Plt 122
--PTT 28.6 INR 1.2
--Na 136, K 6.2 (whole blood K 5.5), Cl 102, HCO3 20, BUN 30, Cr
2.3 (baseline 1.5-2)
--LFTS wnl, lipase wnl, BNP wnl, iron panel wnl
--U/A negative aside from glucose 300
- Studies were notable for:
--RUQUS: 1. Cirrhotic liver, without evidence of focal lesion,
splenomegaly or ascites. 2. Cholelithiasis without ultrasound
findings of cholecystitis. 3. The main portal vein is patent
with hepatopetal flow. There is no ascites.
--CT head: no evidence of intracranial bleed
--CXR: no consolidation
- No consults placed in the ED
- Patient was given:
___ 18:48 IVF LR 500 mL
___ 19:50 IV CefTRIAXone 2g
___ 20:38 IV Albumin 25% (12.5g / 50mL) 100 g
___ 22:24 IV Thiamine 200 mg
___ 22:24 PO/NG Atorvastatin 80 mg
___ 22:24 PO/NG Famotidine 20 mg
___ 00:40 PO/NG ClonazePAM .5 mg
___ 00:40 PO/NG OxyCODONE (Immediate Release) 5 mg
___ 00:40 PO/NG Acetaminophen 500 mg
Clinical course in the ED: on arrival, BP 102/62. Was given LR
and then also albumin for his ___ with his BPs steadily
improving to SBPs 130s. Although concern for polypharmacy
leading to falls, patient had significant pain and was given
reduced doses of home clonazepam 0.5, acetaminophen 500mg, and
oxycodone 5mg. Was also given CTX given h/o of BRBPR in a
cirrhotic.
On arrival to the floor, he states that he does not have a
seizure history. His leg pain went away with the dose of
oxycodone in the ED. He confirms the history above.
Past Medical History:
IDDM
PVD
___ CIRRHOSIS
CAD s/p 3v CABG (___)
HYPERTENSION
HLD
OSA on CPAP
GERD
ARTHRITIS (diffuse and severe, including chest and arms)
CHRONIC PAIN SYNDROME
Social History:
___
Family History:
Per OMR
Father had heart disease, died at ___. Mother died of a blood
clot in her neck.
1 sister = asthma
Physical ___:
ADMISSION PHYSICAL EXAM:
========================
VITALS: reviewed in ___
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: supple
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.
ABDOMEN: Normal bowels sounds, distended but not rigid, no
guarding, some mild tenderness to palpation in all quadrants
EXTREMITIES: 1+ pitting edema bilaterally.
SKIN: Warm. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation. No
asterixis.
DISCHARGE PHYSICAL EXAM:
========================
VITALS: 24 HR Data (last updated ___ @ 729)
Temp: 97.6 (Tm 98.3), BP: 173/84 (110-173/65-97), HR: 67
(62-84), RR: 18, O2 sat: 94% (92-95), O2 delivery: RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: Sclera anicteric and without injection. MMM.
NECK: supple
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.
ABDOMEN: Normal bowels sounds, mild distension, no guarding,
some mild tenderness to palpation in all quadrants. No rebound
tenderness.
EXTREMITIES: trace ___ edema bilaterally.
SKIN: Warm. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
Pertinent Results:
ADMISSION LABS:
===================
___ 04:55PM BLOOD WBC-6.7 RBC-4.01* Hgb-11.1* Hct-33.3*
MCV-83 MCH-27.7 MCHC-33.3 RDW-13.7 RDWSD-41.0 Plt ___
___ 04:55PM BLOOD ___ PTT-28.6 ___
___ 04:55PM BLOOD Plt ___
___ 04:55PM BLOOD Glucose-233* UreaN-30* Creat-2.3* Na-136
K-6.2* Cl-102 HCO3-20* AnGap-14
___ 04:55PM BLOOD ALT-13 AST-23 LD(LDH)-373* AlkPhos-49
TotBili-1.4
___ 04:55PM BLOOD TotProt-6.9 Albumin-4.3 Globuln-2.6
Calcium-9.1 Phos-3.1 Mg-1.5* Iron-71
___ 04:55PM BLOOD calTIBC-313 ___ Ferritn-156 TRF-241
___ 06:06PM BLOOD K-5.5*
INTERVAL LABS:
===============
___ 04:37AM BLOOD WBC-5.9 RBC-4.00* Hgb-11.1* Hct-32.4*
MCV-81* MCH-27.8 MCHC-34.3 RDW-13.2 RDWSD-38.7 Plt ___
___ 04:45AM BLOOD WBC-6.4 RBC-4.37* Hgb-12.2* Hct-35.6*
MCV-82 MCH-27.9 MCHC-34.3 RDW-13.2 RDWSD-38.7 Plt ___
___ 04:37AM BLOOD Glucose-121* UreaN-25* Creat-1.6* Na-141
K-5.5* Cl-105 HCO3-22 AnGap-14
___ 04:45AM BLOOD Glucose-177* UreaN-26* Creat-1.4* Na-136
K-5.3 Cl-101 HCO3-23 AnGap-12
___ 04:45AM BLOOD Calcium-9.8 Phos-2.8 Mg-2.2
DISCHARGE LABS:
===============
___ 04:42AM BLOOD WBC-7.3 RBC-4.68 Hgb-13.3* Hct-38.0*
MCV-81* MCH-28.4 MCHC-35.0 RDW-13.3 RDWSD-39.0 Plt ___
___ 04:42AM BLOOD Plt ___
___ 06:07AM BLOOD Glucose-202* UreaN-41* Creat-2.0* Na-137
K-4.8 Cl-99 HCO3-22 AnGap-16
___ 06:07AM BLOOD Calcium-10.0 Phos-3.9 Mg-1.8
REPORTS
=======
CT HEAD W/O CONTRAST Study Date of ___
There is no evidence of acute intracranial
infarction,hemorrhage,edema,or mass effect. There is prominence
of the ventricles and sulci suggestive of involutional changes.
There is no evidence of acute fracture. The visualized portion
of the
paranasal sinuses, mastoid air cells, and middle ear cavities
are clear.
Patient is status post bilateral cataract surgery. Focal soft
tissue
thickening along the subcutaneous tissues posterior to the
occiput, just to the right of midline has been present on
multiple prior studies, dating back to at least ___, and may relate to a sebaceous cyst or relate to prior
trauma/hematoma.
CHEST (PA & LAT) Study Date of ___
Patient is status post median sternotomy. The cardiac and
mediastinal
silhouettes are stable. No focal consolidation is seen. There
is no large pleural effusion or pneumothorax.
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___
1. Cirrhotic liver, without evidence of focal lesion,
splenomegaly or ascites.
2. Cholelithiasis without ultrasound findings of acute
cholecystitis.
3. Mild splenomegaly.
RENAL U.S. Study Date of ___
1. Normal kidney and bladder ultrasound.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
======================
Mr. ___ is a ___ old man with h/o CAD s/p CABG ___,
diastolic heart failure, HTN, HLD, CKD, OSA, NASH cirrhosis, and
DM who was seen prior to admission in his ___ clinic and was
referred to the ED for hypotension with BP 81/54. We held his
home anti-hypertensives and after receiving IVF and albumin in
the ED, his SBPs were in the 120s-130s. On HD #2, his SBPs were
fluctuating between the 110s to 170s. During his time in the
hospital, we continued his carvedilol and isosorbide, holding
his lisinopril iso ___ with Cr on admission of 2.3 and his
nifedipine given CC of hypotension. After finding him to be
orthostatic on testing, we decided to eventually d/c the
isosorbide and restart nifedipine. Lisinopril continues to be
held iso of ___, pending outpatient Cr lab check. Initially, the
___ was thought to ___ on CKD with a prerenal process as the
Cr responded to IVF. Uptrending Cr prior to d/c was concerning
for a mixed pre-renal and intra-renal process, ATN most likely
given his labile bps and hypotension on arrival to ED. Patient
also saw diabetes nurse educator for his insulin dependent
diabetes.
PROBLEM BASED SUMMARY:
======================
#Hypotensive episode with alternating
#Hypertension
Patient presented with SBP to the ___ at outpatient PCP
___. This was likely in setting of taking extra doses of
his carvedilol and isosorbide mononitrate for a BP reading in
the 200s at home, in addition to likely low intravascular volume
and potentially exacerbated by pain medication regimen. Blood
pressures had improved to SBP 100s on arrival to ED. Received
volume resuscitation with improvement of SBPs to the 130s. No
signs of elevated white count/systemic infection, acute cardiac
ischemia, or massive blood loss, which leads us to consider
polypharmacy and hypovolemia as the primary ddx for his
hypotension. Patient had labile BPs ranging from 110s-170s
systolic in the setting of de-escalating some of his
antihypertensives. Patient was ultimately continued on his home
carvedilol and nifedipine (reduced dose) after discontinuing his
lisinopril iso ___ and his isosorbide iso orthostasis.
Patient educated on warning signs of high and low blood
pressure. Regularly checks his own blood pressure at home.
# ___ on CKD
Patient has a history of CKD stage 3 with baseline Cr between
1.5-2. On presentation had ___ consistent with prerenal
process as Cr responded to IVF in the ED. Possible contribution
from an intrarenal process (?resolving ATN) iso labile BPs plus
hypotension on arrival to ED. Given that patient had good PO
intake at time of discharge, with good UOP, he will follow up as
an outpatient to recheck labs early next week. We held his
lisinopril until these labs return. We will also encourage the
avoidance of nephrotoxic drugs at the time being.
#Polypharmacy
#Concern for Memory impairment
The patient endorsed a long history of memory problems. Has
been evaluated in the past by OT for this, which demonstrated
mild deficits. In combination with the current concern for
polypharmacy, memory related abilities may impede his ability
to safely administer his own medications. SW touched base with
elder services who do not seem to have acute concerns for him
at this time, they will continue to follow. He will continue
with ___ services at home. Potential benefit from blister packs
in the future as able.
#Diabetes Mellitus
Patient stated that he takes tresiba 100u qhs if he eats meals.
He stated that he takes 25u Humalog with each meal when he does
eat. He had been on ISS while inpatient and requiring much lower
daily doses than he endorses at home. It is unclear if he fully
understands how to titrate his doses with meals. There was
additional concern from his outpatient provider about dangerous
fluctuations in his home blood glucose levels. ___ educator
provided teaching to the patient. Will be discharged on the
regimen of Tresiba 21 units with dinner, and Humalog 7 units
with breakfast, lunch, and dinner, and insulin sliding scale
starting at 2 units for BG 150, increasing by 1 unit for every
50 increase in BG. Home metformin was held iso ___.
#Gait instability
#Falls
#Home safety
Per admission history, patient and patient's wife concerned with
recent episode of falling/frequent somnolence. Per the chart,
he's had a prior admission in ___ for the same gait
instability, which at the time was thought to be the result of
polypharmacy. Neurologic, hepatologic, and metabolic processes
were considered as potential ddx contributing to the falls but
have been ruled out/are less likely in his case. Gait
instability and fall history could be ___ poorly controlled HTN
and poor medication adherence/self-dosing. Most likely having
somnolence with the falls from a combination of his OSA coupled
with frequent use of multiple sedating drugs and
HTN/orthostasis. There have been concerns regarding his home
safety, including the ability of his wife to act as a primary
caregiver. The patient is followed closely by ___
___, who will follow him on discharge.
Patient was ambulating fine throughout the hospital course and
___ did not feel that he had any need for ___. We resumed
neuropathic medications including pregabalin and nortryptiline.
We continued his home oxycontin. Held tizanidine and vicodin.
His antihypertensive regimen was modified as above. We recommend
further med consolidation with PCP, with consideration of
blister packing for standing medications so as to minimize
further confusion.
#BRBPR c/w hemorrhoids
#Cirrhosis
The patient was last seen by Dr. ___ ___, has history of
cirrhosis secondary to NASH. Has been LTFU since then. Hepatitis
viral panel on ___ without hepatitis B or A antibodies and
no documentation of receiving vaccinations. Last EGD was in ___
without evidence of varices. Had colonoscopy in ___ without any
mention of hemorrhoids seen but did have a single polyp removed.
Initially, there was concern in ED that the patient had BRBPR
and that this may be contributing to his hypotension on arrival.
Further history was obtained, revealed that patient has not had
frank blood in toilet, only on toilet paper. History of blood on
toilet paper is minimal (drop of blood or a small streak).
Rectal examination was without obvious hemorrhoid or anal
fissure but likely etiology is one of the two. Patient was
observed and was hemodynamically stable after hypotension
resuscitation as above. No ongoing concern for bleeding. The
patient should be immunized for hepatitis, however, and
reestablish care with hepatology.
#Hyperkalemia, resolved
On presentation, whole blood 5.5 without peaked T waves in the
ED. Likely secondary to ___. No insulin or calcium gluconate
given at the time in ED. K 5.5 when rechecked on the floor at
time of admission. Patient was given bolus of IVF, insulin, and
calcium gluconate on the floor. Continued to monitor the
patient's electrolytes. Did not require any further
intervention.
#Thrombocytopenia
#Anemia
#Coagulopathy
Hgb was 11.1 on admission, baseline in past year appears to
fluctuate between ___. Platelet count on admission was low at
122 but appeared to also be at his baseline. Also has
coagulopathy with INR 1.2, also at baseline. This is likely
consistent with his underlying cirrhosis +/- CKD. Trended this
daily, no acute intervention necessary while inpatient. He was
on ppx SQH.
#CAD
History of 3v disease. Previously treated at ___. Modified
anti-hypertensive medications as above. Continued home aspirin
and statin.
#Heart failure with preserved ejection fraction
Not on home diuretics, stress echo earlier in year with normal
EF. Continued aspirin, atorvastatin, carvedilol. Discontinued
lisinopril iso ___.
#Morbid obesity with OSA
Continued CPAP
#Hyperlipidemia
Continued home atorvastatin.
#GERD
Continued home omeprazole and famotidine.
#Anxiety/paranoia
Continued home nortriptyline.
#BPH
Continued on Tamsulosin as home alfusozin not on formulary.
Restarted alfusozin at discharge.
TRANSITIONAL ISSUES:
====================
# CODE: presumed full
# CONTACT: Name of health care proxy: ___
Relationship: wife
Phone number: ___
[ ] F/U appointments: PCP
[ ] F/U labs: Labs on ___ with ___ for recheck of electrolytes
and creatinine
[ ] Held Medications:
HYDROcodone-Acetaminophen (5mg-325mg)
Isosorbide Dinitrate 10 mg PO TID due to orthostatic
hypotension
Lisinopril 20mg due to acute kidney injury (ATN)
Meclizine 25mg BID due to interaction with other medications
Tizanidine 2mg TID due to interaction with other medications
[ ] Changed Medications: Nifedipine ER 30mg
[ ] Will require close monitoring of insulin regimen
[ ] Consider blister packing meds after ___ sees him; need to
get rid of old meds
[ ] Will need hepatitis A and B vaccinations
[ ] Will need to re-establish care with hepatology
[ ] Consider discontinuation of concurrent opioid and
benzodiazepine use
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Famotidine 20 mg PO BID
2. Vitamin D 1000 UNIT PO DAILY
3. Sertraline 25 mg PO DAILY
4. Meclizine 25 mg PO BID:PRN dizziness
5. Nortriptyline 150 mg PO QHS
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. ClonazePAM 1 mg PO Q8H:PRN anxiety
9. Fluticasone Propionate NASAL 1 SPRY NU DAILY
10. Lisinopril 20 mg PO DAILY
11. Miconazole Powder 2% 1 Appl TP TID:PRN rash
12. NIFEdipine (Extended Release) 90 mg PO DAILY
13. Omeprazole 20 mg PO DAILY
14. OxyCODONE SR (OxyconTIN) 20 mg PO TID
15. Pregabalin 100 mg PO TID
16. Tizanidine 2 mg PO TID:PRN pain
17. CARVedilol 25 mg PO BID
18. alfuzosin 10 mg oral DAILY
19. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN
BREAKTHROUGH PAIN
20. MetFORMIN (Glucophage) 500 mg PO BID
21. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
22. Isosorbide Dinitrate 10 mg PO TID
23. Humalog 25 Units Breakfast
Humalog 25 Units Lunch
Humalog 25 Units Dinner
Tresiba 100 Units BedtimeMax Dose Override Reason: home regimen
24. Ranolazine ER 500 mg PO BID
Discharge Medications:
1. Humalog 7 Units Breakfast
Humalog 7 Units Lunch
Humalog 7 Units Dinner
Tresiba 21 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
2. NIFEdipine (Extended Release) 30 mg PO DAILY
RX *nifedipine 30 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. alfuzosin 10 mg oral DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. CARVedilol 25 mg PO BID
7. ClonazePAM 1 mg PO Q8H:PRN anxiety
8. Famotidine 20 mg PO BID
9. Fluticasone Propionate NASAL 1 SPRY NU DAILY
10. Miconazole Powder 2% 1 Appl TP TID:PRN rash
11. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
12. Nortriptyline 150 mg PO QHS
13. Omeprazole 20 mg PO DAILY
14. OxyCODONE SR (OxyCONTIN) 20 mg PO TID
15. Pregabalin 100 mg PO TID
16. Ranolazine ER 500 mg PO BID
17. Sertraline 25 mg PO DAILY
18. Vitamin D 1000 UNIT PO DAILY
19. HELD- Lisinopril 20 mg PO DAILY This medication was held.
Do not restart Lisinopril until you have your labs re-checked
and talk to your primary care
20. HELD- MetFORMIN (Glucophage) 500 mg PO BID This medication
was held. Do not restart MetFORMIN (Glucophage) until instructed
by your doctor.
21.Outpatient Lab Work
N17.9
Please obtain BMP, fax to ___ ATTN: Dr. ___
___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Hypotension
Hypertension
Polypharmacy
Acute kidney injury on chronic kidney disease
Insulin Dependent Diabetes
Secondary Diagnosis:
Peripheral vascular disease
___ Cirrhosis
CAD s/p 3v CABG (___)
Hyperlipidemia
OSA on CPAP
GERD
Arthritis (diffuse and severe, including chest and arms)
Chronic Pain Syndrome
Discharge Condition:
Mental Status: Confused - sometimes.
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 were admitted to the hospital because you had very low
blood pressure when you were at your doctor's office.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- While you were in the hospital we gave you fluids and gave you
a short break from your blood pressure medications until we saw
your blood pressure rise back to your baseline.
- We worked on improving your medication list, so you had to
take less medication for your blood pressure.
- We had the diabetes educator see you and teach you more about
your insulin.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please continue to take all your medications as listed in this
packet and follow up with your doctors at your ___
appointments.
- It is extremely dangerous to take you pain, blood pressure,
and diabetes medications other than how they are currently
prescribed.
- We will have the ___ services check your lab work next week to
make sure your kidneys are doing ok after you leave.
- Please weigh yourself every morning, call your doctor if
weight goes up more than 3 lbs.
We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10639651-DS-32
| 10,639,651 | 26,866,936 |
DS
| 32 |
2144-04-04 00:00:00
|
2144-04-04 21:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / amlodipine
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old man with obesity, ___,
OSA, CKD, DM, HTN, ___ cirrhosis, GERD and ?esophageal
spasm/dysmotility, depression, and chronic pain, who presented
to
the ED with chest pain, abdominal pain, and upper leg pain. Of
note he had presented to the ED 2 days prior with chest pain
that
improved with belching, at which time he was evaluated by
cardiology and felt to be unlikely to have a cardiac cause of
his
pain. He was discharged home but returned today with ongoing
chest pain, as well as complaints of abdominal pain and upper
leg
pain. I obtained history from the patient and also from his
wife.
The patient reports a variety of symptoms with different
chronicities. He reports that many years ago he was diagnosed
with an esophageal motility disorder (the possibility of
esophageal spasm is mentioned in prior OMR notes, and esophagram
in ___ raised concern for dysmotility), and has a long standing
history of choking and throat clearing. The patient states that
he currently feels that food gets down ok, as long as he drinks
water afterwards. However he does feel that he is having more
choking sensation, mostly unrelated to when he eats food, and
that he is bringing up more phlegm. He also sometimes reports an
acid taste. The choking sensation feels like it is in the
throat.
He wonders if it is due to GERD, although he is surprised since
it is worse than his GERD symptoms have been before. He also
states that in recent weeks he has had associated dyspnea. He
denies any component of orthopnea, and in fact states he is
generally more comfortable lying flat due to pain. He states
that
he has abdominal pain, which is chronic and unchanged. He also
endorses midline sternal chest pain, which he states has been
occurring for many years but has been more persistent in recent
weeks. He notes a "raspy" voice in recent weeks. He denies any
significant aggravating or alleviating factors for any of these
symptoms, except that occasionally he has some improvement in
his
chest pain with large volume eructation. He also notes that he
has fibromyalgia and chronic pain of his legs, for which he
takes
lyrica and oxycodone. He notes that he used to also take vicodin
but that his PCP stopped it and he does not understand why. He
endorses chronic rashes that are overall unchanged and pain in
both feet in recent months. He denies fevers, dysuria, or
diarrhea. He denies a history of lung disease, but notes he
smoked for ___ years and has wondered if this would "catch up" to
him.
When I spoke with his wife she states that most of the symptoms
he reports are chronic for years. She states that he was
confused
last night and that she called ___. She states that he is
intermittently confused. Last night she states he was having
trouble getting out of the bathroom, and then saying things
about
___ and the Nazis and that he told her to call the police
because of paranoid thoughts he was having. When I asked the
patient about the confusion, he states that she was the one who
was confused. He states they had been watching a movie and he
was
making a joke related to the movie that she misunderstood. He
notes that they have had an adult protective services inquiry,
although did not state more about the circumstances. His wife
wondered if this was because she was unable to take care of him
at this point.
In the ED, his was afebrile with HRs ___ and BP
120s-160s/50s-70s. RR ___. He was initially 96 % on RA but was
apparently put on ___ L O2 for a sat of 91% on room air partway
through his ED course. His labs showed a leukocytosis (12.5)
which was new and mild thrombocytopenia. ProBNP was 232, Tbili
1.8 (new), Mg 1.5, Phos 2.3, with mild hyponatremia of 134 and
~baseline creatinine of 1.7. Trop negative, lactate normal, and
UA with trace protein. He underwent a CTA without evidence of
PE,
and underwent a RUQUs, which was a limited study but showed
evidence of cirrhotic liver without focal lesion or ascites,
splenomegaly, and cholelithiasis without evidence of
cholecystitis or biliary dilation
ROS: As per HPI, and 10 point ROS completed and otherwise
negative.
Past Medical History:
- morbid obesity
- CAD s/p CABG ___ ((LIMA-proximal LAD, SVG-distal LAD,
SVG-PDA)
known atresia of the ___ LAD, patent SVG to mid LAD, and
patent SVG>PDA,
- OSA on nocturnal PPV
- CKD
- IDDM
- chronic pain
- GERD
- ?esophageal spasm/dysmotility
- ___ cirrhosis
- depression
Social History:
___
Family History:
father heart disease
Physical Exam:
Admission Exam:
=================
98.5 PO 113 / 66 87 18 95 RA
GENERAL: Alert and in no apparent distress; intermittently
coughing and clearing throat
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
MMMs, difficult to visualize OP well
CV: Heart regular, LUSB soft systolic murmur
Chest wall: reproducible chest pain with palpation of
mid-sternum
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 CVA/suprapubic tenderness
MSK: No swollen or erythematous joints
SKIN: scattered areas of scaling and hyperkeratotic areas; R ___
toe with distal ulcer, appears to be well-healing without
erythema or discharge
EXTR: wwp, minimal edema
NEURO: Alert, interactive, oriented to time, date, and able to
___ backwards fluently, face symmetric, gaze conjugate with
EOMI, speech fluent, motor function grossly intact/symmetric
PSYCH: pleasant, appropriate affect
Discharge exam:
================
97.6 PO 106 / 58 64 18 96 Ra
General: Somewhat disheveled but comfortable
HEENT: Anicteric, eyes conjugate, MMM, poor dentition, no JVD
Cardiovascular: RRR no MRG, nl. S1 and S2
Pulmonary: Lung fields clear to auscultation throughout
Gastroinestinal: obese, soft, non-tender, non-distended, bowel
sounds present, no HSM
MSK: trace pitting edema to mid-calf bilaterally
Skin: RIght great toe with well circumscribed ulcer without e/o
infection
Neurological: Alert, interactive, speech fluent, face symmetric,
moving all extremities
Psychiatric: pleasant, odd affect, perseverative
Pertinent Results:
Admission Labs:
=================
___ 03:57AM BLOOD WBC-12.5* RBC-4.24* Hgb-11.8* Hct-34.7*
MCV-82 MCH-27.8 MCHC-34.0 RDW-13.3 RDWSD-39.1 Plt ___
___ 03:57AM BLOOD Neuts-84.6* Lymphs-7.3* Monos-6.3 Eos-1.1
Baso-0.2 Im ___ AbsNeut-10.56* AbsLymp-0.91* AbsMono-0.79
AbsEos-0.14 AbsBaso-0.03
___ 05:40AM BLOOD ___
___ 03:57AM BLOOD Glucose-161* UreaN-27* Creat-1.7* Na-134*
K-5.1 Cl-102 HCO3-20* AnGap-12
___ 03:57AM BLOOD ALT-12 AST-27 AlkPhos-59 TotBili-1.8*
DirBili-<0.2
___ 03:57AM BLOOD proBNP-232*
___ 03:57AM BLOOD cTropnT-<0.01
___ 03:57AM BLOOD Albumin-3.9 Calcium-9.3 Phos-2.3* Mg-1.5*
___ 04:03AM BLOOD Lactate-1.7
___ 05:40AM BLOOD Hapto-84
Discharge Labs:
================
___ 05:45AM BLOOD WBC-8.1 RBC-4.63 Hgb-12.8* Hct-37.8*
MCV-82 MCH-27.6 MCHC-33.9 RDW-13.4 RDWSD-39.2 Plt ___
___ 05:45AM BLOOD Glucose-166* UreaN-20 Creat-1.4* Na-139
K-4.2 Cl-99 HCO3-24 AnGap-16
___ 05:45AM BLOOD ALT-11 AST-19 AlkPhos-62 TotBili-1.0
___ 05:45AM BLOOD Calcium-9.6 Phos-4.0 Mg-2.0
Imaging:
==========
CTA chest ___: No evidence of pulmonary embolism or aortic
abnormality.
Stable nodular liver contour, consistent with cirrhosis,
cholelithiasis and prominent porta hepatis lymph nodes
Liver/Gallbladder US ___:
1. Study was limited by poor penetration and bowel gas. Within
the limits of the study:
2. Cirrhotic liver without evidence of focal lesion or ascites.
Persistent splenomegaly.
3. Cholelithiasis without sonographic evidence of acute
cholecystitis. No
biliary ductal dilatation.
Barium swallow ___:
1. Mild-moderate esophageal dysmotility.
2. Mild gastroesophageal reflux.
3. Small hiatal hernia.
Brief Hospital Course:
___ is a ___ year old man with obesity, ___,
OSA, CKD, DM, HTN, NASH cirrhosis, GERD and ?esophageal
spasm/dysmotility, depression, and chronic pain, who presented
to the ED with multiple symptoms of varying chronicities
including chest pain and confusion, found to have leukocytosis
and new indirect hyperbilirubinemia.
#Chest pain/burning
#Regurgitation
Patient reports that he has been having worsening chest pain,
burning sensation and regurgitation for some time which I
suspect is driver of his ED visit on ___. Reported history of
esophageal dysmotility not previously treated. Based on
description of symptoms, most likely due to GI symptoms. He
underwent barium swallow which showed mild GERD and
mild-moderate esophageal dysmotility with small hiatal hernia.
He was referred to GI as outpatient for ongoing work-up and
counseled on precautions for GERD and dysmotility including
eating slowly and remaining upright post-meals. He was continued
on home PPI and H2 blocker.
#Leukocytosis: No clear signs of infection on admission.
Improved with fluids.
#?Encephalopathy
His wife reports he was confused the night of admission and
intermittently confused at baseline. ___ be component of
underlying cognitive dysfunction vs issues with medication
adherence and polypharmacy. Mental status at baseline throughout
hospitalization. Home ___ reinitiated on d/c for medication
reconciliation and help with medications. ___ benefit from
outpatient neurocognitive testing.
#Hypoglycemia
#Type II diabetes:
Patient very unclear on his home insulin regimen, initially
reporting taking Tresiba up to 100u BID but later stating more
like 70u daily. He was started on dose reduced insulin however
developed severe hypoglycemia on ___ likely in setting of being
made NPO for barium swallow after receiving significant AM
glargine and standing mealtime insulin without eating breakfast.
On further exploration of his insulin regimen, he takes his
insulin very unconventionally including post-meals and somewhat
randomly. I counseled him on taking Humalog immediately prior to
meals and taking Tresiba once daily at night for now. He was
advised to resume home regimen with once daily Tresiba and HISS
which has been working for him as outpatient with rare lows per
patient. Would benefit from ongoing insulin teaching in the
outpatient setting.
#NASH Cirrhosis
#Hyperbilirubinemia: He had bilirubin elevation on admission
with indirect redominance. Hemolysis labs negative. ___ be due
to cirrhosis though no e/o decompensation on exam or other labs.
Improved without intervention. RUQ US unremarkable.
#R first toe wound: Followed by podiatry. Does not appear
infected. Continued dry sterile dressing
#CKD
Appears close to recent baseline
- trend
#Thrombotycopenia: Appeared close to baseline likely related to
liver disease.
#BPH: Tamsulosin given for alfuzosin per formulary.
#Depression/insomnia/pain/anxiety: Continued home sertraline,
lyrica, oxycodone, nortriptyline, clonazepam
#CAD, HTN: Continued carvedilol, nifedipine, ASA, atorvastatin
#OSA: Continued CPAP.
Transitional Issues:
====================
[ ]Please ensure neurology f/u rescheduled
[ ]Patient to follow-up with GI for esophageal dysmotility
[ ]Please consider orthopedic referral for sensation of knee
locking causing falls at home
[ ]He would benefit from ongoing teaching around insulin use and
GERD management
[ ___ benefit from outpatient neurocognitive testing.
[x]>30 minutes spent on discharge planning and care coordination
on day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. alfuzosin 10 mg oral DAILY
2. Atorvastatin 80 mg PO QPM
3. CARVedilol 25 mg PO BID
4. ClonazePAM 1 mg PO TID
5. desoximetasone 0.25 % topical BID:PRN rash
6. Famotidine 20 mg PO BID
7. Fexofenadine 180 mg PO DAILY:PRN allergies
8. imiquimod 5 % topical DAILY:PRN toe rash
9. Tresiba FlexTouch U-200 (insulin degludec) 200 unit/mL (3 mL)
subcutaneous DINNER
10. HumaLOG U-100 Insulin (insulin lispro) 100 unit/mL
subcutaneous QIDACHS
11. Naloxone Nasal Spray 4 mg IH ONCE MR1
12. NIFEdipine (Extended Release) 90 mg PO DAILY
13. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
14. Nortriptyline 100 mg PO QHS
15. Nortriptyline 50 mg PO QHS:PRN takes several hours after
first dose, just before bed
16. nystatin 100,000 unit/gram topical BID groin
17. OxyCODONE SR (OxyCONTIN) 20 mg PO Q8H
18. Pregabalin 100 mg PO TID
19. Sertraline 25 mg PO DAILY
20. Acetaminophen 650 mg PO BID:PRN Pain - Mild/Fever
21. Aspirin 81 mg PO DAILY
22. Vitamin D 1000 UNIT PO DAILY
23. Omeprazole 20 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO BID:PRN Pain - Mild/Fever
2. alfuzosin 10 mg oral DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. CARVedilol 25 mg PO BID
6. ClonazePAM 1 mg PO TID
7. desoximetasone 0.25 % topical BID:PRN rash
8. Famotidine 20 mg PO BID
9. Fexofenadine 180 mg PO DAILY:PRN allergies
10. HumaLOG U-100 Insulin (insulin lispro) 100 unit/mL
subcutaneous QIDACHS
11. imiquimod 5 % topical DAILY:PRN toe rash
12. Naloxone Nasal Spray 4 mg IH ONCE MR1
13. NIFEdipine (Extended Release) 90 mg PO DAILY
14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
15. Nortriptyline 50 mg PO QHS:PRN takes several hours after
first dose, just before bed
16. Nortriptyline 100 mg PO QHS
17. nystatin 100,000 unit/gram topical BID groin
18. Omeprazole 20 mg PO BID
19. OxyCODONE SR (OxyCONTIN) 20 mg PO Q8H
20. Pregabalin 100 mg PO TID
21. Sertraline 25 mg PO DAILY
22. Tresiba FlexTouch U-200 (insulin degludec) 200 unit/mL (3
mL) subcutaneous DINNER
Please take as you were previously at home
23. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Esophageal dysmotility
GERD
Altered mental status
Hypoglycemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with difficulty moving and
intermittent chest discomfort.
You underwent a barium swallow which showed mild-to-moderate
esophageal dysmotility, mild reflux and a small hiatal hernia as
we discussed. Your chest pain and burning is likely due to
reflux and eating too quickly. It is VERY important that you eat
your meals slowly and that you try to stay upright (sitting or
standing) after meals for at least 2 hours. We have arranged
follow-up for you with gastroenterology for ongoing work-up of
your symptomatic esophageal dysmotility.
While you were here, you had low blood sugars which were likely
due to getting more insulin than you normally take at home.
Please resume your home insulin regimen on discharge. Please
notify your PCP if you develop more than 1 sugar that is less
than 70.
Please talk to you doctor about following up with orthopedics
for your sensation of knee locking.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
It was a pleasure taking care of you,
Your ___ Care Team
Followup Instructions:
___
|
10639820-DS-15
| 10,639,820 | 24,237,197 |
DS
| 15 |
2181-08-19 00:00:00
|
2181-08-19 22:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Stevia
Attending: ___.
Major Surgical or Invasive Procedure:
___: arterial line placement
attach
Pertinent Results:
ADMISSION LABS:
==================
___ 08:25PM BLOOD WBC-35.5* RBC-3.00* Hgb-9.6* Hct-32.6*
MCV-109* MCH-32.0 MCHC-29.4* RDW-16.0* RDWSD-64.9* Plt ___
___ 08:25PM BLOOD ___ PTT-45.2* ___
___ 01:00AM BLOOD ___ 04:56AM BLOOD Ret Aut-1.8 Abs Ret-0.05
___ 08:25PM BLOOD Glucose-259* UreaN-111* Creat-4.0* Na-138
K-5.7* Cl-112* HCO3-6* AnGap-20*
___ 08:25PM BLOOD ALT-18 AST-29 AlkPhos-75 TotBili-<0.2
___ 06:45AM BLOOD Lipase-450*
___ 08:25PM BLOOD cTropnT-0.15*
___ 01:00AM BLOOD CK-MB-20* cTropnT-0.16*
___ 01:00AM BLOOD Calcium-8.5 Phos-4.9* Mg-1.7
___ 04:56AM BLOOD calTIBC-212* Ferritn-1422* TRF-163*
___ 04:40AM BLOOD Hapto-102
___ 01:00AM BLOOD Osmolal-337*
___ 02:25AM BLOOD TSH-0.69
___ 02:25AM BLOOD Free T4-1.1
___ 06:45AM BLOOD Vanco-14.6
___ 08:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 08:37PM BLOOD ___ pO2-74* pCO2-45 pH-6.89*
calTCO2-10* Base XS--26
___ 08:37PM BLOOD Lactate-3.1* K-5.2
___ 10:04PM BLOOD Lactate-3.3*
___ 11:44PM BLOOD Lactate-4.6*
___ 01:06AM BLOOD Lactate-4.5* K-4.0
___ 02:19AM BLOOD Lactate-3.9*
___ 05:08AM BLOOD Lactate-2.3*
___ 08:34AM BLOOD Lactate-1.4
MICRO:
================
___ 8:25 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:25 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
ESCHERICHIA COLI. >100,000 CFU/mL SECOND MORPHOLOGY.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R =>32 R
AMPICILLIN/SULBACTAM-- 16 I 16 I
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 32 S <=16 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R =>16 R
___ 2:00 am BLOOD CULTURE Source: Line-A line.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 1:23 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Pending):
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 O157:H7 found.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
___ 1:05 pm STOOL CONSISTENCY: FORMED Source:
Stool.
OVA + PARASITES (Pending):
___ 11:19 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 7:00 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 12:37 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
IMAGING:
================
CXR ___:
IMPRESSION:
1. Standard positioning of the endotracheal and enteric tubes.
2. Bibasilar airspace opacities may reflect atelectasis, with
aspiration or pneumonia not excluded.
CT Head ___:
IMPRESSION:
The study is limited by motion artifact and incomplete image
acquisition.
Within these confines, there is no evidence of acute
intracranial abnormality including hemorrhage or large
territorial infarct. Bilateral occipital infarcts likely
chronic unchanged from previous CT of ___.
TTE ___:
IMPRESSION: Suboptimal image quality. Normal left ventricular
wall thickness and biventricular cavity sizes and
regional/global biventricular systolic function. Rheumatic
appearing mitral valve though not classic appearance;.
Differential also includes valve thickening from rheumatologic
disease such as lupus. Imaging also could be consistent with
marantic endocarditis. There is associated mild mitral stenosis.
CT CHEST ___:
IMPRESSION:
Anterior third left rib and mid sternal fractures.
Asymmetric tracheal wall thickening protruding into the lumen
could correspond to secretions or to a tracheal neoplasm,
three-month follow-up after clear expectoration is recommended
to exclude this possibility.
No evidence of pneumonia.
CT A/P ___:
IMPRESSION:
1. Interval development of findings suggestive of focal
inflammatory changes involving the pancreatic head/uncinate
process and pancreaticoduodenal groove and trace abdominopelvic
free fluid. Given the history of trauma related to chest
compressions during resuscitation, between CT scans, the likely
etiology is posttraumatic. If further evaluation of the
pancreatic integrity is warranted, noncontrast MRCP can be
performed.
2. There is no sign of hematoma or hemorrhage to explain the
patient's anemia.
3. Stable appearance of the age-indeterminate L3 compression
fracture.
4. Although the urinary bladder is decompressed with a Foley
catheter, the
bladder wall appears thickened.
5. Interval placement of left femoral arterial line terminating
in the
external iliac artery. Stable placement of the right femoral
central venous catheter and interval placement of rectal
temperature probe.
6. Diffuse mild anasarca.
CXR ___:
IMPRESSION:
In comparison with the study of ___, the endotracheal
and nasogastric tubes have been removed. Cardiomediastinal
silhouette is stable. No evidence of vascular congestion or
pleural effusion or acute focal pneumonia. Atelectatic changes
are seen at both bases, especially on the left.
Art Dup Ext ___:
Impression patent left lower extremity arteries without evidence
of stenosis. Incidentally noted calf DVT in the left posterior
tibial vein. Clinical correlation is warranted
CXR ___:
IMPRESSION:
In comparison with the study of ___, the
cardiomediastinal silhouette is stable. There is increased
engorgement of poorly defined pulmonary vessels consistent with
elevated pulmonary venous pressure. Developing areas of
opacification at both bases could merely reflect atelectatic
changes with pleural effusion. However, in the appropriate
clinical setting, multifocal aspiration/pneumonia would have to
be seriously considered.
DISCHARGE LABS:
====================
___ 07:16AM BLOOD WBC-21.4* RBC-3.03* Hgb-9.4* Hct-29.8*
MCV-98 MCH-31.0 MCHC-31.5* RDW-18.7* RDWSD-65.3* Plt ___
___ 07:16AM BLOOD Plt ___
___ 07:16AM BLOOD Glucose-65* UreaN-28* Creat-0.7 Na-140
K-3.8 Cl-105 HCO3-20* AnGap-15
___ 07:16AM BLOOD Calcium-8.3* Phos-2.4* Mg-1.6
Brief Hospital Course:
TRANSITIONAL ISSUES:
======================
[] Medications STARTED: Levofloxacin 750mg PO daily for 4 doses,
apixaban 5mg PO BID
[] Medications HELD: lisinopril 20mg daily, mycophenolate
mofetil 1000mg PO BID
[] Medications STOPPED: Warfarin
[] PCP:
- ___ CBC and CMP/extended electrolytes at follow-up
appointment. WBC on discharge 21.4, H/H 9.4/29.8.
- Patient found to have asymmetrical trachea wall thickening
protruding into the lumen on CT Chest. Although this may be
related to secretions, recommend repeat CT chest in 3 months to
assess for resolution and to rule out tracheal neoplasm.
- Recommend repeat TTE and consider repeat TEE to evaluate for
lupus-associated valvular disease vs. possible marantic
endocarditis as there was concern for possible SLE-associated
disease on TTE completed as inpatient.
- Consider outpatient CT A/P vs MRCP to evaluate intraductal v.
intraparenchymal pancreatic lacerations in setting of traumatic
?pancreatitis.
- Consider outpatient neurology follow-up for additional
titration of her home neuro meds.
- Please restart MMF after completion of her levofloxacin
(___)
- Patient noted to have L3 compression fracture of unclear
chronicity. Patient did not complain of pain from fracture
during hospitalization so we believe this problem is chronic.
Discharge Hb: 9.4
Discharge Cr: 0.7
#CODE STATUS: Full code (confirmed)
#CONTACT: HCP/Mother - ___ - ___
SUMMARY
==========
___ woman with a h/o SLE, stroke on Coumadin, seizure disorder on
VPA, and baseline cognitive decline who presented as a transfer
from an outside hospital s/p PEA arrest in the setting of
urosepsis. In the ICU at ___, she was found to be hypotensive
requiring pressors and intubation. Her course was further c/b
delirium, pan-sensitive E. coli bacteremia, DVT in left lower
extremity for which her coumadin was transitioned to apixaban,
concern for marantic endocarditis, sepsis due to presumed
hospital acquired pneumonia and acute kidney injury. She was
discharged back to her long term care facility with close
primary care follow-up.
ACUTE ISSUES
=======================
#PEA Arrest
Patient had PEA arrest x 5 minutes at OSH in the setting of
septic shock likely ___ urinary source. Patient was intubated
and sedated following ROSC. At the outside hospital, she had a R
femoral triple lumen CVL and an OGT placed in addition to an ET
tube. She had an arterial line placed in the ___ emergency
department. On transfer to ICU, she showed signs of neurological
activity; so while she initially underwent targeted temperature
management after arrest, it was discontinued on ___. She was
extubated on ___ after following commands and did not require
subsequent intubation.
# Septic Shock due to urinary tract infection
# Severe Sepsis due to presumed hospital acquired pneumonia
Patient arrived to OSH with c/o fevers, chills, hypotension,
requiring 4 pressors after inadequate response to fluids. Her
urine grew E. coli. She had been started on vanc/zosyn at the
OSH, switched to vanc/ceftaz on arrival to the ICU. She was
started on levophed as well as stress dose steroids (she was on
prednisone chronically), but she was weaned off her pressors
after extubation. Her antibiotics were narrowed to ceftriaxone
once the culture susceptibilities returned, and her course of
ceftriaxone was completed as an inpatient. Although, she
initially recovered, she subsequently developed recurrent
tachycardia and hypotension after transfer to the floor. She was
treated for presumed pneumonia and was started on vancomycin and
cefepime due to concern for resistant organisms in the setting
of recent intubation/extubation. She clinically improved and was
narrowed to levofloxacin to complete a full 8 day course (Ends
___. In the setting of infection, she was found to have
thrombocytopenia, which improved to within normal limits prior
to discharge.
# Type II NSTEMI: Found to have elevated troponin, felt to
likely be demand in the setting of sepsis/infectious process as
above. Her troponin downtrended with a flat CK-MB and she did
not have significant ECG changes. There was no evidence of
ischemic changes on ECG.
# Acute Kidney Injury
Patient had Cr of 2.2 documented at ___ in ___
suggesting component of CKD, although creatinine improved to 0.7
on discharge suggesting less likely a component of CKD. Patient
arrived with Cr of 4.0 iso her hypotension, septic shock, and
PEA arrest as above. Urine sediment with granular casts c/w ATN.
Notably, she maintained adequate UOP throughout the
hospitalization and Cr improved with fluid resuscitation and
pressor support. Her creatinine was 0.7 on discharge.
# Toxic metabolic encephalopathy
# Vascular dementia
# Seizure disorder
After extubation patient was found to be alert and confused
although still able to follow commands and answer questions. In
discussions with her mother, she reportedly has attentional and
recall deficits at baseline. She had multiple explanations for
her altered mental status including sepsis, ICU delirium and PEA
arrest on top of history of stroke and vascular dementia. cEEG
demonstrated epileptiform discharges consistent with increased
risk for seizure. She was continued on home Zyprexa and
trazodone, as well as home valproate. She would likely benefit
from outpatient neurology follow-up to ensure that her
medications can be titrated appropriately in the outpatient
setting. Her mental status improved to her apparent baseline
prior to discharge. In this setting, she was evaluated by the
speech and swallow team who recommend solids and thin liquids
which will be continued on discharge.
# Left posterior tibial vein DVT
Incidentally noted on arterial duplex of LLE to have a left
posterior tibial DVT likely secondary to immobility in the
setting of recent stroke and urosepsis vs. hypercoagulable state
from underlying SLE. Given possible treatment failure on
warfarin, she was transitioned to apixaban, which was continued
on discharge.
# MV thickening
As part of his work-up for shock, she underwent TTE which showed
a "rheumatic appearing mitral valve though not classic
appearance; differential also includes valve thickening from
rheumatologic disease such as lupus. Imaging also could be
consistent with marantic endocarditis." She was also noted to
have a new systolic ejection murmur during the hospitalization.
___ was deferred in the inpatient setting given her acute
medical needs, but should be considered in the outpatient
setting. As above, she was continued on apixaban.
# Acute on chronic anemia
Hb initially ___ at admission, dropped to 6.5 on ___. She
underwent CT C/A/P to evaluate for possible bleed, but this was
negative and her anemia was felt to be due to dilutional and
acute inflammation. She received 1 pRBC ___. Her hemoglobin
improved to 9.4 on discharge.
# Chest pain
# Rib and sternal fractures
# Pancreatic fat stranding
Patient had recurrent chest pain throughout the hospitalization,
which was felt to be due to trauma ___ CPR with subsequent rib
and sternal fractures; however, she was also found on CT A/P to
have fat stranding around her pancreas with an elevated lipase.
This was felt to be post-traumatic and her initial vague
abdominal pain symptoms improved prior to discharge. She would
benefit from consideration of outpatient MRCP to ensure
resolution of possible pancreatitis.
#Skin breakdown and excoriations around rectum
#Diarrhea
Patient developed diarrhea that was felt to be due to antibiotic
side effect. Ischemic colitis in setting of recent PEA arrest
vs. additional pancreatic insufficiency in setting of
post-traumatic pancreatic inflammation were considered, but
these were felt to be less likely as the diarrhea subsequently
resolved. Her diarrhea improved prior to discharge.
CHRONIC/RESOLVED ISSUES
=======================
#SLE
Her home prednisone was initially held while on stress dose
steroids, but she subsequently returned to her home prednisone
on dsicharge. She was continued hydroxychloroquine, but her MMF
was held while in ICU and until her infection resolved. She
should be restarted on her MMF after completing her course of
levofloxacin.
#H/o stroke: Her home warfarin was transitioned to apixaban
given concern for warfarin failure
#Depression
#Anxiety
Continued home citalopram
#HTN
Held home lisinopril iso borderline blood pressures. This can
likely be restarted in the outpatient setting.
#HLD
Continued home atorvastatin
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Alendronate Sodium 70 mg PO QMON
3. Ascorbic Acid ___ mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Baclofen 5 mg PO TID
6. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
7. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
8. Citalopram 20 mg PO DAILY
9. Colchicine 0.6 mg PO DAILY
10. Divalproex (DELayed Release) 750 mg PO BID
11. Docusate Sodium 100 mg PO DAILY
12. Hydrocortisone Cream 1% 1 Appl TP DAILY
13. Hydroxychloroquine Sulfate 200 mg PO BID
14. Lisinopril 20 mg PO DAILY
15. Loratadine 10 mg PO DAILY
16. Melatin (melatonin) 5 mg oral QHS
17. Multivitamins W/minerals 1 TAB PO DAILY
18. Mycophenolate Mofetil 1000 mg PO BID
19. OLANZapine 2.5 mg PO BID
20. Pantoprazole 40 mg PO Q24H
21. PredniSONE 10 mg PO DAILY
22. Probiotic (S.boulardii) (Saccharomyces boulardii) 250 mg
oral DAILY
23. Silver Sulfadiazine 1% Cream 1 Appl TP TID
24. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
25. TraZODone 25 mg PO QHS
26. Warfarin 6 mg PO 4X/WEEK (___)
27. Warfarin 6.5 mg PO 3X/WEEK (___)
Discharge Medications:
1. Apixaban 5 mg PO BID
2. LevoFLOXacin 750 mg PO DAILY Duration: 4 Doses
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. Alendronate Sodium 70 mg PO QMON
5. Ascorbic Acid ___ mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Baclofen 5 mg PO TID
8. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
9. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
10. Citalopram 20 mg PO DAILY
11. Colchicine 0.6 mg PO DAILY
12. Divalproex (DELayed Release) 750 mg PO BID
13. Docusate Sodium 100 mg PO DAILY
14. Hydrocortisone Cream 1% 1 Appl TP DAILY
15. Hydroxychloroquine Sulfate 200 mg PO BID
16. Loratadine 10 mg PO DAILY
17. Melatin (melatonin) 5 mg oral QHS
18. Multivitamins W/minerals 1 TAB PO DAILY
19. OLANZapine 2.5 mg PO BID
20. Pantoprazole 40 mg PO Q24H
21. PredniSONE 10 mg PO DAILY
22. Probiotic (S.boulardii) (Saccharomyces boulardii) 250 mg
oral DAILY
23. Silver Sulfadiazine 1% Cream 1 Appl TP TID
24. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
25. TraZODone 25 mg PO QHS
26. HELD- Lisinopril 20 mg PO DAILY This medication was held.
Do not restart Lisinopril until you see your primary care
physician
27. HELD- Mycophenolate Mofetil 1000 mg PO BID This medication
was held. Do not restart Mycophenolate Mofetil until you finish
your antibiotics
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
===================
s/p PEA Arrest
Septic shock due to urinary tract infection
Severe sepsis due to pneumonia
Secondary Diagnoses:
====================
Type II NSTEMI
Rib/Sternal Fracture
Toxic metabolic encephalopathy
Vascular dementia
Seizure disorder
Acute Kidney Injury
Deep Vein thrombosis
Acute on Chronic anemia
Thrombocytopenia
Rib and sternal fractures
SLE
Stroke
Depression
Anxiety
Hypertension
Hyperlipidemia
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 Ms. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for cardiac arrest and urinary infection
What was done for me while I was in the hospital?
- You were in the ICU after your heart stopped (cardiac arrest)
at the outside hospital
- You were given a breathing tube to help you breath. This was
removed
- You were found to be confused after your ICU stay, but this
improved prior to discharge
- You were given antibiotics for your urinary tract infection
- You were given antibiotics for your pneumonia
- You were found to have a blood clot in your legs. Your
coumadin was switched to apixaban, a different blood thinner
- You were found to have low blood counts, and got a blood
transfusion
- You were found to have chest pain felt to be due to rib
fractures
What should I do when I leave the hospital?
Please take all of your medications as prescribed.
Please go to your follow up appointments as scheduled.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10640017-DS-5
| 10,640,017 | 27,848,396 |
DS
| 5 |
2147-09-24 00:00:00
|
2147-09-24 19:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Ms ___ is a ___ h/o alcohol use disorder, HTN, afib, breast
cancer, lung cancer who was brought in by ambulance after being
found down minimally responsive by her neighbor. Per report,
patient's neighbor noted 3 days of accumulating mail which
prompted him to perform a well-check and called EMS. Patient was
found down covered in feces and urine. She was minimally
responsive with BPs 60/30s, and afib with RVR. She received
fluids en route with improvement of BPs to 102/50. Her mentation
improved to the point where she could open her eyes and obey
basic commands. She was able to state she is in the hospital and
deny any complaints. Patient went to get trauma pan-scan but
desatted while there prompting intubation. On CTs she was noted
to have large intracranial mass w/ vasogenic edema which
prompted
Neurosurgery consult. Patient was due to receive MRI prior to
coming to ICU but became hypotensive to ___ requiring norepi
initiation. MRI was deferred.
In the ED,
Initial Vitals: T99.8, HR140, BP156/95, RR34, 96% 4 L NC
Patient initially triggered for VS abnormalities and hypoxia.
She
received aggressive hydration but re-triggered for dyspnea and
sats to ___ iso SBPs 200s. She was placed on a non-rebreather
and
bipap with improvement in oxygenation and BPs. She was then
weaned to 4L NC but desaturated while at CT, requiring
intubation.
Past Medical History:
RUL bronchioalveolar carcinoma
Hypertension
Hyperlipidemia
Breast Cancer s/p lumpectomies, XRT
Right Mastectomy
DJD s/p Right THR and revision
Atrial fibrillation
Social History:
___
Family History:
Siblings: breast CA (sister), pancreatic CA (brother)
Physical Exam:
ADMISSION EXAM
General: Elderly female who is responsive to verbal stimuli
minimally answers questions properly. After intubation, ETT @20
cm at lip
HEENT: NC, AT. PERRLA. EOMI. Dry mucous memories.
Skin: Breakdown to the left lateral thigh/buttock, left chest,
and left forearm.
Neck: No cervical lymphadenopathy,
Chest: Bilateral rhonchi, tachypnea
CV: Tachycardic, no appreciable M/G/R. Pulses equal in all ___.
Abdomen: Involuntary guarding appreciated. No appreciable
tenderness to palpation.
Extremities: TTP to left humerus, left hip/femur.
Neuro: opens eyes to pain, withdraws in all 4, has cough, and
corneals, pupils equal and reactive, exam confounded by ___ and
impaired liver function
DISCHARGE EXAM:
VS: ___ 1119 Temp: 98.8 PO BP: 138/95 HR: 96 RR: 18 O2 sat:
97% O2 delivery: Ra
GENERAL: Awake, alert, in no apparent distress, holding receipt,
appears confused
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
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 mildy
decreased in left arm/leg
NEURO: Patient not willing to participate in interview to assess
orientation. Moves all extremities spontaneously. Pupils equal.
Speech fluent.
PSYCH: pleasant and cooperative at the time, however
intermittently slightly agitated
Pertinent Results:
ADMISSION LABS
___ 03:17PM BLOOD WBC-12.0* RBC-5.10 Hgb-16.6* Hct-51.4*
MCV-101* MCH-32.5* MCHC-32.3 RDW-13.7 RDWSD-51.1* Plt ___
___ 03:17PM BLOOD Neuts-78.7* Lymphs-8.1* Monos-12.6
Eos-0.0* Baso-0.2 Im ___ AbsNeut-9.46* AbsLymp-0.97*
AbsMono-1.52* AbsEos-0.00* AbsBaso-0.02
___ 03:17PM BLOOD ___ PTT-23.0* ___
___ 03:17PM BLOOD Glucose-133* UreaN-80* Creat-4.5* Na-155*
K-3.5 Cl-110* HCO3-19* AnGap-26
___ 01:04AM BLOOD ALT-168* AST-258* CK(CPK)-6377*
AlkPhos-120* TotBili-4.1*
___ 03:17PM BLOOD Calcium-10.0 Phos-5.2* Mg-2.4
___ 03:30PM BLOOD ___ pO2-68* pCO2-37 pH-7.38
calTCO2-23 Base XS--2
MICROBIOLOGY
___ 3:17 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 3:50 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 5:18 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
DISCHARGE LABS:
___ 05:15AM BLOOD WBC-16.6* RBC-4.22 Hgb-13.5 Hct-40.3
MCV-96 MCH-32.0 MCHC-33.5 RDW-13.0 RDWSD-45.2 Plt ___
___ 05:15AM BLOOD Glucose-95 UreaN-14 Creat-0.4 Na-141
K-3.6 Cl-101 HCO3-25 AnGap-15
___ 05:15AM BLOOD ALT-83* AST-31 AlkPhos-100 TotBili-1.3
___ 05:15AM BLOOD Calcium-8.6 Phos-2.8 Mg-1.7
IMAGING:
___ CT TORSO
1. No evidence of acute intrathoracic or intraabdominal injury
within the
limitation of an unenhanced scan.
2. Please consider advancing the nasogastric tube by at least 15
cm, and the ETT by 1-2 cm for optimal positioning.
3. Subsegmental atelectasis, with a few patchy and ground-glass
opacities that may be infectious or inflammatory, including
aspiration. A three-month follow-up CT thorax is suggested to
ensure resolution.
___ CT C SPINE
1. No evidence of traumatic cervical malalignment or acute
fracture.
2. Multilevel degenerative changes of the cervical spine, most
pronounced at C5/C6 and C6/C7, causing up to mild narrowing of
the neural foramina, but no significant narrowing of the central
canal.
3. 1.5 cm right thyroid lobe nodule. This may be further
characterized with dedicated thyroid ultrasound.
RECOMMENDATION(S): Thyroid nodule. Ultrasound follow up
recommended.
___ College of Radiology guidelines recommend further
evaluation for
incidental thyroid nodules of 1.0 cm or larger in patients under
age ___ or 1.5 cm in patients age ___ or ___, or with suspicious
findings.
Suspicious findings include: Abnormal lymph nodes (those
displaying
enlargement, calcification, cystic components and/or increased
enhancement) or
invasion of local tissues by the thyroid nodule.
___, et al, "Managing Incidental Thyroid Nodules Detected on
Imaging: White Paper of the ACR Incidental Findings Committee".
J ___ ___ 12:143-150.
___ CXR
Right infrahilar opacity, could be secondary to atelectasis
however a superimposed infectious process cannot be excluded.
___ HIP XRAYS
There is no fracture or dislocation. There are mild to moderate
degenerative changes of the left hip. There is no suspicious
lytic or sclerotic lesion. There is no soft tissue calcification
or radio-opaque foreign body.
___ POOT XRAY
1. No acute fracture or dislocation of either foot.
2. Postsurgical changes from right first metatarsal osteotomy
and screw
fixation.
3. Mild to moderate degenerative changes of the first
metatarsophalangeal
joint.
___ MRI HEAD
1. Redemonstrated overall stable 4.1 cm frontal parafalcine mass
with imaging features suggestive of an olfactory groove
meningioma. No additional lesions.
2. Extensive vasogenic edema appears minimally increased
posteriorly.
3. Mass effect on the frontal horns of the lateral ventricles
and
10 mm of leftward midline shift are overall stable. Patent
basal
cisterns.
4. No acute infarct or intracranial hemorrhage.
___ CT HEAD
Stable anterior skullbase meningioma. Extensive surrounding
parenchymal
edema, stable, consider atypical meningioma.
Stable midline shift anterior frontal lobes.
Mild hydrocephalus.
Brief Hospital Course:
Ms. ___ is a ___ F h/o afib, HTN, HLD, lung cancer s/p RUL
and RML resections, breast cancer s/p lumpectomies and R
mastectomy here after being found down at home with
rhabdomyolysis and evidence of large frontal lobe mass with
significant vasogenic edema and concern for epileptiform
activity on EEG, now with continued poor mental status.
ACUTE ISSUES
===============
#GOALS OF CARE:
See transitional issue below. Patient's family wants her to be
DNAR/DNI. However, unable to get MOLST signed while she was here
due to coordination difficulties with getting HCP in person.
Therefore, will need to be filled out upon arrival to rehab once
healthcare proxy can be there in person. HCP ___ is
interested in transitioning ___ to hospice care, however,
plan for now to attempt ___ rehab care, and possibly
transition to hospice upon completing acute rehabilitation.
# Meningioma w/ vasogenic edema:
# Epileptiform discharges:
Patient has history of known meningioma, now with evidence of
vasogenic edema and 9mm midline shift. No evidence of
herniation. Neuro exam only notable for lack of withdrawal in
LUE, though patient continues to move this limb spontaneously.
Neurosurgery and neuro-oncology were consulted and concluded
that neurosurgical procedure would be indicated after recovery
of acute illness if within goals of care. However, not in line
with goals of care per family. Started on dex 4 BID and keppra
1g BID. She will follow-up with neurosurgery and neuro-oncology
on discharge to determine further plans.
#Acute hypoxic respiratory failure:
Etiology of respiratory failure unclear, could be in setting of
flash pulmonary edema vs. blooming pneumonia/aspiration given
worsening mental status. Of note, patient with ___
breathing pattern on ___ when on pressure support. Unclear
etiology of this as patient with no prior evidence of brainstem
lesion. Possibly related to mental status. Patient was
successfully extubated on ___ after goals of care discussion
with family, at which point it was decided that patient would
not want re-intubation if necessary.
#Unresponsive episode:
#Acute toxic/metabolic encephalopathy:
Likely in setting of altered mental status and alcohol use
disorder. Patient with what sounds like subacute deterioration
and repeated falls over the last several months. Tertiary trauma
survey w/o evidence of fracture or soft tissue trauma. Patient
awake, however significant confused on discharge
#Afib with RVR (CHADS2VASC=4):
#Possible sick sinus syndrome:
Noncompliance with medications at home. Here in RVR initially.
Rates improved with rehydration, off metoprolol and other rate
control agents. Intermittently into RVR when agitated. Was
briefly taken off of BB due to ___ second pauses, however was
tachycardic to 120s intermittently off, so dose reduced to
37.5mg BID. Long term anticoagulation should be discussed as a
transitional issue.
#Hypertension:
Hypertensive up to 170s/90s iso adjustment of home meds,
agitation, and occasional refusal of PO meds. She was briefly on
hydralazine in MICU. Was switched to PO metop as above (home
med) and added amlodipine. Off home HCTZ/triamterene due to
concerns regarding risk of dehydration.
#T4N2A inflammatory breast cancer:
Resected, s/p PET ___ without any active disease.
Followed by Dr. ___. Was on Herceptin with plan to finish
total of 12 months, only got through 9 months as of ___
and no longer went to appointments. Continued home anastrazole.
Recommend outpatient follow up with her oncologist to decide on
restarting Herceptin.
#Leukocytosis:
Likely ___ steroids. WBC remains elevated at 16.6 on discharge,
but without other obvious infectious source.
#Acute kidney injury:
Cr 4.5 on admission, improved to 0.4 on day of discharge after
IV hydration.
#Transaminitis:
Initially LFTs elevated likely from ETOH plus ischemic injury,
downtrended during admission. However, ALT remains elevated at
discharge (83). Recommend recheck as outpatient, consideration
of further workup if persistent.
#Rhabdomyolysis: Treated with IV fluids/supportive care. Of note
troponin also elevated to 0.15, which could be type II NTSTEMI,
however could be just due to rhabdo of cardiac muscles.
TRANSITIONAL ISSUES:
[] consideration of anticoagulation for a fib (CHADSVASC4) if
patient amenable to taking this or within goals of care
[] metop dosing for a fib: had several asymptomatic ___ second
pauses on 50 BID, was tachycardic off of metop. Dose reduced to
37.5 BID, recommend recheck HR in ___ days at rehab and
consideration of further reducing this dose.
[] blood pressure - regimen changed during admission. was on
hydral in ICU, started on amlodipine after. intermittently
refused, BP ranged normal to high. Off home HCTZ/triamterene due
to concerns about dehydration on diuretics. may need further
dose adjustments, recommend repeat BP within ___ weeks
[] dex plan to be determined on follow-up with neuro-onc, likely
taper to minimal effective dose for palliation, possible
re-imaging
[] Thyroid nodule incidentally seen on CT c-spine, recommend
non-emergent follow-up ultrasound if aligned with goals of care
[] Atelectasis seen on CT torso on admission. Recommend repeat
imaging for stability if aligned with goals of care
[] Repeat LFTs with fax to PCP ___ ___ weeks (if aligned with
goals of care), consideration of further work-up as to cause of
ALT elevation/referral to hepatology if persistent
[] GOALS OF CARE: Patient's family wishes her to be DNAR/DNI.
Unfortunately, we were unable to have healthcare proxy sign form
while Ms. ___ was admitted. This will need to be completed
while she is at rehab. For now, she is FULL CODE for the
ambulance ride to rehab
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Triamterene-HCTZ (37.5/25) 1 CAP PO QAM
2. Metoprolol Succinate XL 100 mg PO DAILY
3. Apixaban 5 mg PO BID
4. Allopurinol ___ mg PO DAILY
5. Anastrozole 1 mg PO DAILY
6. Glucosamine Sulf-Chondroitin (glucosamine ___ 2KCl-chondroit)
1000-800 mg oral DAILY
7. flaxseed oil 1,000 mg oral DAILY
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
2. Dexamethasone 4 mg PO Q12H
3. FoLIC Acid 1 mg PO DAILY
4. LevETIRAcetam 1000 mg PO Q12H
5. Metoprolol Tartrate 37.5 mg PO BID
6. Miconazole Powder 2% 1 Appl TP Q4H:PRN fungal rash
___ be discontinued once rash resolves
7. Multivitamins W/minerals 1 TAB PO DAILY
8. QUEtiapine Fumarate 75 mg PO QHS:PRN agitation/insomnia
9. Ramelteon 8 mg PO QHS:PRN insomnia
10. Thiamine 100 mg PO DAILY Duration: 5 Days
Continue through ___. Anastrozole 1 mg PO DAILY
12. Glucosamine Sulf-Chondroitin (glucosamine ___
2KCl-chondroit) 1000-800 mg oral DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Meningioma
A fib
Pneumonia
Breast cancer
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:
___,
You were admitted to the hospital for confusion, found to have a
significantly increased size of benign brain tumor (meningioma)
that has grown so large that there's fluid in your brain that's
pushing it to one side. You were treated with steroids and
anti-seizure medications.
Since ultimately it was determined that you were not going to
get surgery, you will be treated medically to manage your
symptoms. The goal for your care is comfort going forward. Your
family is interested in hospice, which can be discussed further
once you go to rehab.
It was a pleasure taking care of you!
Sincerely, your ___ Team
Followup Instructions:
___
|
10640054-DS-7
| 10,640,054 | 29,388,046 |
DS
| 7 |
2175-06-01 00:00:00
|
2175-06-02 08:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall
Alcohol withdrawal
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old man with a history of EtOH abuse
and craniotomy for an unclear reason (thought to be due to ___
secondary to fall) who presented to ___ on ___ after being
found unresponsive and combative with multiple contusions and
abrasions, blood in his mouth. Pt does not recall what happened
to him; reports being at work (dry cleaners) and feeling dizzy.
Coworkers called EMS, he recalls paramedics showing up but no
other recollection. Unclear where his bruising came from. In the
ED, a non-contrast head CT showed falcine SDH and he was
admitted to the ___ for monitoring. Repeat imaging ___ was
stable, but labs notable for leukopenia (2.9), anemia (29.4),
thrombocytopenia (plt 25), INR 1.5, normal electrolytes,
transaminitis (ALT ___, AST 200s), tbili 8, dbili 3.6. Now s/p
plt transfusion x3, FFP x1. Was transferred to medicine last
night for further evaluation.
.
Pt does have a history of head trauma. Reports he hit his head
in a MVA a couple years ago; also hit his head after falling
down the stairs about a year ago. Reports that he developed
headache and blurry vision a couple months (?) after the fall,
went to the hospital and had a craniotomy.
.
In terms of alcohol history, he denies any prior history of
significant liver disease. Has noticed increased bruising on his
body over the last year. Does report one seizure a few years
ago, the history is unclear but may have been in the setting of
alcohol withdrawal, reports was hospitalized afterward. Also
reports occasional night sweats. Drinks pint of tequila multiple
days per week (usually weekends), 2 shots/night a few times a
week as well. Reports interested in quitting alcohol, has tried
to quit in the past.
.
On review of systems
(+) Per HPI, also notes yellow eyes and dark urine
(-) Denies fever, chills, headache, cough, shortness of breath.
Denied chest pain or tightness, palpitations. Denied nausea,
vomiting, diarrhea, constipation or abdominal pain. No dysuria.
Past Medical History:
- Prior head traumas s/p MVA and fall c/b SDH s/p right
craniotomy
- ETOH abuse
Social History:
___
Family History:
No history of etoh abuse, liver disease or seizures
Physical Exam:
Neurology admission exam:
Vitals: P: 90 R: 18 BP: 95/50 SaO2: 100% RA
General: Awake, cooperative, NAD.
HEENT: has dried blood in mouth and on face.
Neck: hard collar in place
Pulmonary: lcta b/l
Cardiac: RRR, S1S2, no murmurs appreciated
Abdomen: soft, NT/ND, +BS
Extremities: warm, well perfused
Skin: has multipls abrasions and contusions over body
Neurologic:
Mental Status: Awake, alert, oriented to person, "hospital,"
month, year, and day of week but not date. Unable to provide
history of today's event. Inattentive, unable to name ___
forwards or backwards but able to name ___ backwards. Able to
follow both midline and appendicular commands. No right-left
confusion. Difficulty following multi-step commands. Able to
register 3 objects and recall ___ at 5 minutes. No evidence of
apraxia or neglect.
Language: speech is clear, fluent, nondysarthric with intact
naming, repetition and comprehension.
Cranial Nerves:
I: Olfaction not tested.
II: R pupil 5 mm and reactive to light (5-->4 mm). L pupil 4 mm
and reactive to light (4-->3 mm). VFF to confrontation. Optic
disc pallor b/l on fundoscopic exam but no hemorrhages noted.
III, IV, VI: EOMI without nystagmus, but with saccadic
intrusions
on left gaze.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5
Sensory: No deficits to light touch or pinprick. Has mild
proprioceptive loss at great toe b/l.
DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
Coordination: No intention tremor or dysmetria on finger-nose,
FNF or HKS bilaterally.
Gait: deferred.
Discharge Exam:
98.6 98/54 88 20 100%RA
General: A&Ox3, no acute distress
HEENT: PERRL, Sclera icteric, MMM
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: NABS, sNTND, obese, -HSM
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: jaundiced
Neuro: CN grossly intact, no asterixis, moving all extremities
symmetrically
Pertinent Results:
___ 01:00PM BLOOD WBC-3.9* RBC-3.61* Hgb-12.0* Hct-34.5*
MCV-96 MCH-33.2* MCHC-34.7 RDW-16.7* Plt Ct-25*
___ 12:59AM BLOOD WBC-2.9* RBC-3.08* Hgb-10.4* Hct-29.4*
MCV-95 MCH-33.7* MCHC-35.3* RDW-16.8* Plt Ct-50*
___ 04:55AM BLOOD WBC-5.8# RBC-3.18* Hgb-10.8* Hct-31.2*
MCV-98 MCH-34.0* MCHC-34.7 RDW-16.7* Plt Ct-73*
___ 05:10AM BLOOD WBC-5.3 RBC-3.16* Hgb-10.5* Hct-31.8*
MCV-101* MCH-33.2* MCHC-33.0 RDW-17.4* Plt Ct-56*
___ 04:40AM BLOOD WBC-4.5 RBC-3.09* Hgb-10.3* Hct-31.0*
MCV-100* MCH-33.2* MCHC-33.1 RDW-17.6* Plt Ct-77*
___ 06:40AM BLOOD WBC-4.1 RBC-3.06* Hgb-10.4* Hct-31.1*
MCV-102* MCH-34.1* MCHC-33.5 RDW-18.0* Plt Ct-93*
___ 06:49AM BLOOD WBC-4.0 RBC-2.98* Hgb-10.1* Hct-30.9*
MCV-104* MCH-34.0* MCHC-32.8 RDW-18.0* Plt ___
___ 04:25AM BLOOD WBC-5.0 RBC-3.17* Hgb-10.5* Hct-33.1*
MCV-104* MCH-33.3* MCHC-31.9 RDW-18.2* Plt ___
___ 05:00AM BLOOD WBC-5.4 RBC-3.22* Hgb-10.9* Hct-33.7*
MCV-105* MCH-33.9* MCHC-32.4 RDW-18.1* Plt ___
___ 04:40AM BLOOD WBC-6.4 RBC-3.09* Hgb-10.6* Hct-32.4*
MCV-105* MCH-34.1* MCHC-32.6 RDW-18.0* Plt ___
___ 04:45AM BLOOD WBC-6.9 RBC-3.03* Hgb-10.4* Hct-32.0*
MCV-106* MCH-34.4* MCHC-32.5 RDW-18.0* Plt ___
___ 04:25AM BLOOD WBC-8.9 RBC-2.93* Hgb-10.1* Hct-31.3*
MCV-107* MCH-34.5* MCHC-32.3 RDW-18.0* Plt ___
___ 07:40AM BLOOD WBC-9.1 RBC-2.99* Hgb-10.4* Hct-32.2*
MCV-108* MCH-34.9* MCHC-32.4 RDW-18.0* Plt ___
___ 07:40AM BLOOD WBC-9.1 RBC-2.99* Hgb-10.4* Hct-32.2*
MCV-108* MCH-34.9* MCHC-32.4 RDW-18.0* Plt ___
___ 05:30AM BLOOD WBC-9.5 RBC-2.93* Hgb-10.3* Hct-31.3*
MCV-107* MCH-35.2* MCHC-32.8 RDW-17.8* Plt ___
___ 04:50AM BLOOD WBC-9.7 RBC-2.72* Hgb-9.6* Hct-29.0*
MCV-106* MCH-35.1* MCHC-33.0 RDW-17.9* Plt ___
___ 05:05AM BLOOD WBC-10.2 RBC-2.78* Hgb-9.8* Hct-30.0*
MCV-108* MCH-35.5* MCHC-32.8 RDW-17.7* Plt ___
___ 04:40AM BLOOD WBC-13.1* RBC-3.01* Hgb-10.6* Hct-32.7*
MCV-108* MCH-35.3* MCHC-32.6 RDW-17.9* Plt ___
___ 04:30AM BLOOD WBC-14.6* RBC-2.86* Hgb-10.1* Hct-30.9*
MCV-108* MCH-35.2* MCHC-32.6 RDW-17.7* Plt ___
___ 04:30AM BLOOD WBC-16.6* RBC-3.10* Hgb-10.8* Hct-33.8*
MCV-109* MCH-35.0* MCHC-32.1 RDW-17.7* Plt ___
___ 07:10AM BLOOD WBC-20.9* RBC-3.47* Hgb-12.1* Hct-38.3*
MCV-110* MCH-34.7* MCHC-31.5 RDW-18.0* Plt ___
___ 08:00AM BLOOD WBC-20.0* RBC-3.29* Hgb-11.5* Hct-36.4*
MCV-111* MCH-35.0* MCHC-31.6 RDW-18.0* Plt ___
___ 01:00PM BLOOD ___ PTT-35.7 ___
___ 08:18PM BLOOD ___ PTT-33.1 ___
___ 12:59AM BLOOD ___ PTT-34.0 ___
___ 04:26AM BLOOD ___ PTT-32.7 ___
___ 11:18AM BLOOD ___ PTT-34.7 ___
___ 04:55AM BLOOD ___ PTT-32.1 ___
___ 04:55AM BLOOD ___ PTT-32.1 ___
___ 05:10AM BLOOD ___
___ 02:30PM BLOOD ___ PTT-37.8* ___
___ 06:49AM BLOOD ___ PTT-36.9* ___
___ 04:25AM BLOOD ___ PTT-35.9 ___
___ 05:00AM BLOOD ___ PTT-36.8* ___
___ 04:40AM BLOOD ___ PTT-36.1 ___
___ 04:45AM BLOOD ___ PTT-37.1* ___
___ 04:25AM BLOOD ___ PTT-37.6* ___
___ 04:25AM BLOOD ___ PTT-37.6* ___
___ 07:40AM BLOOD ___ PTT-37.9* ___
___ 05:30AM BLOOD ___ PTT-37.9* ___
___ 04:50AM BLOOD ___ PTT-36.9* ___
___ 05:05AM BLOOD ___ PTT-40.6* ___
___ 04:40AM BLOOD ___ PTT-40.1* ___
___ 04:30AM BLOOD ___ PTT-40.4* ___
___ 04:30AM BLOOD ___ PTT-36.0 ___
___ 01:00PM BLOOD Glucose-108* UreaN-12 Creat-1.1 Na-130*
K-3.0* Cl-91* HCO3-24 AnGap-18
___ 05:10AM BLOOD Glucose-79 UreaN-4* Creat-0.6 Na-137
K-3.7 Cl-105 HCO3-24 AnGap-12
___ 04:25AM BLOOD Glucose-79 UreaN-5* Creat-0.5 Na-138
K-3.7 Cl-103 HCO3-22 AnGap-17
___ 04:45AM BLOOD Glucose-73 UreaN-7 Creat-0.5 Na-136 K-3.6
Cl-103 HCO3-23 AnGap-14
___ 05:05AM BLOOD Glucose-92 UreaN-7 Creat-0.5 Na-138 K-3.6
Cl-104 HCO3-25 AnGap-13
___ 04:30AM BLOOD Glucose-76 UreaN-10 Creat-0.5 Na-140
K-3.9 Cl-105 HCO3-26 AnGap-13
___ 01:00PM BLOOD ALT-57* AST-237* AlkPhos-144*
TotBili-8.0* DirBili-3.6* IndBili-4.4
___ 12:59AM BLOOD ALT-56* AST-218* AlkPhos-136*
TotBili-8.0*
___ 04:55AM BLOOD ALT-54* AST-188* LD(LDH)-248 AlkPhos-135*
TotBili-8.0*
___ 05:10AM BLOOD ALT-48* AST-135* LD(___)-203 AlkPhos-128
TotBili-7.5* DirBili-5.6* IndBili-1.9
___ 04:40AM BLOOD ALT-48* AST-117* TotBili-7.7*
___ 06:40AM BLOOD ALT-42* AST-97* LD(___)-193 AlkPhos-125
TotBili-9.2* DirBili-6.5* IndBili-2.7
___ 06:49AM BLOOD ALT-42* AST-100* LD(___)-173 AlkPhos-129
TotBili-9.8*
___ 04:25AM BLOOD ALT-35 AST-94* LD(___)-169 AlkPhos-141*
TotBili-11.5* DirBili-8.0* IndBili-3.5
___ 05:00AM BLOOD ALT-38 AST-103* LD(___)-172 AlkPhos-149*
TotBili-13.5*
___ 04:40AM BLOOD ALT-32 AST-90* LD(___)-155 AlkPhos-148*
TotBili-14.8*
___ 04:45AM BLOOD ALT-30 AST-93* LD(___)-155 AlkPhos-148*
TotBili-15.8*
___ 04:25AM BLOOD ALT-27 AST-90* LD(___)-155 AlkPhos-163*
TotBili-16.7*
___ 07:40AM BLOOD ALT-26 AST-89* LD(___)-163 AlkPhos-170*
TotBili-17.7*
___ 07:40AM BLOOD ALT-26 AST-89* LD(___)-163 AlkPhos-170*
TotBili-17.7*
___ 05:30AM BLOOD ALT-25 AST-96* LD(___)-147 AlkPhos-161*
TotBili-17.7* DirBili-13.6* IndBili-4.1
___ 04:50AM BLOOD ALT-23 AST-94* LD(___)-134 AlkPhos-160*
TotBili-18.5*
___ 05:05AM BLOOD ALT-22 AST-101* LD(___)-148 AlkPhos-165*
TotBili-17.8*
___ 04:40AM BLOOD ALT-23 AST-105* LD(LDH)-189 AlkPhos-177*
TotBili-18.6*
___ 04:30AM BLOOD ALT-21 AST-68* AlkPhos-165* TotBili-16.6*
___ 04:30AM BLOOD ALT-21 AST-58* LD(___)-138 AlkPhos-170*
TotBili-14.9*
___ 07:10AM BLOOD ALT-32 AST-96* AlkPhos-209* TotBili-16.9*
___ 08:00AM BLOOD ALT-37 AST-99* AlkPhos-202* TotBili-14.8*
___ 01:00PM BLOOD Lipase-214*
___ 04:40AM BLOOD TSH-1.5
___ 04:55AM BLOOD Hapto-45
___ 10:25AM BLOOD calTIBC-296 Ferritn-298 TRF-228
___ 10:25AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
___ 05:05AM BLOOD IgM HAV-NEGATIVE
___ 10:25AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 10:25AM BLOOD ___
___ 10:25AM BLOOD IgG-981
___ 01:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:25AM BLOOD HCV Ab-NEGATIVE
___ 01:16PM BLOOD Lactate-1.9
___ 12:11PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-MOD Urobiln-NEG pH-6.5 Leuks-NEG
___ 01:03PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-LG Urobiln-4* pH-6.5 Leuks-NEG
___ 02:39AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-LG Urobiln-2* pH-7.0 Leuks-NEG
___ 02:43AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-LG Urobiln-2* pH-7.0 Leuks-NEG
___ 11:30AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-LG Urobiln-NEG pH-7.0 Leuks-NEG
___ 01:03PM URINE RBC-0 WBC-0 Bacteri-FEW Yeast-NONE Epi-<1
___ 11:30AM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1
CT Chest ___:
IMPRESSION:
1. Hepatosplenomegaly without focal lesion. These likely
relate to the
patient's underlying history of alcoholic hepatitis.
2. Nonspecific but prominent short gastric lymph nodes may be
reactive.
3. Nonspecific mild pelvic free fluid.
4. No pulmonary nodules, mass or consolidation. No
intrathoracic
lymphadenopathy.
Abdominal U/S ___
FINDINGS AND IMPRESSION: There is no ascites identified.
Brief Hospital Course:
This is a ___ year old man with a history of EtOH abuse and
multiple TBIs who presents after alcohol withdrawal seizure with
stable SDH, alcoholic hepatitis, and pancytopenia.
# Alcoholic hepatitis - LFTs trended up to peak ~18, significant
EtOH history, AST>>ALT, c/w acute alcoholic hepatitis; however,
given increasing bili checked for other etiologies: no acute
hepatitis, no evidence of autoimmune hepatitis, iron studies
show no evidence of hemochromatosis. RUQ u/s showed e/o
hepatitis, no ascites, normal ducts and portal vein. Fatty liver
on CT, no signs of cirrhosis on exam. No evidence of
encephalopathy. Patient was encouraged to maintain good
nutrition with goal ___ calories/day; given thiamine,
folate, MVI. He was also started on lactulose once daily on
___ as his tbili continued to rise (never shows signs of
encephalopathy). Hepatology followed while inpatient and due to
persistently elevated bili recommended initiation of prednisone,
after which he showed a gradual improvement in his bilirubin.
Upon discharge he has hepatology f/u for further labwork and
consideration of continuation of steroids.
# Fever: Developed persistent low grade fevers at night
concerning for infection initially and delaying initiation of
prednisone. No clear source of infection. No ascites evident on
exam or RUQ u/s done initially; repeat ultrasounds confirmed no
ascites. Ultimately doxepin was stopped (started due to itching)
for concern of drug fever which showed resolution of his fevers.
# Pruritis: Developed significant itching particularly at night
as his tbili continued to rise, likely secondary to elevated
bilirubin. Patient started on ursodiol but felt dizzy so it was
decreased from TID to BID. Doxepin was initiated at night per
hepatology recs but then discontinued due to fever above.
Benadryl was also effective for the itching.
# Unresponsive Episode - Likely etiology was an alcohol
withdrawal seizure, given the patient's history and his
description of how he felt prior to the episode. He has no
history of an underlying seizure disorder and EEG did not show
signs of epilepsy. Neurology followed initially but signed off,
did not recommend AED.
# EtOH abuse, withdrawal with history of seizures: Initially on
diazepam CIWA but discontinued once no longer scoring for 24
hours. In terms of EtOH cessation, appears to be in
contemplative stage, interested in quitting, previously quit for
___ years. SW followed to discuss abstinence. The medical team
also had multiple long conversations with the patient about the
importance of alcohol cessation. He appeared to understand that
the severity of his liver injury and the importance of alcohol
cessation. He was referred to ___ for
ongoing social work and mental health eval.
# Depression: At multiple points during his hospital stay he
reported feeling "depressed" and "lonely" and stated that he had
felt this way for several years. Endorses difficulty sleeping,
guilt, decreased appetite, feelings of depression. The patient
was seen by social work during his stay and was encouraged to
follow up with outpatient psychiatry and therapy once
discharged.
# Thrombocytopenia and anemia - Initially the patient required
three platelet transfusions. Hemolysis labs were negative. He
was followed by heme, who felt that his thrombocytopenia and
anemia were likely ___ EtOH abuse. His labs improved over the
course of the admission, and stabilized.
# Falcine SDH - Patient was found to have acute falcine SDH on
admission imaging, with no focal neuro deficits on exam. He had
radiologic findings on CT that were stable at 24 hrs, so
neurosurgery signed off. He had no clinical evidence of
worsening SDH so CT was not repeated; his neuro exam remained
stable. Given the patient's history of multiple TBIs and
craniotomy, he had an OT consult which showed overall
functioning intact, some minor deficits.
Transitional Issues:
- ongoing social work and behavioral health support for EtOH
cessation
- hepatology f/u
Medications on Admission:
None
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Capsule
Refills:*0
2. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 capsule(s) by mouth daily Disp #*30 Capsule
Refills:*0
3. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Capsule Refills:*0
4. DiphenhydrAMINE 25 mg PO HS:PRN itching
RX *Benadryl 25 mg 1 capsule(s) by mouth every 8 hours Disp #*30
Capsule Refills:*0
5. Lactulose 30 mL PO DAILY
RX *lactulose 10 gram/15 mL (15 mL) 30 ml by mouth daily Disp
#*900 Milliliter Refills:*0
6. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*40
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Alcoholic hepatitis
Chronic falcine subdural hematoma
Pancytopenia due to alcohol
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure participating in your care at ___. You were
admitted after a fall which appears to have been due to a
seizure from alcohol withdrawal. You were found to have a
subdural hematoma (a bleed in your brain) that has been stable
and likely existed before your recent fall.
You were found to have alcoholic hepatitis, which is
inflammation of the liver due to alcohol use. We treated you
with supportive care, including vitamins and fluids, and we
treated you to prevent alcohol withdrawal. You were also found
to have low blood counts due to your alcohol use. Your platelets
are low, which increases your risk of bruising and bleeding,
since platelets are need to make blood clots. You also have
anemia due to alcohol use.
It is incredibly important that you stop drinking alcohol. This
is the only way to keep your liver and blood function from
worsening. You also are not legally allowed to drive a car for
the next six months since you had a seizure.
You were started on steroids for your alcoholic hepatitis which
helped improve your hepatitis.
Followup Instructions:
___
|
10640203-DS-14
| 10,640,203 | 27,629,999 |
DS
| 14 |
2127-02-16 00:00:00
|
2127-02-21 14:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
BRBPR, altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a. fib, aortic stenosis who presents from ___
after reportedly being combative with nursing staff in addition
to them noticing one episode of BRBPR today.
The patient reports that he feels fine today. He is incontinent
at baseline. He denies fever, chills, weakness, dizziness, chest
pain, shortness of breath, abdominal pain, dysuria, nausea,
vomiting.
He is unsure of his last colonoscopy. He denies any history of
blood in his stool.
From records, daughter, and assisted living facility, patient
has just recently transitioned to ___.
Patient was admitted to ___ on ___ from ___
after a fall. He was found to have a L subtrochanteric fracture
and ortho recommended non-operative management. However, he did
poorly at ___ and his daughter obtained a second
opinion at ___ and they recommended surgical repair. On ___,
he was admitted to ___ and discharged on ___ back to
___. His post-op course was uneventful except for
delium. He has been making good progress in rehab and is now
walking with walker. His daughter reports that the transition
back to ___ has been difficult ___ to delirium. Per
nurse at ___ living, this AM, he was attempting to jump out
of bed and was asking for his police uniform and kept referring
to his wife and family. At baseline, he has dementia and require
assistance with ADLs.
He has dementia and requires assistance with ADLS. However,
daughter notes that he is usually with it and watches the new
and can reiterate current events.
In the ED, initial vitals were: 98.8 74 118/60 18 100% RA
Labs were notable for H/H 11.2/36.1 and WBC 13.0. Received a L
of fluid and azithromycin.
On the floor, he was AOx2 and did not know the year. He reports
that for the past couple of days he felt that he was developing
a cold and had a worsening cough. He denied any shortness of
breath, abdominal pain, nausea, vomiting, diarrhea, or urinary
symptoms. He denies being told he had blood in his stool before
today.
Past Medical History:
-Squamous Cell Carcinoma of the Face
-Hypothyroidism
-Vitamin D Deficiency
-Depressive Disorder
-HTN
-Aortic Valve Stenosis
-Atrial Fibrillation
-OA s/p ORIF of left hip
-Spinal stenosis of lumbar region
-Cough (likely from prior tobacco use)
Surgical history:
Left ORIF in ___
Unknown abdominal surgery
Social History:
___
Family History:
Not relevant to current admission
Physical Exam:
================
ADMISSION EXAM
================
Vital Signs: 97.5 PO 124 / 68 R Sitting 69 18 98 RA
General: Alert, very pleasant. Oriented x 2. Did not know year,
knew he was at a ___ but did not know he was at
___
HEENT: Sclerae anicteric, dry mucous membranes, oropharynx
clear, EOMI, PERRL, neck supple, JVP not elevated,
hypopigmentation on the tip of the nose
CV: ___ systolic ejection murmur best heard at the apex
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding. Surgical scar midline
and around umbilicus
Rectal: No masses palpated, stool was brown with no blood.
guaiac negative.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Surgical scar on left lower extremity
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
==============
DISCHARGE EXAM
==============
Vital Signs: 97.8 132 / 71 64 18 97 RA
General: Alert, very pleasant. Oriented x 2. Able to state that
we are in the hospital but not the year or name of hospital.
Knows we are in ___ but names the wrong hospital. Able to
name president ___. Aware that the presidency is changing soon
but cannot remember the name of the incoming president.
HEENT: Sclerae anicteric, MMMs, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated
CV: ___ systolic ejection murmur best heard at the apex
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding. Surgical scar midline
and around umbilicus
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Surgical scar on left lower extremity
Pertinent Results:
======================
ADMISSION LABS
======================
___ 03:38PM URINE Color-Yellow Appear-Hazy Sp ___
___ 03:38PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 03:38PM URINE RBC-38* WBC-1 Bacteri-NONE Yeast-NONE
Epi-0
___ 12:24PM BLOOD WBC-13.0* RBC-3.95* Hgb-11.2* Hct-36.1*
MCV-91 MCH-28.4 MCHC-31.0* RDW-13.7 RDWSD-46.3 Plt ___
___ 12:24PM BLOOD Neuts-78.9* Lymphs-13.1* Monos-5.9
Eos-0.6* Baso-0.5 Im ___ AbsNeut-10.26* AbsLymp-1.71
AbsMono-0.77 AbsEos-0.08 AbsBaso-0.06
___ 12:24PM BLOOD ___ PTT-27.2 ___
___ 12:24PM BLOOD Plt ___
___ 12:24PM BLOOD Glucose-117* UreaN-14 Creat-0.8 Na-143
K-4.1 Cl-105 HCO3-25 AnGap-17
___ 12:24PM BLOOD cTropnT-0.02*
___ 07:00PM BLOOD CK-MB-2 cTropnT-<0.01
================
KEY INTERIM LABS
================
___ 06:20AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.1
___ 07:25AM BLOOD VitB12-356
___ 07:25AM BLOOD TSH-1.6
___ 12:49PM BLOOD Lactate-1.6
___ 08:13AM BLOOD CK-MB-2 cTropnT-0.02*
___ 02:17PM BLOOD CK-MB-2 cTropnT-0.01
=================
DISCHARGE LABS
=================
___ 08:13AM BLOOD WBC-8.4 RBC-3.79* Hgb-10.7* Hct-34.2*
MCV-90 MCH-28.2 MCHC-31.3* RDW-13.7 RDWSD-44.8 Plt ___
___ 08:13AM BLOOD Plt ___
___ 08:13AM BLOOD Glucose-94 UreaN-13 Creat-0.8 Na-142
K-4.2 Cl-104 HCO3-26 AnGap-16
___ 08:13AM BLOOD Calcium-8.9 Phos-4.1 Mg-2.1
==============
MICROBIOLOGY
==============
Urine culture ___ - No growth
Blood culture ___ - No growth to date
==============
IMAGING
==============
CXR ___: In comparison with the study of ___,
there is little interval change.
No evidence of cardiomegaly, vascular congestion, pleural
effusion, or acute
focal pneumonia.
Little change in the multiple previous rib fractures on the
right.
CXR ___: In comparison with the study of ___, the
patient has taken a better inspiration. Cardiac silhouette is
within normal limits and there is no evidence of vascular
congestion, pleural effusion, or acute focal pneumonia.
CXR ___: 1. Mild pulmonary vascular congestion. Trace
right pleural effusion.
2. Faint bibasilar opacities, may represent atelectasis or early
pneumonia.
Brief Hospital Course:
SUMMARY: ___ year old gentleman with PMH of atrial fibrillation
and recent ORIF for left hip fracture who presents to ___ for
BRBPR, agitation, and confusion. He had negative stool guiac x2
and workup was negative for infection. He had no acute medical
issues and was discharged to rehab.
ACUTE ISSUES:
# Altered mental status: Patient was initially noted to be
agitated at his assisted living facility. Upon admission,
patient was A&Ox1-2, able to identify being in a hospital but
not the name of the hospital, and unable to identify the year. A
workup for delirium was unremarkable; B12/TSH normal, review of
medications does not reveal any culprit medications, infectious
workup negative including blood and urine cultures, patient not
constipated or retaining urine, denies any pain, has a normal
sleep-wake cycle. Multiple conversations were held with the
daughter and the assisted living facility, and ultimately
patient was felt to be close to his recent baseline. There was a
question of subacute decline related to anesthesia received for
his ORIF around one month ago.
#?Aspiration: Patient presented with confusion and WBC of 13.0
with worsening cough x 2 days. CXR showed faint bibasilar
opacities concerning for possible aspiration. Patient did
receive one dose of ceftriaxone/azithro to cover for pneumonia,
however this was subsequently discontinued as clinical picture
was not consistent with pneumonia. The speech and swallow team
evaluated the patient and recommended regular diet, thin
liquids, but to avoid the use of straws.
# Right ischial ulcer: Wound care evaluated partial thickness
ulcer. Recommendations as follows:
- Pressure relief, turn and reposition every ___ hours and PRN
off affected area
- Waffle boots, heels off bed surface at all times
- Limit sit time to one hour at a time off OOB
- Moisturize bilateral LEs and feet BID
- Apply commercial wound cleanser or normal saline to cleanse
right ischial ulcer.
- Pat tissue dry with dry gauze
- Cleanse perianal tissue with foam cleanser, pat dry and apply
- Critic aid skin barrier ointment daily. ___ reapply after each
___ cleansing.
# BRBPR: Patient reportedly had BRBPR but was guaiac negative in
the ED. Rectal exam was performed again on medical floor, which
was guiac-negative and did not reveal any fissures or
hemorrhoids. He remained hemodynamically stable and without
changes in hemoglobin and hematocrit.
# Hematuria: Found to have microscopic hematuria. Repeat UA
# Chest pain: Patient reported transient chest pain on ___.
This resolved within ___ seconds. EKG and troponins were
unremarkable, and a CXR was also unremarkable. Low suspicion for
cardiac-related pain.
CHRONIC ISSUES:
# Depression: Continue mirtazapine, trazodone.
# Insomnia: Continue Ramelteon.
TRANSITIONAL ISSUES:
- Noted right ischial ulcer. Please refer to acute issues for
full wound care recommendations
- Please continue to assess patient's appropriateness from a
___ perspective for an assisted living facility
- Found to have microscopic hematuria. Please repeat UA ___ days
after discharge to assess for continued hematuria. If present,
the patient should be referred to a urologist for further
evaluation.
- Speech and swallow recommendations: regular solids, thin
liquids, NO STRAWS
- Please monitor swallowing to determine if he needs a future
outpatient videofluoroscopic swallow study. Does NOT require one
at this time per speech/swallow team
# Contact: ___ (daughter, POA) ___
# Code Status: DNR/DNI (confirmed by daughter)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraMADol 25 mg PO Q4H:PRN Pain - Moderate
2. TraZODone 12.5 mg PO QHS:PRN insomnia
3. Senna 8.6 mg PO BID:PRN constipation
4. Acetaminophen 325 mg PO TID:PRN Pain - Mild
5. nystatin 100,000 unit/gram topical BID:PRN
6. Multivitamins 1 TAB PO DAILY
7. Ramelteon 8 mg PO QHS
8. Vitamin D 1000 UNIT PO DAILY
9. Mirtazapine 15 mg PO QHS
10. Tamsulosin 0.4 mg PO QHS
11. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Ascorbic Acid ___ mg PO BID Duration: 14 Days
2. Multivitamins W/minerals 1 TAB PO DAILY
3. Acetaminophen 325 mg PO TID:PRN Pain - Mild
4. Docusate Sodium 100 mg PO BID
5. Mirtazapine 15 mg PO QHS
6. nystatin 100,000 unit/gram topical BID:PRN
7. Ramelteon 8 mg PO QHS
8. Senna 8.6 mg PO BID:PRN constipation
9. Tamsulosin 0.4 mg PO QHS
10. TraMADol 25 mg PO Q4H:PRN Pain - Moderate
11. TraZODone 12.5 mg PO QHS:PRN insomnia
12. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Altered mental status
Right ischial ulcer
SECONDARY DIAGNOSIS:
Aortic stenosis
Atrial fibrillation
Hypertension
Osteoarthritis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ because you were found to be more
confused and there was concern that you had blood in your stool.
We did a full evaluation of you and did not find any new
infection or any blood in your stool.
Our physical and occupational therapists evaluated you and felt
that you required rehabilitation to be safe for your assisted
living facility. Therefore you will return to your assisted
living facility with 24 hour supervision.
It was a pleasure taking care of you. We wish you all the best!
- Your ___ care team
Followup Instructions:
___
|
10640492-DS-4
| 10,640,492 | 29,480,813 |
DS
| 4 |
2146-06-15 00:00:00
|
2146-06-15 18:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
cc: dysuria
Major ___ or Invasive Procedure:
NONE
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
___ year old male with a history of HTN, HL, NSTEMI, stroke with
residual L sided weakness, prostatic hypertrophy presents with 4
days of dysuria and suprapubic pain.
Patient has been having severe, sharp pain with urination
limiting his ability to empty his bladder. Denies hematuria,
fever, chills, nausea, vomiting, flank pain. In the ED,
underwent
a CT of the abdomen/pelvis which was consistent with acute
cystitis with herniation of part of the bladder into a right
inguinal hernia and also suggested a possible tiny left distal
ureter stone. ACS was consulted and reduced the hernia
recommending further outpatient discussion regarding possibility
of elective inguinal hernia repair. ACS also suggested further
work-up for hematuria and cystitis as this would not necessarily
follow from herniated bladder.
In the ED VS T 97.8 HR 144 BP 150/90 RR 18 SpO2 97% ra. He was
treated with 2L of NS, morphine sulfate 2mg IV X 1 and
Ceftriaxone 1g IV. His heart rate normalized. He is recorded as
having been on nasal cannula but the oxygen flow is unknown.
Labs
notable for a WBC count of 11.4 and UA with moderate blood, few
bacteria, no nitrate, no leukesterase. Patient admitted to
medicine for further management.
When seen, Mr. ___ reports that his pain has improved
overnight. Dysuria is now mild. He recalls having similar pain
when he presented to the ED ___ years ago. At that time he also
had dysuria and there was no evidence for UTI or prostatitis and
he was discharged home to f/u with Urology.
REVIEW OF SYSTEMS:
GENERAL: No fever, chills, night sweats, recent weight changes.
HEENT: No sores in the mouth, painful swallowing, intolerance to
liquids or solids, sinus tenderness, rhinorrhea, or congestion.
CARDS: No chest pain, chest pressure, exertional symptoms, or
palpitations.
PULM: No cough, shortness of breath, hemoptysis, or wheezing.
GI: No nausea, vomiting, diarrhea, constipation or abdominal
pain. No recent change in bowel habits, hematochezia, or melena.
GU: As above.
MSK: No arthritis, arthralgias, myalgias, or bone pain.
DERM: Denies rashes, itching, or skin breakdown.
NEURO: No headache, visual changes, numbness/tingling,
paresthesias, or focal neurologic symptoms.
PSYCH: No feelings of depression or anxiety. All other review of
systems negative.
Past Medical History:
HTN
HL
Prostate Hypertrophy
NSTEMI in the context of cervical laminectomy
CVA with residual L weakness
s/p C3-C6 laminectomy/fusion
s/p R hip surgery
Social History:
___
Family History:
N/C
Physical Exam:
PHYSICAL EXAM:
VITAL SIGNS: T 98 BP 157/98 HR 107 RR 18 SpO2 95% RA
General: Well-appearing, elderly AA man in NAD.
HEENT: NC/AT, MMM, no OP lesions, no cervical, supraclavicular,
or axillary adenopathy
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB other than left base crackles
ABD: mild distension, soft, +bs, +suprapubic ttp with light
palpation, no CVAT
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
NEURO: A&OX3, sensation grossly intact, ___ strength in LLE
otherwise ___ strength
EXAM on Discharge:
97.8 BP: 102/60 HR: 93 R: 18 OP2: 91%RA
General: Well-appearing, elderly man in NAD
HEENT: NC/AT, MMM, no OP lesions
CV: RRR S1 S2 present, +tachycardic
PULM: CTAB
ABD: mild distension, soft, +bs, Slightly Tender on palpation
of
suprapubic area.
EXT: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
NEURO: A&OX3, moving all extremites
Pertinent Results:
___ 10:42AM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 10:42AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-300
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 10:42AM URINE RBC-74* WBC-9* BACTERIA-FEW YEAST-NONE
EPI-2
___ 10:42AM URINE MUCOUS-RARE
___ 09:10AM URINE HOURS-RANDOM
___ 09:10AM URINE UHOLD-HOLD
___ 09:10AM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 09:10AM URINE BLOOD-LG NITRITE-NEG PROTEIN->600
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-2* PH-6.5 LEUK-NEG
___ 09:10AM URINE RBC-102* WBC-81* BACTERIA-FEW YEAST-NONE
EPI-7 TRANS EPI-<1
___ 09:10AM URINE GRANULAR-5* HYALINE-7___ 09:10AM URINE AMORPH-RARE
___ 09:10AM URINE MUCOUS-RARE
___ 08:56AM LACTATE-2.8*
___ 08:47AM GLUCOSE-123* UREA N-19 CREAT-1.3* SODIUM-136
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-17* ANION GAP-20
___ 08:47AM estGFR-Using this
___ 08:47AM proBNP-87
___ 08:47AM WBC-11.4*# RBC-4.78 HGB-14.5 HCT-39.6*
MCV-83# MCH-30.2 MCHC-36.5* RDW-13.7
___ 08:47AM NEUTS-66.5 ___ MONOS-6.7 EOS-2.6
BASOS-0.3
___ 08:47AM PLT COUNT-222
CTU: ___
IMPRESSION:
1. Acute cystitis.
2. Right inguinal hernia, containing small amount of fat, fluid
and to a
lesser extent the anterolateral bladder wall.
3. Interval increase in left lower lobe subpleural nodule -
follow-up chest CT in ___ year if low-risk, or ___ months if
high-risk.
CXR ___
IMPRESSION:
Mildly engorged central pulmonary vasculature without overt
pulmonary edema. No definite focal consolidation.
Brief Hospital Course:
___ year old male with a history of HTN, HL, NSTEMI, CVA with
residual L sided weakness, BPH presents with 4 days of dysuria
and suprapubic pain.
#Cystitis
#Dysuria
Presented with dysuria/ suprapubic pain. On CT abdomen/pelvis
was found to have a partial bladder herniation into inguinal
hernia which was reduced by ACS in the emergency department.
Kidney stone not seen on final read of CT scan. Case was
discussed with urology who recommended symptomatic management.
Dysuria and cystitis is likely due to herniation. The pateint
will need to follow up with surgery to discuss hernia repair. He
was discharged on Pyridium x 3 days and advised to return or
call his PCP if dysuria does not improve. U/A should be repeated
to asses for resolution of hematuria and if persistent, would
consider additional work up. Follow up with surgery was
arranged. Please provide risk assesment at PCP follow up.
# Hypoxia
Patient with reported hypoxia in ED. No signs of volume overload
on exam. Once on the medical floor, resolved without
intervention.
#Acute renal failure
Patient presented with creatinine of 1.3, with elevated lactate
likely in setting of dehydration and herniated bladder. Resolved
to baseline creatinine of 1.1 on discharge.
# CAD, hx NSTEMI
Recent evaluation by cardiology without changes to home meds
despite tachycardia in clinic. Continued home regimen of baby
ASA, Atorvastatin, Lisinopril
# Pulmonary nodule
Noted to have increase in LLL pleural nodule noted on CT a/p;
f/u in 6 mo to
___ year depending on risk factors, letter sent to PCP and
discussed risk of cancer and need to repeat CT with patient and
his son today.
========================
Transitional issues:
========================
- surgical evaulation arranged to discuss repair of inguinal
hernia, please provide risk assesment at ___ follow up
- needs repeat CT scan in ___ months for evaluation of lower
lobe pulmonary nodule
- repeat U/A to asses for resolution of hematuria
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Docusate Sodium 100 mg PO DAILY
4. Lisinopril 30 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Terazosin 10 mg PO QHS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Docusate Sodium 100 mg PO DAILY
4. Lisinopril 30 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Terazosin 10 mg PO QHS
7. Phenazopyridine 100 mg PO TID Duration: 3 Days
RX *phenazopyridine [Pyridium] 100 mg 1 tablet(s) by mouth three
times a day Disp #*6 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Inguinal hernia
Cystitis
Lung nodule
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 recent
admission to ___. You were admitted with buring on urination
and had a CT scan which showed part of your bladder was trapped
in a hernia. You were seen by surgery who were able to reduce
your hernia. You will need to follow up with surgery to discuss
surgical repair. Your case was discussed with urology who
recommended symptomatic treatment of your urinary symptoms. If
your pain on urination does not improve, please see your primary
care physician and discuss urology follow up.
You were also noted to have a lung nodule on a CT scan of your
chest. You will need a repeat chest CT scan in ___ months.
Followup Instructions:
___
|
10640492-DS-5
| 10,640,492 | 28,543,134 |
DS
| 5 |
2146-11-30 00:00:00
|
2146-11-30 17:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
inguinal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a ___ y.o male with h.o HTN, HL, BPH, NSTEMI, CVA with
L.sided residual weakness, with h.o inguinal hernia containing
bladder tissue who presented with dysuria and L.sided inguinal
pain only with urination x 3 days. Pt also reports 1 episode of
hematuria. Pt reports that he has had these symptoms before. He
denies penile discharge or pain without urination, fever,
chills, other abdominal pain, n/v/d/c/melena/brbpr. He also
denies cp, sob, palpitations, paresthesias.
.
IN the ED, pt was noted to have a L. and R.inguinal hernias but
no testicular tenderness. He was given morphine, 2L IVF, and
ceftriaxone. VSS other than some tachycardia on admission.
.
10 pt ros reviewed and otherwise negative.
Past Medical History:
HTN
HL
Prostate Hypertrophy
NSTEMI in the context of cervical laminectomy
CVA with residual L weakness
s/p C3-C6 laminectomy/fusion
s/p R hip surgery
Social History:
___
Family History:
MOther with DM
Physical Exam:
Gen: well appearing, NAD
vitals:T 98.5 BP 141/83 HR 96 RR 16 sat 97% on RA
HEENT: ncat eomi anicteric MMM
neck: supple
chest: b/l ae no w/c/r
heart: s1s2 rr no m/r/g
abd: +bs, soft, NT, ND, no guarding or rebound
GU:+suprapubic tenderness, no penile discharge or edema noted,
no inguinal swelling noted
ext: no c/c/e 2+pulses
neuro: face symmetrc, L.sided weakness 4+/5 compared to R.sided
___
psych: calm, cooperative
Discharge PE:
vitals: T 98.1 BP 135/89 HR 87 RR 20 sat 98% on RA
Gen: well appearing, NAD
HEENT: ncat eomi anicteric MMM
neck: supple
chest: CTAB no w/r/
heart: RRR nl s1s2 no m/r/g
abd: +bs, soft, NT, ND, no guarding or rebound
GU: no flank or suprapubic tenderness, no penile discharge or
edema noted, no inguinal swelling noted
ext: no c/c/e 2+pulses
Pertinent Results:
___ 01:30PM URINE COLOR-DKMB APPEAR-Cloudy SP ___
___ 01:30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-8* PH-6.0 LEUK-LG
___ 01:30PM URINE RBC-36* WBC-38* BACTERIA-MOD YEAST-NONE
EPI-<1
___ 01:30PM URINE HYALINE-52* CELL-4*
___ 12:29PM LACTATE-4.0* K+-5.2*
___ 12:20PM GLUCOSE-150* UREA N-42* CREAT-2.3*#
SODIUM-130* POTASSIUM-7.3* CHLORIDE-99 TOTAL CO2-17* ANION
GAP-21*
___ 12:20PM estGFR-Using this
___ 12:20PM WBC-23.1*# RBC-4.68 HGB-14.2 HCT-39.1* MCV-84
MCH-30.3 MCHC-36.3 RDW-13.1 RDWSD-39.3
___ 12:20PM NEUTS-84* BANDS-2 LYMPHS-8* MONOS-6 EOS-0
BASOS-0 ___ MYELOS-0 AbsNeut-19.87* AbsLymp-1.85
AbsMono-1.39* AbsEos-0.00* AbsBaso-0.00*
___ 12:20PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL
OVALOCYT-OCCASIONAL TARGET-1+ BURR-OCCASIONAL
TEARDROP-OCCASIONAL
___ 12:20PM PLT SMR-NORMAL PLT COUNT-183
.
CXR:
FINDINGS:
AP portable upright view of the chest. Overlying EKG leads
noted. Lung
volumes are low. No large consolidation concerning for
pneumonia. No overt signs of edema or congestion. Mild left
basal atelectasis likely present. No large effusion or
pneumothorax. Cardiomediastinal silhouette is stable. Bony
structures appear grossly intact. Cervical spinal hardware is
partially noted.
IMPRESSION:
As above.
URINE CULTURE (Final ___:
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
___ y.o male with h.o HTN, HL, NSTEMI, CVA with L.sided weakness,
BPH who presents with dysuria and inguinal pain.
.
#Urinary tract infection/dysuria/leukocytosis-Pt with
leukocytosis, elevated lactate, dysuria and a u/a suggestive of
infection. He was placed on IV ceftriaxone initially, his
leukocytosis and ___ resolved. Pain significantly improved. He
had a sensation of not fully emptying his bladder but post void
residuals were <50 cc. Urine culture grew E. coli and he was
changed to PO ciprofloxacin.
-PO ciprofloxacin for total 14 day course for complicated UTI
-Pyridium for dysuria
-F/u with PCP and urologist
.
#acute renal failure-likely due infection, quickly resolved with
IV fluids. His ACE-inhibitor was initially held but restarted
on discharge when the creatinine normalized.
.
#hyponatremia, hypovolemic: resolved with fluids.
.
#HTN/HL-continue statin, asa, ACE-inhbitior
.
#H.o CVA with L.sided weakness-continue asa, statin
.
#BPH-continue tamsulosin
.
#GERD-PPI
.
#FEN-cardiac diet
.
#ppx-hep sc TID
.
#access-PIV
.
#communication-pcp ___
.
#code-full
.
#dispo-home without services
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tamsulosin 0.4 mg PO QHS
2. Atorvastatin 80 mg PO QPM
3. Lisinopril 30 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Senna 8.6 mg PO BID:PRN c
7. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Docusate Sodium 100 mg PO BID
4. Omeprazole 20 mg PO DAILY
5. Senna 8.6 mg PO BID:PRN c
6. Tamsulosin 0.4 mg PO QHS
7. Ciprofloxacin HCl 500 mg PO Q12H Duration: 12 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*24 Tablet Refills:*0
8. Phenazopyridine 100 mg PO TID Duration: 2 Days
RX *phenazopyridine 100 mg 1 tablet(s) by mouth three times a
day Disp #*6 Tablet Refills:*0
9. Lisinopril 30 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
urinary tract infection, sepsis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for pain with urinating and were found to have
a severe urinary tract infection. Your infection significantly
improved with antibiotics. You are being discharged on a total
14 day course of antibiotics with oral ciprofloxacin. Please
follow-up with your primary care physician and urologist.
Followup Instructions:
___
|
10640623-DS-23
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DS
| 23 |
2133-01-26 00:00:00
|
2133-01-26 18:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim DS / Phenothiazines / Morphine / Compazine / Effexor
Attending: ___.
Chief Complaint:
Low back pain
Major Surgical or Invasive Procedure:
Port placement (___)
Radiation treatment x 10
History of Present Illness:
___ year old femal with PMH significant for chronic low back pain
with known spinal stenosis (with previous L4-L5 laminectomy in
___, NIDDM, HTN, HLD, GERD, depression and obestity who
presents with inability to ambulate in the setting of acute on
chronic low back pain.
The patient has been followed closely by her PCP for chronic low
back pain complaints and was recently seen in clinic on
___. At that time, her gabapentin was no longer providing
relief. She was instructed to engage in ___ and see the Spine
Center regarding her pain. On ___, her gabapentin was
increased to 600mg PO BID without benefit. She now presents
because on the morning of admission her low back pain resulted
in her being unable to get out of bed or ambulate. She notes no
inciting event or trauuma. She notes that the pain is a ___
in intensity located in the middle of her lower back, described
as sharp and intermitten. She notes that lying flat improves
the pain, but that movement makes it worse. The pain does not
radiate below the buttocks and there is no radiculopathy
component. At baseline, she is able to ambulate without an
assistive device. This morning she was unable to get out of bed
and her day program RN called and had EMS sent to her home. She
denies weakness, numbness or tingling in her extremities. She
denies fever or chills. She has no bladder or bowel
incontinence. No recent weight loss or nightsweats.
On arrival to the ED, intiial VS 98.5, 68, 136/70, 14, 97% RA.
Laboratory studies were notable for a WBC 6.1, HCT 31.6%, PLT
141. Her Cr was elevated to 2.2 (baseline 0.9-1.1). Her INR
was 1.2. A T/L/S spine radiograph revealed an acute L1
compression fracture and orthopedic spine was consulted.
Physical therapy was alco consulted. She was given Diazepam mg
PO x 1, Zofran ODT 4mg PO x 1, Dilaudid 2mg PO x 1, and toradol
30mg IV x 1 with some improvement in her pain.
Past Medical History:
1.) Chronic low back pain, spinal stenosis
2.) HTN
3.) HLD
4.) NIDDM
5.) GERD, reflux esophagitis
6.) Obesity
7.) migraine headaches
8.) depression
9.) DVT (with pulmonary embolism, has ___ IVC filter due
to poor anticoagulation).
10.) Hiatal hernia
11.) s/p choleystectomy
12.) s/p hysterectomy, BSO
13.) s/p L4-L5 laminectomy
14.) s/p right perional craniotomy for clipping of an anterior
communicating artery aneurysm (___)
Social History:
___
Family History:
Most of family history is unavailable since patient was a foster
child. Denies significant family history of cardiovascular
disease, early MI, arrhythmia or sudden cardiac death. Denies
family history of malignancy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 99.4, 122/60 64 16 95% RA
GENERAL: Appears in no acute distress. Alert and interactive.
Well nourished appearing and obese.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy. JVD unable to assess given
body habitus.
___: Regular rate and rhythm, II/VI early systolic murmur at
___ without radiation, no rubs or gallops. S1 and S2 normal.
RESP: Clear to auscultation bilaterally without adventitious
sounds. No wheezing, rhonchi or crackles. Stable inspiratory
effort.
ABD: soft, obese and non-tender, non-distended, with normoactive
bowel sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses
NEURO: CN II-XII intact throughout. Alert and oriented x 3. DTRs
2+ throughout, strength ___ bilaterally, sensation grossly
intact. Gait deferred.
MUSK: Lumbar spine without point tenderness along the vertebra;
tender to palpation just lateral to L1-2 region. Straight leg
raise negative.
DISCHARGE PHYSICAL EXAM:
PHYSICAL EXAM:
VS - T 99.4 BP 136/80 HR 74 RR 20 SaO2 94% on RA.
GENERAL - Alert, oriented to self, location, my name. Does not
know the year. No acute distress. Does not remember going to
radiation treatments or her diagnosis. Appears in mild
distress.
HEENT - PERRLA, EOMI, MMM, no thrush
NECK - Supple, no JVD
CARDIOVASCULAR - RRR, ___ systolic murmur loudest at the LUSB,
no r/g, anterior chest pain is reproducible on palpation
LUNGS - CTAB. Breathing unlabored, no accessory muscle use,
lungs clear to auscultation bilaterally.
ABDOMEN - BS normoactive, soft, ND. Pain on deep palpation of
midepigastrium.
EXTREMITIES - Nonedematous, 2+ pulses, no c/c/e. Ecchymoses
present at PIV sites.
SKIN - No rashes.
NEUROLOGICAL - CN ___ grossly intact. Moving all four limbs
spontaneously. Follows commands.
ACCESS: Tunneled line in double-lumen Power Port-A-Cath in right
Pertinent Results:
#ADMISSION LABS:
___ 09:03PM GLUCOSE-94 UREA N-47* CREAT-2.2*# SODIUM-138
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-28 ANION GAP-12
___ 09:03PM estGFR-Using this
___ 09:03PM WBC-6.1 RBC-3.17* HGB-10.7* HCT-31.6*
MCV-100* MCH-33.8* MCHC-33.8 RDW-14.9
___ 09:03PM NEUTS-26.9* LYMPHS-64.1* MONOS-5.5 EOS-2.7
BASOS-0.8
___ 09:03PM HYPOCHROM-OCCASIONAL ANISOCYT-1+
POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL
POLYCHROM-OCCASIONAL
___ 09:03PM PLT SMR-LOW PLT COUNT-141*
___ 09:03PM ___ PTT-34.2 ___
CBC TREND
=========
___ 09:03PM BLOOD WBC-6.1 RBC-3.17* Hgb-10.7* Hct-31.6*
MCV-100* MCH-33.8* MCHC-33.8 RDW-14.9 Plt ___
___ 06:30AM BLOOD WBC-4.8 RBC-2.68* Hgb-8.8* Hct-27.0*
MCV-101* MCH-33.0* MCHC-32.8 RDW-14.9 Plt ___
___ 05:50AM BLOOD WBC-5.3 RBC-2.26* Hgb-7.9* Hct-23.1*
MCV-102* MCH-34.8* MCHC-34.0 RDW-15.9* Plt ___
___ 07:35AM BLOOD WBC-4.0 RBC-2.58*# Hgb-8.3* Hct-24.9*
MCV-97 MCH-32.1* MCHC-33.2 RDW-18.6* Plt ___
___ 06:10AM BLOOD WBC-3.8* RBC-2.73* Hgb-9.0* Hct-26.6*
MCV-98 MCH-33.0* MCHC-33.9 RDW-17.5* Plt ___
___ 12:00AM BLOOD WBC-3.4* RBC-2.68* Hgb-8.9* Hct-26.3*
MCV-98 MCH-33.3* MCHC-33.8 RDW-17.0* Plt ___
___ 12:00AM BLOOD WBC-2.3* RBC-2.46* Hgb-8.4* Hct-24.6*
MCV-100* MCH-34.0* MCHC-34.0 RDW-17.2* Plt ___
___ 12:00AM BLOOD WBC-2.4* RBC-2.52* Hgb-8.5* Hct-25.2*
MCV-100* MCH-33.8* MCHC-33.8 RDW-17.2* Plt ___
MULTIPLE MYELOMA LABS
=====================
___ 03:53PM BLOOD FREE KAPPA AND LAMBDA, WITH K/L RATIO
Test Result Reference
Range/Units
FREE KAPPA, SERUM 226.9 H 3.3-19.4 mg/L
FREE LAMBDA, SERUM 7.0 5.7-26.3 mg/L
FREE KAPPA/LAMBDA RATIO 32.41 H 0.26-1.65
___ 12:44PM URINE U-PEP-NO PROTEIN
___ 01:05PM BLOOD PEP-ABNORMAL B b2micro-6.3* IgG-3184*
IgA-51* IgM-21* IFE-MONOCLONAL
___ 07:35AM BLOOD PEP-ABNORMAL B b2micro-2.7* IgG-2900*
IgA-41* IgM-17*
MICROBIOLOGY:
=============
___ 11:50 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
C-diff PCR (___): Negative.
IMAGING:
========
Spine Films:
Compression deformity of the superior end plate of the L1
vertebral body with 40% loss of anterior height; indeterminate
chronicity, correlate with clinical examination.
Skeletal Survey:
1. Superior endplate wedge deformity of L1 with 30% loss of
height.
2. Focal scalloping of medial cortex along the mid shaft of the
right femur, as well as lucencies in the cavarium and in
bilateral femoral shafts, suggestive of myelomatous disease
involvement.
MRI L-SPINE AND T-SPINE W/OUT CONTRAST (___):
1. Extensive multiple myeloma, with infiltration of virtually
the entire spine.
2. Compression deformity of the L1 vertebra, with ~40% loss of
height. A large soft tissue component retropulsed into epidural
space, and occupies roughly one-third of the total
cross-sectional area of the canal, but without significant nerve
root crowding or compression.
3. Tumoral infiltration of the L1 posterior elements
bilaterally, right more marked than left, resulting in right
neural foraminal narrowing, contacting and likely impinging upon
the exiting right L1 nerve root.
3. Additional most marked disease at T1, T2, T3, T7, T9,
without compression fracture or epidural or paraspinal soft
tissue abnormality. No acute malalignment of the cervical,
thoracic or lumbar spine.
4. No spinal cord compression or signal abnormality.
5. Degenerative disease, unrelated to the underlying
malignancy, most significant at L4/5, with severe bilateral
neural foraminal stenosis and exiting neural compression.
6. Bilateral pleural effusions.
V/Q Scan (___): Low likelihood ratio for recent pulmonary
embolism.
EEG (___): This telemetry captured no pushbutton activations.
It showed a slow, encephalopathic background throughout.
Systemic illnesses and medications are most common causes of
such findings. There was also some additional focal right
frontal slowing suggestive of a subcortical dysfunction on the
right. There were no epileptiform features or electrographic
seizures.
ECG: SR, NANI, no e/o ischemia, no change from prior ECG
CT CHEST (___):
1. Generalized osteolytic bone lesions.
2. Small bilateral pleural effusions with subsequent areas of
atelectasis. The morphology of the opacities is not suggestive
of pneumonia.
3. No evidence of metastatic disease, but two non-suspicious
perifissural pulmonary nodules.
4. Borderline size of the heart. No lymph node enlargement.
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION
==================================
#) MULTIPLE MYELOMA - Skeletal survey consistent with
myelomatous disease in conjunction with elevated SPEP and B2
microglobulin. Blood viscosity was normal. Bone marrow biopsy
on ___ confirmed diagnosis, showing hypercellularity with
involvement by plasma cell dyscrasia. Presented with ___ to Cr
of 3.3 on admission, likely from myelomatous light chain
glomerular injury as outlined below. Received bortezomib
(Velcade) on ___, and ___. Radiation oncology was
consulted and delivered XRT to L1 vertebra during this admission
fractionated into ten 300 cGy treatments for a total dose of
3000 cGy. One dose of radiation was missed on ___ since the
field was unable to be visualized given overlying bowel gas.
The patient tolerated both bortezomib and radiation treatments
without incident. She continued to experience constipation
which is baseline, but probably worsened given bortezomib
therapy. This was appropriately addressed using scheduled
laxatives.
#) ACUTE ON CHRONIC LOW BACK PAIN, ACUTE L1 COMPRESSION
DEFORMITY - Patient has strong history of chronic low back pain
in the setting of known spinal stenosis and prior L4-5
laminectomy. Now presenting with an acute L1 compression
fracture. Ortho-spine evaluated the patient, decided that she is
not a surgical candidate, and recommended a TLSO brace and
physical therapy given the stability and have asked for her to
follow-up in clinic. She was predisposed to compression
fractures given DEXA scan ___ with a T-score of -0.3 and the
myelomatous lesion further weakened the vertebra. The patient's
pain was controlled in-house with Oxycodone SR (OxyconTIN) 60 mg
PO BID, OxycoDONE (Immediate Release) ___ mg for breakthrough,
and Gabapentin 300 mg QD. To follow-up with orthopedics (Dr.
___ as an outpatient.
#) CONFUSION - Since CVA in ___, patient apparently has had
baseline confusion, with severe deficits in short-term memory
and confabulation as compensation. Oriented to self only
initially. Continually forgot meeting healthcare staff that had
seen her daily. Consistently did not recall diagnosis of
multiple myeloma, XRT treatments, or receiving chemotherapy with
Velcade. Daughter (HCP) contacted and reported that this was
baseline for her since her stroke in ___. Was seen by
neurology while in house and had EEG which did not show
epileptic activity, but did show encephalopathy. MRI was
unrevealing other than her known history of CVA. Neurology
offered LP but patient declined. Of note, vitamin B12 was noted
to be low, so supplementation was started with plan to continue
as an outpatient.
#) CHEST PAIN - Noted to have nonexertional, palpable chest pain
throughout admission. Given distribution of lytic bone lesions
on CT chest and EKG negative for ischemia, felt to be noncardiac
chest pain more related to lytic rib lesions.
#) HYPOXEMIA - Noted to be transiently hypoxemic with O2
saturations in low ___ and labored breathing. V/Q scan showed
no evidence of thromboembolic disease. Felt to be due to
splinting from lytic chest wall lesions; O2 saturation
normalized when pain control improved.
#) ACUTE RENAL INSUFFICIENCY - Acute creatinine elevation to 3.3
(with baseline of 0.8-1.1) and elevated BUN to 47. No history
of decreased PO intake. Renal ultrasound normal. Creatinine
improved to 1.0 by ___ with IVF hydration and remained WNL
for the remainder of her hospitalization. Medications were
renally-dosed.
#) NON-INSULIN DEPENDENT DIABETES MELLITUS - History of diabetes
mellitus without retinopathy or known nephropathy or neuropathy.
Maintained on oral hypoglycemics and not requiring insulin
treatment. Last HbA1c was 8.6% in ___, which has been
climbing. We added glipizide to the patient's regimen on
___. We did not add back her metformin because her blood
glucose readings stabilized in the 100-150 range.
#) HYPERTENSION - BP well controlled and continued to be well
controlled while holding her thiazide and ACEI. We continued
her metoprolol 50mg PO BID.
#) HYPERLIPIDEMIA - Continue Simvastatin 5 mg PO daily.
#) DEPRESSION - Continue Fluoxetine 10 mg PO daily
TRANSITIONAL ISSUES
===================
- Close follow-up with Dr. ___
- ___ of social work while at ___ since patient
likely cannot complete her ADLs without significant assistance.
- Continue vitamin B12 supplementation since this deficit could
be contributing to her encephalopathy/confusion
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Fluoxetine 10 mg PO DAILY
2. Gabapentin 600 mg PO BID
3. GlipiZIDE XL 5 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
Do Not Crush
7. Metoprolol Tartrate 50 mg PO BID
8. Omeprazole 10 mg PO DAILY
9. Simvastatin 5 mg PO DAILY
10. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Gabapentin 300 mg PO Q24H
3. Metoprolol Tartrate 50 mg PO BID
4. Omeprazole 10 mg PO DAILY
5. Simvastatin 5 mg PO DAILY
6. Acyclovir 400 mg PO Q8H
RX *acyclovir 400 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
7. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea
8. Atovaquone Suspension 1500 mg PO DAILY
9. Bisacodyl 10 mg PO DAILY
Hold for diarrhea
10. Docusate Sodium 100 mg PO BID
Hold for diarrhea
11. Lactulose 15 mL PO BID
Hold for diarrhea
12. Lorazepam 0.5-1 mg IV Q4H:PRN Anxiety/Agitation
13. Oxycodone SR (OxyconTIN) 60 mg PO Q12H bone pain from
multiple myeloma
hold for sedation or RR < 12
RX *oxycodone [OxyContin] 60 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
14. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN
breakthrough pain
Hold for sedation.
Hold for RR < 12.
RX *oxycodone 10 mg 1 tablet(s) by mouth every four (4) hours
Disp #*180 Tablet Refills:*0
15. Polyethylene Glycol 17 g PO DAILY
Hold for diarrhea
16. traZODONE 25 mg PO ONCE:PRN insomnia
hold for oversedation or RR<12
17. GlipiZIDE XL 5 mg PO DAILY
18. Lisinopril 10 mg PO DAILY
19. Fluoxetine 10 mg PO DAILY
20. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses-
Multiple myeloma
L1 Compression fracture - Spinal canal involvement, but no
cord compression.
Dementia
Spinal stenosis
Secondary diagnoses-
Obesity
Non-insulin dependent diabetes mellitus
GERD
Depression
Migraine headaches
Hypertension
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 ___,
___ was a pleasure taking care of you at ___
___. You were admitted for back pain and after
getting imaging of your back, you were found to have evidence of
a blood cancer called multiple myeloma. The cancer was found to
be located in numerous bones throughout your body, including
your rib cage, arms, and your vertebrae. You had an especially
concerning lesion in the L1 lumbar vertebra which was impinging
on the spinal canal but fortunately not compressing the spinal
cord. You will need to continue wearing your back brace when
you are out of bed in order to avoid potential spinal cord
injury and paralysis since your spine continues to be weak.
Please follow-up with Dr. ___ for an office
appointment and labs and with Dr. ___ surgery)
for an office visit.
Followup Instructions:
___
|
10640857-DS-14
| 10,640,857 | 20,786,339 |
DS
| 14 |
2180-05-29 00:00:00
|
2180-05-30 18:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
blood in stool
Major Surgical or Invasive Procedure:
___ - sigmoidoscopy
___ -
1. Right common femoral artery access and limited angiogram
2. Celiac artery catheterization and splenic artery
catheterization and angiography (with DynaCT and rotational
angiography)
3. Selective third and fourth order branch (splenic) angiography
4. Selective transarterial embolization of two third/fourth
order branches supplying the superior portion of the spleen
5. Post-embolization DSA angiography of the spleen
History of Present Illness:
___ year old male with PMH stage IIb pancreatic adenocarcinoma
___ whipple and ajuvent chemoradiation. He was believed to be in
remission until presenting in ___ with weightloss and
abdominal pain. Found to have cholelithiasis ___ uptrending,
PED scan showed Focal FDG avidity in proximal pancreatic body
just distal to the anastomosis is concerning for recurrent
disease. He underwent EUS ___ which confirmed adenocarcinoma.
Post proceedure, he had bright red blood in the toilet bowel and
has noted intermittant blood intermixed with stool. He has had
episotic abdominial pain and nausea after eating and ___ weight
loss over 1 month. Seen in clinic on ___ where vitals were HCT
28.5 (down from 32.8 on ___, and 43.8 on ___ where rectal
exam showed external hemorrhoids GUIAC positive. He was admitted
to OMED but left AMA because of frustrations with not being able
to get endocsopy over the weekend. He went to his MD on ___
where he described melena and black, tarry stools. Repeat Hct
was 20, so he was admitted to the hospital from ___ - ___.
.
The patient was admitted to the ICU and received 6 units of
packed red cells. Initial upper endoscopy did not reveal the
source of bleeding, but the scope could not be advanced passed
his surgical anastomosis. Patient continued to have melenic
stools and had repeat EGD showing bleeding from the GEJ,
engorged splenic vessels, and gastric varix most likely due to
splenic vein thrombosis ___ Whipple. This could not be clipped
successfully and bleeding continued necesitating addition 5
units of red cells, 6 pack of platelets and 2 units of FFP via
the massive transfusion protocol. Tagged RBC scan did not reveal
bleeding and ___ angiogram did not show extravasation. Patient
finally underwent repeat EGD where cyanoacrylate glue was
injected on ___. Patient received additional 3 units red cell
transfusion and hematocrit remained relatively stable following
the procedure without need for further transfusion.
On day of discharge and the day prior, patient is having some
ongoing maroon color to his stools. However, he remains
completely asymptomatic and hemodynamically stable, and
importantly his Hct had been stable ~30 for > 3 days.
.
Patient had routine HCT check 2 days prior to admission which
was 30, and the day prior to admission was 29. He came back for
repeat check on the day of admission where it was 24.5. Patient
noted BRBPR spotting over the past few days which he describes
as not "bright" but not marroon or "dark like the last time."
He also noted a change in his diet the past week which caused
hemorrhoids which he thinks may also be a source of his anemia.
.
Vitals in the ER: 98.2 79 94/60 20 100% ra but repeat bp was
138/74 on arrival to his room in the ER. He received 1L of IVF
and 1 unit PRBCs. He also notes some chronic, mild abdominal
pain for weeks which is ___ and relieved with oxycodone.
.
Review of Systems:
(+) Per HPI, weight loss
(-) Denies fever, chills, night sweats, recent weight gain.
Denies blurry vision, diplopia, loss of vision, photophobia.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies chest pain or tightness, palpitations, lower extremity
edema. Denies cough, shortness of breath, or wheezes. Denies
nausea, vomiting, diarrhea, constipation, hematemesis. Denies
dysuria, stool or urine incontinence. Denies arthralgias or
myalgias. Denies rashes or skin breakdown. No numbness/tingling
in extremities. All other systems negative.
Past Medical History:
# Onc Dx: Stage IIB (T3N1MO) pancreatic adenocarcinoma
# Onc Tx: ___ Whipple ___ followed by adjuvant chemoradiation
with
gemcitabine and radiation with concurrent ___ which finished
___.
# Onc Hx: Mr. ___ was diagnosed with Stage II pancretic
cancer
in ___ when he presented with a two week history of
abdominal pain and jaundice. FNA of a pancreatic head mass
showed
atypical cells suspicious for adenocarcinoma and he underwent a
Whipple at ___ on ___. Pathology revealed a 4.5cm
moderately to poorly differentaited adenocarcinoma of the
pancreatic head with extension directly into the ___
soft tissue and peripancreatic lymph nodes and wall of the
duodenum and duodenal mucosa. There was LVI and perineurla
invasion, although the margins were negative. Two out of 26
lymph
nodes were involved. Of note, chronic pancreatitis and PanIN 3
were present diffusely. He recieved adjuvant chemoradiation with
gemcitabine and radiation with concurrent ___ which finished
Finished ___.
# Pt lost to follow up from ___ to ___, represented ___
abdominal pain, weight loss - CT imaging ___ demonstrated a
new heterogenously enhancing 2.7x3.6cm lesion in the posterior
aspect of the right lobe of the liver abutting the liver
capsule. Also noted was a stable 1.3x0.7 mesenteric lymph node
adjacent to the SMA. Labs demonstrated glucose to 318 ___s
___ of 742. He was evaluated by Dr. ___ discussed
systemic chemotherapy options for a presumed metastatic
pancreatic cancer.
PAST MEDICAL HISTORY:
- Liver cysts
- Pancreatic insufficiency
- chronic pancreatitis on whipple specimen
- PanIN 3 diffusely on whipple specimen.
- tonsillectomy as a youth
- surgical repair for wrist/forearm injury
Social History:
___
Family History:
- no pancreatic cancer
Mother: diabetes
Father: HTN
Cousin: Stomach cancer.
Physical Exam:
Admission Exam
VS: T 97.9 bp 110/67 HR 69 RR 19 SaO2 100RA Wt 169.9 lbs
GEN: NAD, awake, alert
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and
without lesion
NECK: Supple, no JVD
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Soft, NT, ND, bowel sounds present
MSK: normal muscle tone and bulk
EXT: No c/c/e, 2+ ___ bilaterally
SKIN: No rash, warm skin
NEURO: oriented x 3, normal attention, CN II-XII intact, ___
strength throughout, intact sensation to light touch
PSYCH: appropriate
Discharge Exam
GEN: NAD, awake, alert
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and
without lesion
NECK: Supple, no JVD
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use. CTAB
ABD: Soft, NT, ND, bowel sounds present
MSK: normal muscle tone and bulk
EXT: No c/c/e, 2+ ___ bilaterally
SKIN: No rash, warm skin
NEURO: oriented x 3
Pertinent Results:
Admission Labs:
___ 03:15PM BLOOD WBC-3.0* RBC-3.03* Hgb-9.1* Hct-27.1*
MCV-90 MCH-30.0 MCHC-33.5 RDW-14.6 Plt ___
___ 03:15PM BLOOD ___ PTT-29.9 ___
___ 06:02AM BLOOD Ret Aut-3.7*
___ 03:15PM BLOOD Glucose-162* UreaN-18 Creat-1.2 Na-138
K-4.1 Cl-101 HCO3-27 AnGap-14
___ 06:02AM BLOOD Calcium-8.1* Phos-4.2 Mg-2.1
___ 03:25PM BLOOD Vanco-7.9*
Pertinent Interval Labs:
___ 11:25PM BLOOD CK-MB-1 cTropnT-<0.01
___ 08:45AM BLOOD CK-MB-1 cTropnT-<0.01
___ 03:25PM BLOOD Vanco-7.9*
___ 03:40PM BLOOD Vanco-13.4
Discharge Labs:
___ 09:10AM BLOOD WBC-7.4 RBC-3.62* Hgb-10.5* Hct-32.7*
MCV-90 MCH-28.9 MCHC-32.0 RDW-14.9 Plt ___
___ 09:10AM BLOOD Glucose-182* UreaN-6 Creat-1.0 Na-139
K-4.0 Cl-102 HCO3-28 AnGap-13
___ 06:02AM BLOOD ALT-21 AST-20 LD(LDH)-118 AlkPhos-41
TotBili-0.4
___ 09:10AM BLOOD Calcium-8.0* Phos-2.5* Mg-1.8
Studies:
Splenic Embolization (___):
CONCLUSION: Successful transarterial embolization of the
approximately 60% of the spleen using a combination of coil
embolization and Gelfoam.
Brief Hospital Course:
BRIEF CLINICAL SUMMARY:
___ with stage IIb pancreatic adenocarcinoma ___ Whipple and
adjuvant chemoradiation with oncologic recurrence, splenic varix
and history of GIB who presents with recurrent GIB. During this
course of hospitalization, pt is now ___ splenic embolization
for varix on ___ with resultant abdominal pain, requiring
PCA. He received 3 uPRBC throughout this hospitalization, with
stabilization of Hct at ~ 30.
ISSUES:
# Acute blood loss anemia secondary to gastric varix
Etiology of GIB is most likely secondary to known gastric varix.
Patient had flex sigmoidoscopy this admission (___) that
revealed hemorrhoids but no other pathology. Patient had
extensive work-up during last hospitalization with EGD showing
bleeding from GEJ, engorged splenic vessels, and a gastric varix
most likely due to splenic vein thrombosis ___ Whipple. Prior
surgical evaluation did not find area to intervene upon. Patient
has undergone ___ embolization of splenic artery on ___ for
definitive therapy. Hct has been stable throughout
hospitalization with no active signs/symptoms of bleeding after
receiving 3 unit pRBC. Hct is now stable around 30. Hct at
discharge was 32.7.
# ___ splenic embolization
Patient had splenic embolization on ___ in attempts to
intervene upon varix. He has significant post-procedure pain in
LUQ with no peritoneal signs, initially requiring a morphine
PCA. Patient was transitioned to morphine long acting and short
acting to manage post-procedural pain (both in L abdomen and
more so in L shoulder). L shoulder appeared to be referred pain,
worse w/ deep breath, no MSK appearing pain. The patient was
educated on strategies to wean morphine as pain improves at
home. He had no apparent vascular complications in the right
groin as result of access. No bruit or hematoma was detected.
His pulse exam showed femoral, DP, ___ intact and 2 +
bilaterally. ___ also advised that he continue on
vancomycin/zosyn for a 48hr course of vancomycin and a 5-day
course of zosyn (___). The patient completed both
before discharge.
# Thrombocytopenia
Uncertain etiology - may have marrow suppresion from cancer. He
has had low platelets since ___. No evidence of DIC. Resolved
by d/c w/ plt 160 on day of d/c.
# Pancreatic Ca ___ whipple with recurrence ___
Of note, only the patient's sister (___) is aware of his
diagnosis and recurrence of cancer. The patient wishes that his
family not be made aware of his diagnosis for now. The patient
will follow-up with his primary oncologist ___ discharge to
strategize future therapeutic/palliative approaches.
#Type 2 diabetes mellitus:
He was continued on insulin therapy in house.
#Anxiety: He was continued on at___ during hospitalization.
# CODE STATUS: Full (confirmed)
# EMERGENCY CONTACT: Sister ___ ___
TRANSITIONAL ISSUES:
1. ___ follow-up: ___ contacted, will arrange for
post-discharge f/u, if any necessary.
2. oncology follow-up: to to f/u w/ Dr. ___ discharge.
3. pain control: pt sent home with MS contin and MS ___, and was
explained strategies to wean with pain relief
4. f/u EGD by Dr. ___ to assess for ? resolution of varices
___ splenic embolization
5. GI f/u w/in 2 weeks
Medications on Admission:
1. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: ___ Caps PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain/ headache.
3. NPH insulin human recomb 100 unit/mL (3 mL) Insulin Pen Sig:
Ten (10) units Subcutaneous at bedtime.
4. Humalog 100 unit/mL Solution Sig: sliding scale units
Subcutaneous with meals.
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
6. Klonopin 2mg PO qHS
Discharge Medications:
1. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: ___ Capsule, Delayed Release(E.C.)s
PO three times a day: with meals.
2. insulin lispro 100 unit/mL Solution Sig: per sliding scale
units Subcutaneous three times a day: Take with meals. Continue
your previous sliding scale that you were on prior to
hospitalization.
3. NPH insulin human recomb 100 unit/mL (3 mL) Insulin Pen Sig:
Ten (10) units Subcutaneous at bedtime.
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
5. clonazepam 1 mg Tablet Sig: Two (2) Tablet PO QHS (once a day
(at bedtime)): do not drive or drink alcohol while taking this
medication.
6. morphine 15 mg Tablet Sig: One (1) Tablet PO every ___ hours
as needed for pain for 2 weeks: Do not drive or drink alcohol
while taking this medication. As your pain improves, you should
decrease your frequency of taking.
Disp:*80 Tablet(s)* Refills:*0*
7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
Disp:*180 Tablet(s)* Refills:*0*
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Continue taking while taking morphine pain
medication. Hold for loose stools. .
Disp:*60 Capsule(s)* Refills:*0*
9. senna 8.6 mg Tablet Sig: ___ Tablets PO BID (2 times a day)
as needed for constipation: Continue taking while taking
morphine pain medication. Hold for loose stools.
Disp:*80 Tablet(s)* Refills:*0*
10. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q8H (every 8 hours) for 2 weeks: Do not
drive or drink alcohol while taking this medication. .
Disp:*42 Tablet Extended Release(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis:
gastrointestinal bleeding
secondary diagnosis:
portal hypertension
pancreatic adenocarcinoma
diabetes mellitus, type II
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.
You were admitted to the ___
for bleeding from your gastrointestinal tract.
We performed a splenic embolization procedure to relieve the
pressure in your portal venous system, which should relieve the
bleeding. We initially gave you some blood products before your
procedure. After the procedure, your blood counts were all
stable.
After the procedure, you did have left abdominal pain and left
shoulder pain, which we treated with morphine.
You should continue to take all of your previous medications
that you had prior to your hospitalization, EXCEPT:
ADD morphine immediate release, 15mg tablet, every ___ hours, as
needed for pain. You should reduce the frequency that you take
this medication as you begin to feel better.
ADD morphine extended release, 15mg tablet, every 8 hours. You
should reduce the frequency that you take this medication over
time as well. When you only require one or two of the short
acting tablets every day, you should reduce your extended
release pill to twice per day. Continue to titrate down as able
over two weeks.
ADD senna, colace, miralax for constipation, while you are
taking the morphine.
ADD tylenol
STOP oxycodone
Followup Instructions:
___
|
10640977-DS-12
| 10,640,977 | 20,252,070 |
DS
| 12 |
2166-10-26 00:00:00
|
2166-10-28 06:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lactose
Attending: ___.
Chief Complaint:
cough, SOB, fevers
Major Surgical or Invasive Procedure:
placement of right IJ central line
History of Present Illness:
___ year old woman with mixed connective tissue disease with
features of scleroderma (on chronic prednisone), ILD, trigeminal
neuralgia, esophageal dysmotility, HTN, and diastolic CHF, who
presents with 2 days of fatigue, non-productive cough, and
subjective fevers. Has also been feeling more SOB. Denies
headache, neck pain, chest pain, palpitations, abdominal pain,
diarrhea, or dysuria.
.
In the ED initial VS were 102.8, 138, 141/60, 30, 93% on RA.
Exam notable for bibasilar rales, benign abdominal exam. Labs
notable for WBC 18.9 (90% PMNs), lactate 6.1, trop 0.12 -> 0.14,
UA neg. EKG with STD laterally, though resolved with decreasing
HR. CXR showed small right pleural effusion, mild pulmonary
edema, possible pneumonia. Patient was given vanc/zosyn for
suspected pneumonia, ASA 325mg, hydrocortisone 100mg, and 1L NS
and repeat lactate was 2.6. She remained borderline hypotensive
with MAPs 55-60 so a right IJ was placed and patient was started
on levophed. She received a total of 2.5L NS. CT abd/pelvis was
performed and patient was transferred to the MICU for further
evaluation.
.
On arrival to the MICU, the patient is comfortable and states
that her breathing is improved and she is feeling more
comfortable.
Past Medical History:
- Mixed connective tissue disease with features of scleroderma
(high-titer positive ___, 1:1280 in a speckled pattern, positive
RNP antibodies,normal RF, neg anti-CCP antibody testing, neg
Ro/La, neg anti-Scl-70 Ab, neg ___, neg anticentromere Ab)
- Interstitial lung disease
- Patulous esophagus
- GERD
- Trigeminal neuralgia
- Raynaud's complicated by right index finger ischemic
ulceration s/p surgical intervention one year ago
- Diastolic CHF
- HTN
- Hyperlipidemia
- Rectal prolapse
- Bilateral knee osteoarthritis
- Chronic low back pain/lumbar stenosis
- Venous stasis, RLE>LLE
- RLE complicated fractures more than ___ years ago following MVA
- H/o right retinal vein occlusion greater than ___ years ago
Social History:
___
Family History:
The patient's brother with diabetes and MI in his ___. No other
family history of any rheumatologic diseases or lung diseases.
Physical Exam:
ADMISSION EXAM:
General: Alert, oriented x3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD, RIJ in place
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Decreased breath sounds and rales at both bases, no
wheezing
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: + foley
Rectal: No prolapse
Ext: Left leg > right leg (chronic), no pitting edema, warm and
well perfused, 2+ ___ pulses, no evidence of raynaud's
Neuro: Slightly dysarthric speech (unchanged and secondary to
the trigeminal neuralgia), decreased sensation over right side
of face, CNs otherwise intact, strenth ___ throughout, sensation
in extremities grossly intact, gait not assessed.
.
DISCHARGE EXAM:
Vitals: 118/69 75 100%RA
General: Alert, oriented x3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Decreased breath sounds and mild course rhonchi at both
bases, no wheezing
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: Left leg > right leg (chronic), no pitting edema, warm and
well perfused, 2+ ___ pulses, no evidence of raynaud's
Neuro: Slightly dysarthric speech (unchanged and secondary to
the trigeminal neuralgia), decreased sensation over right side
of face, CNs otherwise intact, strenth ___ throughout, sensation
in extremities grossly intact, gait intact
Pertinent Results:
ADMISSION LABS:
___ 11:30AM BLOOD WBC-18.9* RBC-5.18 Hgb-13.4 Hct-41.9
MCV-81* MCH-25.8* MCHC-31.9 RDW-16.8* Plt ___
___ 11:30AM BLOOD Neuts-90.8* Lymphs-7.3* Monos-1.2*
Eos-0.4 Baso-0.3
___ 02:20PM BLOOD Glucose-104* UreaN-18 Creat-0.8 Na-136
K-3.6 Cl-98 HCO3-22 AnGap-20
___ 02:20PM BLOOD ALT-24 AST-28 AlkPhos-55 TotBili-0.5
___ 11:30AM BLOOD cTropnT-0.12*
___ 02:20PM BLOOD cTropnT-0.14*
___ 08:00PM BLOOD cTropnT-0.05*
___ 02:20PM BLOOD Albumin-3.3*
___ 11:45AM BLOOD Lactate-6.1*
___ 02:52PM BLOOD Lactate-2.6*
.
DISCHARGE LABS:
___ 06:10AM BLOOD WBC-9.4 RBC-4.51 Hgb-11.1* Hct-36.4
MCV-81* MCH-24.6* MCHC-30.4* RDW-16.6* Plt ___
___ 06:10AM BLOOD Neuts-77.5* ___ Monos-2.3 Eos-0.2
Baso-0.4
___ 06:10AM BLOOD Calcium-8.5 Phos-3.5 Mg-1.9
___ 01:58PM URINE Color-Straw Appear-Clear Sp ___
___ 01:58PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
.
MICROBIOLOGY:
___ BLOOD CULTURE X 2: Pending
___ URINE CULTURE: Negative
.
IMAGING:
CXR PORTABLE AP ___ 11:00: Mild pulmonary vascular
congestion and small right pleural effusion, possibly
exaggerated by low lung volumes or slightly worse compared to
___. Right base consolidation/ infection cannot be
excluded.
.
CXR PORTABLE AP ___ 14:43: There are low lung volumes due
to poor inspiratory effort. There is prominence of the
pulmonary vascular markings suggestive of pulmonary edema.
There is also a right-sided pleural effusion and a developing
left retrocardiac opacity. Heart size is upper limits of normal
but stable. No pneumothoraces are seen.
.
CXR PORTABLE AP ___ 16:25:
There is a right IJ central line with distal lead tip at the
cavoatrial junction. Heart size is again seen enlarged. There
is prominence of the pulmonary vascular marking suggestive of
moderate pulmonary edema. There is a right-sided pleural
effusion. There is a wide vascular pedicle. No pneumothoraces
are seen.
.
CT CHEST ___:
1. Superimposed consolidation within the lower lobes
bilaterally on a background of pulmonary fibrotic changes. This
may represent superimposed pneumonia or aspiration.
2. Bilateral atelectasis within the dependent portions of the
upper lobes which along with the lower lobe consolidation limits
identification of previously noted bilateral pulmonary nodules.
3. Stable enlarged left supraclavicular lymph nodes.
4. Coronary artery calcifications.
5. Patulous esophagus with fluid within the upper esophagus
which places the patient at risk for aspiration.
6. Bilateral hypodense thyroid nodules which could be further
evaluated with thyroid ultrasound on a nonurgent basis if not
previously performed.
.
VIDEO SWALLOW ___: Essentially normal pharyngeal swallow
with one episode of penetration with thin liquids.
Brief Hospital Course:
___ year old woman with mixed connective tissue disease with
features of scleroderma (on chronic prednisone), ILD, HTN, and
diastolic CHF, admitted with bilateral pneumonia complicated by
hypotension, now improving.
.
# Pneumonia/Sepsis: Patient with bilateral infiltrates on CT,
dyspnea and hypoxia on admission. She was found to be in sepsis
on admission, and was briefly placed on levophed. With
initiation of vancomycin and zosyn, respiratory symptoms
improved and hypotension resolved. She was narrowed to
ceftriaxone/azithro, and continued to have stable vital signs
and breath comfortably. She was transferred to the medical
floor. On the floor, she was transitioned to levofloxacin for a
PO outpatient regimen. She continued to saturate well on room
air, and had no fevers. She underwent speech and swallow
evaluation for possible aspiration as the source of her
bilateral pneumonia, but was not found to aspirate. The patient
was discharged on 5 remaining days of levofloxacin. She should
follow up with her primary care physician at discharge.
# Mixed connective tissue disease: Currently on prednisone 20 mg
daily, which is being tapered in preparation for colorectal
surgery. Patient with patulous esophagus and evidence of food
retention, likely due to scleroderma. The patient underwent
speech and swallow bedside evaluation and video swallow. She
was noted to have some oropharyngeal discoordination, without
evidence of aspiration. The patient was also noted to have some
mild food retention in the esophagus. Swallowing difficulties
discussed with outpatient rheumatologist (___), who would
like to start the patient on a promotility agent following her
colorectal surgery. The patient was also started on Bactrim
prophylaxis, as she has been on prolonged high dose steroids.
The patient will follow up with rheumatology as previously
scheduled.
.
# Rectal prolapse: New over past few weeks and associated with
significant pain and decreased quality of life. Has been
evaluated by surgery who would like to wait to repair until
after patient is off steroids. Patient currently undergoing
outpatient steroid taper in preparation for surgery. The
patient was kept on current steroid dose of 20 mg Prednisone
daily throughout admission. She will decrease to 15 mg
prednisone daily per rheumatology recommendations on ___
___. Patient will follow up with surgery as an outpatient
as previously scheduled.
.
# Chronic, compensated, diastolic CHF: Patient was found to have
a small pleural effusion and pulmonary edema on CXR, but overall
appeared euvolemic on exam. She did not require diuresis during
admission. She was continued on aspirin 81 mg daily throughout
admission. Losartan was held for hypotension, but was restarted
with blood pressure stability and transition to the medical
floor.
.
# HTN: Chronic. Losartan held for hypotension on admission.
Once the patient's blood pressure stabilized and she was
transferred to the medical floor, she was resumed on home
losartan.
.
# Hyperlipidemia: Chronic. Continued simvastatin.
.
# GERD: Chronic. Patient was continued on home omeprazole.
.
# ILD: Spirometry from ___ with restrictive defect, though
seems to be improving. Followed by Dr. ___.
.
# Communication: Son ___ ___
.
# Code: Full (confirmed)
========================================
TRANSITIONAL ISSUES:
# Patient to f/u with ___ regarding prednisone taper and
possible promotility agent for esophageal dysmotility
# Patient to f/u with colorectal surgery as previously scheduled
Medications on Admission:
1. Hydromorphine 2mg daily prn pain
2. Losartan 25mg daily (for raynaud's)
3. Omeprazole 20mg BID
4. Prednisone 20mg daily (currently being tapered by rheum)
5. Simvastatin 10mg daily
6. Aspirin 81mg daily
7. Calcium carbonate-Vitamin D3 500mg(1,250 mg)-400 unit; 2 tabs
daily
8. Oxazepam 10mg QHS for insomnia
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 500 mg PO QID:PRN heartburn
3. Levofloxacin 750 mg PO DAILY Duration: 5 Days
RX *levofloxacin 750 mg daily Disp #*5 Tablet Refills:*0
4. Omeprazole 20 mg PO BID
5. PredniSONE 20 mg PO DAILY
Please continue this through ___, then decrease to 15 mg daily
from ___, then decrease to 10 mg daily starting ___.
Tapered dose - DOWN
6. Oxazepam 10 mg PO HS:PRN insomnia
hold for sedation or rr<10
7. Simvastatin 10 mg PO DAILY
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg daily Disp #*30
Tablet Refills:*0
9. HYDROmorphone (Dilaudid) ___ mg PO DAILY:PRN back pain
Hold for sedation or RR<12.
10. Losartan Potassium 25 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: Pneumonia
Secondary diagnosis: Mixed connective tissue disorder,
dysphagia
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 a severe pneumonia
requring a short stay in the intensive care unit. You were
started on antibiotics and your infection improved. You were
transitioned to the medical floor. On the medical floor, you
continued to feel better and were breathing comfortably on room
air. You were transitioned to an oral antibiotic called
levofloxacin. You should continue this for 5 days following
discharge.
.
During your admission, you also complained of difficulty with
swallowing. You underwent a swallow evaluation that showed you
have some difficulty coordinating swallowing, but that you are
still able to do so without causing danger to yourself. Part of
your difficulty swallowing may be caused by your mixed
connective tissue disorder. You should follow up with Dr.
___ this issue. In the mean time, eat multiple
small meals daily and chew food finely before swallowing.
.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
.
MEDICATIONS CHANGED THIS ADMISSION:
START levofloxacin 750 mg by mouth daily for 5 days
START bactrim single strength daily
You should continue prednisone 20 mg daily through this week.
Next ___ - ___ you should decrease to 15 mg
daily, then the following week starting ___ you should
decrease to 10 mg daily.
.
If your symptoms worsen with this slow taper, you should call
Dr. ___ for further management.
Followup Instructions:
___
|
10640977-DS-13
| 10,640,977 | 21,340,360 |
DS
| 13 |
2166-12-04 00:00:00
|
2166-12-04 13:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Lactose
Attending: ___.
Chief Complaint:
nausea, vomiting, diarrhea, abdominal pain
Major Surgical or Invasive Procedure:
Altemeier procedure
History of Present Illness:
.___ year old female with history of a scleroderma-like
autoimmune condition, recent admission for pneumonia, presenting
with acute onset of nausea, vomiting, diarrhea, and abdominal
pain.
.
Patient has been tapering off steroids for the last week and a
half in order to have surgery on her rectal prolapse. She
presents with acute onset of lower abdominal pain, very severe,
around ___ yesterday. She does have chronic abdominal pain,
but states this pain is different and significantly worse than
what she normally experiences. Pain is associated with nausea
and vomiting, she has been incontinent of stools which is
baseline for her given her rectal prolapse. She denies any
bloody stool or melena. No fever/chills/sweats. She denies any
shortness of breath over her baseline. There was also
concomitant onset of back pain. No hematuria, no dysuria.
.
___ ED Course (labs, imaging, interventions, consults):
- Initial Vitals: 97.4 97 162/93 22 96%
- CT Scan - colitis, no abscess, no free fluid
- general surgery consulted in ED, see OMR for note
- received hydromorphone and ondansetron in ED
.
Prior to transfer:
Mental Status: AXOX3
Lines & Drains: 20g L AC
Fluids: 1000mlns
Belongings: Wiht pt
Most Recent Vitals: 98.4 109 20 138/69 98% 2 liters
.
Upon arrival to floor, patient felt better. She still was
reporting ___ lower abdominal pain, but improved since
initial presentation.
.
12 point ROS as noted above, otherwise negative.
.
Past Medical History:
- Recent hospitalization for pneumonia, likely due to aspiration
- Mixed connective tissue disease with features of scleroderma
(high-titer positive ___, 1:1280 in a speckled pattern, positive
RNP antibodies,normal RF, neg anti-CCP antibody testing, neg
Ro/La, neg anti-Scl-70 Ab, neg ___, neg anticentromere Ab)
- Interstitial lung disease
- Patulous esophagus
- GERD
- Trigeminal neuralgia
- Raynaud's complicated by right index finger ischemic
ulceration s/p surgical intervention one year ago
- Diastolic CHF
- HTN
- Hyperlipidemia
- Rectal prolapse
- Bilateral knee osteoarthritis
- Chronic low back pain/lumbar stenosis
- Venous stasis, RLE>LLE
- RLE complicated fractures more than ___ years ago following MVA
- H/o right retinal vein occlusion greater than ___ years ago
Social History:
___
Family History:
The patient's brother with diabetes and MI in his ___. No other
family history of any rheumatologic diseases or lung diseases.
Physical Exam:
VS: 97.8 135/57, HR 73 RR 20 96% RA
General: NAD, AAOx3
Neck: supple
CV: RRR, normal S1, S2, no m,r,g
Pulm: CTAB
Abd: soft, nontender to palpation, no rebound or guarding.
Ext: 2+ radial and DP pulses. chronic venous stasis changes
with trace ___ edema
Pertinent Results:
CXR ___
Comparison is made with prior study ___ and ___.
Moderate cardiomegaly is stable. Widened mediastinum is also
unchanged.
Peripheral opacities in the right lower lobe and right upper
lobe perihilar
opacities are worrisome for pneumonia/aspiration. There is mild
vascular
congestion. Medial bibasilar opacities are likely atelectasis.
There is no
pneumothorax. There is no pleural effusion.
CT ___
IMPRESSION:
1. Stable bibasilar ground-glass opacities compatible with
pneumonia or
aspiration on a background of chronic interstitial lung disease
with interval
development of small bilateral pleural effusions.
2. Interval resolution of the splenic flexure colitis. No
acute
intra-abdominal pathology. No sign of obstruction, stricture or
infection.
3. Small amount of ascites.
4. Prominent enlarged bilateral inguinal and iliac lymph nodes.
This is a
nonspecific finding. Please correlate clinically.
Brief Hospital Course:
___ year old female with history of mixed connective tissue
disease on chronic prednisone, recent hospitalization for
pneumonia presents with acute onset of n/v/d and abdominal pain
with colitis evident on CT imaging.
.
# Acute Colitis- splenic flexure location suggests watershed
area. Cardiovascular risk factors include age, hyperlipidemia,
hypertension. Recent taper off blood pressure medications and
no known hypotension at home but had several episodes in house.
Patient was on chronic immunosuppressive therapy, so must
consider infectious etiology as well. Mesenteric vasculitis is
sometimes associated with MCTD, and prednisone was recently
discontinued about 10 days ago. Initial presentation of IBD
less likely. Given Cipro/Flagyl and IVF. Sent stool cultures
which were all negative. Surgery consulted and recommended
medical management. GI was consulted and did a flex sig which
was incomplete and could not reach the splenic flexure. The
patient improved with supportive care and maintaining her blood
pressure. Dr. ___ team was also following and they
requested a repeat CT scan which was negative. Her cirpo/flagyl
were subsequently discontinued.
.
# Aspiration PNA
During her stay the patient spiked a fever to about 102. A CXR
on ___ revealed RUL and RLL PNA concerning for aspiration.
The patient was started on broad spectrum coverage with
vanco/zosyn. The patiennt was weaned off oxygen and improved.
She completed her course of vanc/zosyn and the antibiotics were
discontinued ___. She was also evaluated by speech and
swallow and they recommended thin liquids and soft consistency
solids.
.
# Hypotension:
Episode of hypotension to 88/42, asymptomatic in setting of
dilaudid and volume depletion. No fever, WBC, or tachcyardia.
Hct stable. Gave IVF and decreased opiate dose. Also checked a
cortisol due to recent tapering of steroids, which was normal.
Her blood pressure normalized until a repeat episode ___,
when she had another episode in the setting of right arm pain
and diuresis. This also improved with IV fluids. Post-operative
day 0 after the Altemeier procedure, she also had an episode of
hypotension to ___ and was resuscitated with 250 cc LR and
500cc 5% albumin. Her BP improved to 90-100s systolic. She had
no further issues with hypotension during her stay.
.
# acute on Chronic diastolic CHF:
The patient was last admitted with dCHF in ___. The patient
had intermitent issues with hypotension requiring IV fluids over
the course of the hospitalization. Her weight increased to over
150 lbs when her baseline weight is closer to 140 lbs. She was
asymptomatic but her CXR showed pulmoanry edema. It was
attempted to diurese her but after one day she dropped her
pressure. Cardiology was consulted and they recommended slow
diuresis. She was kept fluid restricted to no more than 1500 cc
of fluid per day, with a goal of net -500cc/day. And ECG was
obtained during her hypotensive episode on ___ and troponins
x2 were negative, showing mild elevation but no upward increase.
An ECG was also obtained during her hypotensive episode on
___, which showed T-wave inversions. A cardiac work-up was
initiated with troponins x3 and she was found to be negative for
MI. There was some mild elevation in her troponins (0.05) likely
due to her baseline cardiac dysfunction, but no upward
progression of her troponins. Her ECG remained negative for ST
segment changes and patient denied chest pain. T-wave inversions
were also seen on prior ECGs. She was continued on her aspirin
81mg. She otherwise remained stable cardiovascularly during her
stay.
.
# Mixed connective tissue disease: Patient was taken off
prednisone in preparation for colorectal surgery. Patient with
patulous esophagus and evidence of food retention, likely due to
scleroderma. The patient underwent speech and swallow bedside
evaluation and video swallow during recent admission, noted to
have some oropharyngeal discoordination, without evidence of
aspiration. The patient will need to follow-up with her primary
care doctor to determine future prednisone use.
# Rectal prolapse: The patient underwent an Altemeier procedure
on ___ without complication. Post-operatively in the PACU,
the patient's temperature rose to 101.1, HR 110s, and RR ___.
The patient was having chills and evacuated a large amount of
stool. She was given tylenol and closely monitored in the PACU.
She remained afebrile for the rest of her stay and her vital
signs quickly normalized. Post-operatively she did have some
anal pain, which was treated with dilaudid PO. She was able to
have bowel movements POD #2 without pain or discomfort. She was
started on a clear liquid diet POD #1 and advanced to a regular
diet on POD #2. She experienced some nausea and vomiting after
starting a regular diet that was treated with zofran.
.
# Chronic back and neck pain: Patient continued to have chronic
back and neck pain throughout her hospital stay. She was treated
with PO dilaudid and heat packs.
Post-Surgical Complications During Inpatient Admission:
[ ] Post-Operative Ileus resolving w/o NGT
[ ] Post-Operative Ileus requiring management with NGT
[ ] UTI
[ ] Wound Infection
[ ] Anastomotic Leak
[ ] Staple Line Bleed
[ ] Congestive Heart failure
[ ] ARF
[ ] Acute Urinary retention, failure to void after Foley D/C'd
[ ] Acute Urinary Retention requiring discharge with Foley
Catheter
[ ] DVT
[ ] Pneumonia
[ ] Abscess
[ ] None
Social Issues Causing a Delay in Discharge:
[ ] Delay in organization of ___ services
[ ] Difficulty finding appropriate ___ hospital
disposition.
[ ] Lack of insurance coverage for ___ services
[ ] Lack of insurance coverage for prescribed medications.
[ ] Family not agreeable to discharge plan.
[ ] Patient knowledge deficit related to ileostomy delaying
discharge.
[x] No social factors contributing in delay of discharge.
Medications on Admission:
Aspirin 81 mg PO DAILY
Calcium Carbonate 500 mg PO QID:PRN heartburn
Omeprazole 20 mg PO BID
Oxazepam 10 mg PO HS:PRN insomnia
Simvastatin 10 mg PO DAILY
Sulfameth/Trimethoprim SS 1 TAB PO DAILY
HYDROmorphone (Dilaudid) ___ mg PO DAILY:PRN back pain
Losartan Potassium 25 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
hold for increased sedation or RR<12
RX *hydromorphone 2 mg 1 tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
3. Lidocaine 5% Patch 1 PTCH TD DAILY
RX *lidocaine 5 % (700 mg/patch) once a day Disp #*10
Transdermal Patch Refills:*0
4. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram 1 packet by mouth once a
day Disp #*30 Packet Refills:*0
6. Senna 1 TAB PO BID:PRN constipation
RX *sennosides 8.6 mg 1 tablet by mouth twice a day Disp #*60
Tablet Refills:*0
7. Simvastatin 10 mg PO DAILY
RX *simvastatin 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
8. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
RX *zolpidem 10 mg 1 tablet(s) by mouth at bedtime Disp #*10
Tablet Refills:*0
9. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
10. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute colitis likely ischemic in nature
Aspiration Pneumonia
Mixed Connective Tissue Disease
Interstitial Lung Disease
Rectal Prolapse
GERD
Hypertension
acute on Chronic diastolic CHF
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with acute abdominal pain. CT scan showed the
presence of a left sided Colitis. You were started on
antibiotics and IV fluids, and seen by the surgery team who
didn't think you needed a surgical intervention. GI also
evalauted you and did a sigmoidoscopy which did not show any
abnormalities but it was incomplete. During you stay your were
also found to have a pneumonia, which was treated, as well as
heart failure. You underwent an Altemeier procedure for your
rectal prolapse, which went well and without complications. You
will be discharged to ___ in ___.
.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. Please avoid having more than 1500cc of intake (IV
fluids + orally). No standing maintenance IV fluids, only bolus
as necessary.
Please take all medications as prescribed, and keep all follow
ups. Opiate medications may cause excessive sedation, so please
avoid with alcohol, driving, or with machinery
Please follow-up with your primary care doctor within the next
two weeks to go over your medications, including whether or not
to restart prednisone.
Please take laxatives and stool softeners in order to soften the
consistency of the stool, which will decrease discomfort during
bowel movements post-operatively. Also take fiber supplements or
eat a high-fiber diet. ___ baths can also help with any pain or
discomfort. Try to avoid straining during bowel movements.
Followup Instructions:
___
|
10641052-DS-3
| 10,641,052 | 22,025,489 |
DS
| 3 |
2154-05-30 00:00:00
|
2154-05-30 11:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
morphine
Attending: ___.
Chief Complaint:
Headache.
Major Surgical or Invasive Procedure:
___: Left craniectomy and evacuation of ___
History of Present Illness:
___ c/o headache for several days, increasing. Taking tylenol
and aleve without relief. Went to PCP today and had labs, sent
home. Mental status worsened, went to OSH, head CT showed ___
left ___. He was intubated and transferred to ___ for further
treatment.
Past Medical History:
diabetes, h/o low platelets and elevated INR saw hematologist in
past with no clear diagnosis
Social History:
___
Family History:
He denies any bleeding or clotting disorders in any of his
family members. His father has diabetes.
Physical Exam:
EXAM ON ADMISSION:
O: T:100.5 BP:166 /72 HR:81 R 20 O2Sats 95%
Gen: obese male, intubated, examined in ED trauma bay
Neuro:
intubated, sedated
pupils 4 to 3 bilat
follows commands all 4, no gross motor deficits
EXAM ON DISCHARGE:
VS - AVSS
GEN - NAD, well healing incision without erythema, swelling, or
drainage, helmet in place.
NEURO - A/Ox3. Speech fluent with intact comprehension. Face
symmetric with smile. Tongue midline. No pronator drift. ___ in
deltoid, bicep, tricep, wrist extension, hand grip, finger
abduction bilaterally. SILT in C4-T1 bilaterally. ___ in
___ bilaterally. SILT in L2-S1 bilaterally.
Pertinent Results:
Labs:
___ 08:00PM ___ PTT-29.5 ___
___ 08:00PM PLT SMR-LOW PLT COUNT-93*
___ 08:00PM NEUTS-84.8* LYMPHS-9.6* MONOS-5.1 EOS-0.1
BASOS-0.4
___ 08:00PM WBC-8.7 RBC-5.29 HGB-15.7 HCT-46.1 MCV-87
MCH-29.6 MCHC-34.0 RDW-14.___:
IMPRESSION: Partial evacuation of left convexity subdural
hematoma. Mild
increase in the left parafalcine subdural hematoma is likely
related to
decompression of the parafalcine subdural space. Decreased mass
effect,
including resolution of left uncal herniation and partial
ventricular
reexpansion.
Head CT ___:
1. Status post left frontoparietal craniectomy, with stable
transcranial
herniation with surrounding hemorrhage and scattered
pneumocephalus.
2. Residual left-sided subdural hematoma with redistribution of
left
parafalcine hemorrhage along the falx.
3. Rightward shift of normally-midline structures, improved.
Abdominal US ___: IMPRESSION:
Severe hepatic steatosis. Given the patient's splenomegaly, the
possibility of more significant liver disease such as fibrosis
or cirrhosis should be considered.
Abdominal CT ___:
1. Nodular liver contour and splenomegaly consistent with
cirrhosis and
portal hypertension.
2. Symmetric mural thickening of the distal esophagus, probably
representing esophagitis. Endoscopy is recommended for further
evaluation.
Brief Hospital Course:
Mr. ___ was seen in the ER and admitted to the ICU for
observation. He was taken to the OR on ___ for a left
craniectomy and evacuation of the ___. Post-op head CT showed
interval decrease in SDH and midline shift. He was admitted with
an elevated INR and Hematology was consulted. Repeat INR on
___ remained elevated and his platelets remained low. His
Dilantin level was 3.1 and he received a 500cc bolus and the
standing Dilantin level was increased to 150mg PO TID.
Hematology was consulted and requested lab work and a spleen
ultrasound. U/S revealed severe hepatic steatosis and
spleenomegaly. The drain output remained significant and was not
removed. His exam remained stable and was cleared for transfer
from the ICU on ___. His diet was advanced and head CT
performed which was stable. On ___, hematology recommended
that hepatology be consulted for question of cirrhosis. Keppra
was started due to subtheraputic dilantin level. His JP drain
was removed and vit K was given for an elevated INR. On ___,
hepatology also questions cirrhosis and requested LFTs and
hepatitis serologies be sent. They also recommended that he
follow up with the ___ as an outpatient. He remained
neurologically stable on examination.
He worked with physical therapy who determined that he was safe
for discharge to home with outpatient ___. His hospital course
was otherwise unremarkable. At the time of discharge the patient
was afebrile with stable vital signs that were within normal
limits, pain was well controlled with oral medications,
incisions were clean/dry/intact, the patient was ambulating
safely, was voiding and moving bowels spontaneously, and the
patient's neurological exam was stable/improved. The patient
will follow up with Dr. ___ with a repeat non-contrast head
CT in 4 weeks and with the ___ EGD and outpatient
investigation of his liver disease. A thorough discussion was
had with the patient regarding the diagnosis/surgery and
expected post-discharge course, and all questions were answered.
Medications on Admission:
metformin, glipizide
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever, pain
2. Docusate Sodium 100 mg PO BID
3. GlipiZIDE 5 mg PO DAILY
4. LeVETiracetam 1000 mg PO BID
5. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on chronic subdural hematoma
Cerebral edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Have a friend/family member check your incision daily for
signs of infection.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Your wound was closed with sutures/staples. You may wash your
hair only after sutures and/or staples have been removed.
You may shower before this time using a shower cap to cover
your head.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
Followup Instructions:
___
|
10641243-DS-9
| 10,641,243 | 28,340,890 |
DS
| 9 |
2152-04-20 00:00:00
|
2152-04-21 11:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
___
Attending: ___.
Chief Complaint:
S/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
A ___ male with h/o epilepsy presented to the ED on ___
after a fall from 15-feet with +HS/LOS. He states that he was up
on a lift for work and "lost his momentum" and fell. He reports
that he tried to grab a tree "on the way down" and denies any
seizure activity. In the ED he was found to have a scalp
laceration, L1-l4 transverse process fractures, and L 11th rib
fracture. He was admitted to the trauma service, and today an
over read of a CT abdomen/pelvis identified non-displaced
fractures through the right inferior and superior pubic rami. He
notes that he is having intermittent mid to low back pain that
is exacerbated by movement. He reports he is having some mild
discomfort in the right hip but denies any numbness or tingling
in the right leg. He denies any chest pain, SOB, abdominal pain,
nausea or vomiting.
Past Medical History:
Epilepsy
S/p R hip surgery ___ ___ c/b chronic R foot drop
Social History:
___
Family History:
Non-contributory
Physical Exam:
Physical Exam on Admission:
Gen: NAD, AAOx3
CV: RRR
Resp: CTAB
Abdomen: Soft,
Wound: Incisions clean, dry, intact scalp lacerations sutured
with no active bleeding
Ext: Warm
Physical Exam on Discharge:
Pertinent Results:
___ 06:21AM BLOOD WBC-7.8 RBC-3.73* Hgb-11.5* Hct-36.0*
MCV-97 MCH-30.8 MCHC-31.9* RDW-12.9 RDWSD-46.2 Plt ___
___ 09:25AM BLOOD Neuts-74.2* Lymphs-12.9* Monos-11.5
Eos-0.0* Baso-0.4 Im ___ AbsNeut-5.82 AbsLymp-1.01*
AbsMono-0.90* AbsEos-0.00* AbsBaso-0.03
___ 06:21AM BLOOD Glucose-127* UreaN-17 Creat-0.9 Na-141
K-4.4 Cl-99 HCO3-32 AnGap-10
___ 02:29AM BLOOD CK-MB-11* cTropnT-<0.01
___ 06:21AM BLOOD Calcium-8.7 Phos-2.8 Mg-2.5
___ 02:32AM BLOOD Type-ART pO2-132* pCO2-48* pH-7.41
calTCO2-31* Base XS-5
___ 02:32AM BLOOD Lactate-1.0
___ 02:32AM BLOOD freeCa-1.13
TRAUMA #3 (PORT CHEST ONLY) ___:
IMPRESSION:
No definite acute cardiopulmonary process. Prominent contour of
the
mediastinum most likely a function of technique, to be followed
on subsequent CT.
CT CHEST/ABD/PELVIS W/CONTRAST ___:
IMPRESSION:
1. Acute fracture of the left posterior eleventh rib. Multiple
left
transverse process fractures from L1 through L4.
2. Nondisplaced fractures through the right inferior and
superior pubic rami.
3. No evidence of visceral organ injury.
4. 6 mm hyperdensity in the gallbladder which may represent
stone or polyp.
CT C-SPINE W/O CONTRAST ___:
IMPRESSION:
No fracture or dislocation.
PELVIS AP ___ VIEWS ___:
IMPRESSION:
No new fractures identified on the single AP view of the pelvis.
CTA CHEST ___:
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Extensive consolidation in the bilateral lower lobes and
right middle lobe with air bronchograms. Patchy consolidative
and ground-glass opacities in the right upper lobe. Findings are
compatible with multifocal pneumonia.
3. Right hilar lymphadenopathy, likely reactive.
4. Component of enhancing atelectasis in the left lower lobe.
Small left
pleural effusion.
5. Please see separately dictated report for CT of the
abdomen/pelvis
performed the same day.
CT ABD & PELVIS WITH CONTRAST ___:
IMPRESSION:
1. No source of infection in the abdomen or pelvis.
2. Known fractures are unchanged compared to CT of the torso
from ___.
3. Please refer to separately dictated report for CTA of the
chest performed the same day.
Brief Hospital Course:
Mr. ___ is a ___ year old male, with a PMH significant for
epilepsy who fell 15 ft w/ head strike and +LOC. His imaging
upon admission showed left posterior scalp hematoma/abrasion,
frontal scalp laceration, L1-4 transverse process fractures,
left 11th rib fracture, and right inferior and superior pubic
rami fracture. He was seen by the orthopedics service for his
pubic rami fracture, who felt he did not need surgical
intervention and weight-bearing as tolerated. He was transferred
to the floor hemodynamically stable. His pain was controlled on
oral analgesics. ___ were consulted and he was ambulating with
crutches. On HD3, he was noted to be in respiratory distress
with tachypnea, increased oxygen requirement, and tachycardia to
the 160s. CXR, CTA, ABGs, and labs were ordered. He was
transferred to the TSICU due to his acute hypoxia. He was weaned
off the non-rebreather to hiflow oxygen and eventually nasal
cannula. On HD4, he was transferred back to the floor. Patient
recuperated well on the floor, he worked with physical therapy
which recommended discharge to home. He was weaned off O2 and on
___ was found ready to head home. Patient was instructed
regarding warning signs and discharge instructions, he was also
instructed to continue his respiratory recovery at home using
his IS. He will follow up with us in clinic.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clobazam 20 mg PO QHS
2. LamoTRIgine 375 mg PO QAM
3. LamoTRIgine 450 mg PO QPM
4. LORazepam 1 mg PO Q6H:PRN seizure
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - Third Line
3. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*14 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
5. Clobazam 20 mg PO QHS
6. LamoTRIgine 375 mg PO QAM
7. LamoTRIgine 450 mg PO QPM
8. LORazepam 1 mg PO Q6H:PRN seizure
Discharge Disposition:
Home
Discharge Diagnosis:
Polytrauma
head lacerations
L1-4 transverse process fx,
L 11th rib fx
nondisplaced fx through the R inf and sup pubic rami
Discharge Condition:
Weight baring as tolerated on Right Lower Extremity
Discharge Instructions:
Dear Mr. ___,
You suffered a fall and were admitted to ___ due to your
injuries, you suffered a spine fracture, rib fracture and pelvic
fracture along with lacerations in your scalp. You have
recuperated well and you are now ready to head home.
Please follow this instructions in order to continue your
recovery
* Your injury caused 1 rib fractures which can cause severe pain
and subsequently cause you to take shallow breaths because of
the pain. Please use your IS machine every 10 minutes in order
to continue improving your breathing.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Followup Instructions:
___
|
10641465-DS-21
| 10,641,465 | 22,897,596 |
DS
| 21 |
2126-05-14 00:00:00
|
2126-06-01 15:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right sided pain ___ right posterior stab wound
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with no significant PMHx presents to the ED s/p stab wound,
transfer from ___. The patient was stabbed in his R flank
earlier tonight with an unknown weapon. CT scan at ___ was
concerning for R renal laceration BP to 137/86, stable en route.
O2 Sats 100%. Patient given fentanyl, 2g Ancef, and transerred
here for further evaluation. No meds, history, or allergies. No
head trauma.
Past Medical History:
none
Social History:
___
Family History:
non-contributory
Physical Exam:
Prior to Discharge:
Vitals: T:98.9 BP:134/86 HR:68 RR:18 O2 Sat:93% Ra
___: Patient sitting comfortably in bed; no acute distress
CV: RRR
Pulm: no increased work of breathing
Abd: minimally tender on deep palpation. Dressed stab wound R
posterior flank. Dressing clean, dry, intact.
Extremities: Warm, dry
Pertinent Results:
AT OUTSIDE HOSPITAL:
CT ABD/PELVIS W/ CON: ___ 9:52:28PM
IMPRESSION:
GRADE 3 RIGHT RENAL LAC WITH SMALL PERINEPHRIC HEMATOMA AND
RIGHT RETROPERITONEAL HEMORRHAGE. NO INVOLVEMENT OF RENAL
COLLECTING SYSTEM OR APPARENT ACTIVE BLEEDING.
2. STAB WOUND INJURY RIGHT PARAVERTEBRAL REGION AT LEVEL OF T12
AT ___:
Radiology Report TRAUMA #3 (PORT CHEST ONLY) Study Date of
___ 11:50 ___
IMPRESSION:
Low lung volumes with bibasilar atelectasis. Small right
pleural effusion.
No displaced rib fractures.
CHEST (PORTABLE AP) Study Date of ___ 8:33 AM
IMPRESSION:
Comparison to ___. Lung volumes remain low. The
bilateral
parenchymal opacities are stable in extent and severity. No
evidence of
larger pleural effusions. No pulmonary edema. No pneumothorax.
___ 05:14AM BLOOD WBC-9.9 RBC-5.26 Hgb-15.0 Hct-46.1 MCV-88
MCH-28.5 MCHC-32.5 RDW-12.6 RDWSD-40.3 Plt ___
___ 11:35PM BLOOD ___ PTT-24.9* ___
___ 05:14AM BLOOD Glucose-94 UreaN-7 Creat-0.8 Na-137 K-4.5
Cl-103 HCO3-28 AnGap-6*
___ 05:14AM BLOOD Calcium-9.4 Phos-3.6 Mg-2.2
___ 11:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 11:30PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
Brief Hospital Course:
The patient was transferred from ___ to
___ Emergency Department the evening of ___ . Prior to
being transferred he was CAT scanned at ___ and found to have
stable right renal lac with perirenal hematoma and a small right
hemothorax. He was x-rayed in at the ___ which illustrated the
injuries to be stable and not requiring surgical intervention.
Injuries were managed in a conservative manner and the patients
cardiopulmonary status were monitored closely and his pain
controlled.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed with an opiod-limiting,
multimodal approach.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO. Diet was
advanced sequentially to a Regular diet, which was well
tolerated. Patient's intake and output were closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
___ not take more than 3000 mg in 24 hours. Do not take with
alcohol or other meds with Tylenol
2. Ibuprofen 800 mg PO Q8H
Take with food. Do not exceed 2400 mg in 24 hours
3. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe Duration: 5 Days
Reason for PRN duplicate override: Alternating agents for
similar severity
Only take as few as possible to treat severe pain. Do not take
with alcohol. ___ partially fill.
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*18 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right small hemothorax, Right kidney laceration.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___, You were admitted to ___
___ and underwent monitoring and management of your
injuries from your stab wound. You are recovering well and are
now ready for discharge. Please follow the instructions below to
continue your recovery:
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. -___
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 may 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).
If your incisions are closed with dermabond (surgical glue),
this will fall off on it's own in ___ days. -Your incisions may
be slightly red. 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 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. -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.
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. o 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 ___ 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 your
hospitalization, unless you have been told differently. If you
have any questions about what medicine to take or not to take,
please call your surgeon. Warm regards, Your ___ Surgery Team
Followup Instructions:
___
|
10641592-DS-10
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DS
| 10 |
2178-05-14 00:00:00
|
2178-05-14 18:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / iodine / clonazepam
Attending: ___.
Chief Complaint:
Influenza
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is an ___ ___ speaking female with a history of
hypothyroidism presents with 2 days of cough, fever, vomiting.
Her husband was diagnosed with the flu earlier this week and is
currently intubated in the ICU. She saw her PCP this morning who
prescribed Tamiflu. She has had worsening symptoms since then so
presented to the ER. She denies chest pain, dyspnea, abdominal
pain.
In the ED,
- Initial vitals: T 103.4 HR 111 BP 176/98 RR 20 SPO2 95% RA
- Exam notable for:
General-very uncomfortable
HEENT- PERRL, EOMI, normal oropharynx
Lungs-tachypneic, clear to auscultation bilaterally
CV-tachycardic, no murmurs, normal S1, S2, no S3/S4
Abd- Soft, nontender, nondistended, no guarding, rebound or
masses
Msk- No spine tenderness, moving all 4 extremities
Neuro-A&O x3, CN ___ intact, normal strength and sensation in
all extremities, normal speech and gait.
Ext- No edema, cyanosis, or clubbing
- Labs notable for:
CBC: WBC 4.0 Hb 12.8
BMP: K 4.2 BUN/Cr ___
UA: neg
Flu A PCR: positive
Flu B PCR: negative
- Imaging notable for:
+ CXR
IMPRESSION:
No acute cardiopulmonary process. No definite focal
consolidation
to suggest pneumonia.
- Pt given:
PO Acetaminophen 1000 mg
IV Ondansetron 4 mg
PO Benzonatate 100 mg
IVF LR 1000 mL
PO/NG OSELTAMivir 75 mg
PO/NG Cyclobenzaprine 10 mg
PO Oxybutynin 2.5 mg
PO/NG Propranolol 40 mg
PO Ibuprofen 600 mg
- Vitals prior to transfer:
T 100 HR 74 BP 114/75 RR 18 SPO2 95% RA
Upon arrival to the floor, the patient reports that she has a
severe headache, chills, and feels feverish. She denies
shortness
of breath or chest pain, but does endorse a cough for which she
would like medication. She appears uncomfortable. She would also
like water and cold/damp towels.
REVIEW OF SYSTEMS:
A 10-point ROS was taken and is negative except otherwise stated
in the HPI.
Past Medical History:
PAST MEDICAL HISTORY:
- HTN
- Herpes Virus
- HFpEF
- Hypothyroidism
- GERD
SURGICAL HISTORY
- ___: total thyroidectomy for thyroid CA-SURGERY
- ___: bladder suspension surgery
- ___: cholecystectomy
- Appendectomy with peritonitis in ___
- ___: Melanoma surgery - Dr. ___
- ___: parathyroid surgery
- ___: Total abdominal hysterectomy
Social History:
___
Family History:
FAMILY HISTORY
Her family history is unremarkable for Breast/Ovarian or Colon
cancer.
Physical Exam:
PHYSICAL EXAM:
VITALS: ___ 2336 Temp: 98.1 PO BP: 112/66 HR: 69 RR: 20 O2
sat: 95% O2 delivery: RA Dyspnea: 3 RASS: 0 Pain Score: ___
General: Alert, oriented, appears uncomfortable, but in no
distress.
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
NECK: Neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs,
rubs, gallops. Tachypneic.
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
ABD: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis
or edema
SKIN: Warm, dry, no rashes or notable lesions.
Neuro: A&O x3.
DISCHARGE PHYSICAL EXAM:
VITALS:
24 HR Data (last updated ___ @ 839)
Temp: 98.1 (Tm 98.5), BP: 132/69 (122-154/65-90), HR: 76
(59-76), RR: 18, O2 sat: 94% (93-97), Wt: 171.1 lb/77.61 kg
General: Alert, oriented, appears uncomfortable, but in no
distress.
HEENT: sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
NECK: neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops.
LUNGS: clear to auscultation bilaterally, no wheezes, rales,
rhonchi, non-productive cough w/ deep breaths
ABD: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding, mild tenderness to
palpation on left side
EXT: arm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: arm, dry, no rashes or notable lesions.
Neuro: AxO x3.
Pertinent Results:
ADMISSION LABS:
=============
___ 06:00PM BLOOD WBC-4.0 RBC-4.10 Hgb-12.8 Hct-39.1 MCV-95
MCH-31.2 MCHC-32.7 RDW-13.2 RDWSD-46.7* Plt ___
___ 06:00PM BLOOD Neuts-81.5* Lymphs-9.3* Monos-7.8
Eos-0.3* Baso-0.3 Im ___ AbsNeut-3.26 AbsLymp-0.37*
AbsMono-0.31 AbsEos-0.01* AbsBaso-0.01
___ 05:01AM BLOOD ___ PTT-26.0 ___
___ 06:00PM BLOOD Glucose-121* UreaN-22* Creat-1.0 Na-138
K-4.2 Cl-103 HCO3-22 AnGap-13
___ 05:01AM BLOOD ALT-166* AST-99* LD(LDH)-188 AlkPhos-94
TotBili-0.5
___ 05:01AM BLOOD Albumin-3.6 Calcium-8.8 Phos-4.8* Mg-1.8
DISCHARGE LABS:
==============
___ 05:21AM BLOOD WBC-2.6* RBC-4.13 Hgb-12.8 Hct-40.4
MCV-98 MCH-31.0 MCHC-31.7* RDW-13.2 RDWSD-47.5* Plt ___
___ 05:21AM BLOOD Neuts-49.8 ___ Monos-10.6 Eos-2.7
Baso-0.0 Im ___ AbsNeut-1.31* AbsLymp-0.96* AbsMono-0.28
AbsEos-0.07 AbsBaso-0.00*
RADIOLOGY:
=========
FINDINGS:
No focal consolidation, pleural effusion, or evidence of
pneumothorax is seen.
There are relatively low lung volumes. The cardiac and
mediastinal
silhouettes are unremarkable.
IMPRESSION:
No acute cardiopulmonary process. No definite focal
consolidation to suggest
pneumonia.
Brief Hospital Course:
This is an ___ ___ speaking female with a history of
hypothyroidism presents with 2 days of cough, fever, vomiting.
# Influenza A:
# Fevers/Chills:
Patient presented to PCP ___/ fevers, chills, and cough after her
husband was admitted to the MICU ___. She was started on
oseltamivir and referred to the ED. In the CXR without pneumonia
and she was influenza positive and continued on Oseltamivir. She
was continued on oseltamivir. She received acetaminophen and
benzonatate.
#Transaminitis
Improved during admission, thought to be ___ the flu. Needs to
be trended as an outpatient and consider hepatitis panel
#Leukopenia:
ANC > 1000, likely ___ infection, trend as an outpatient
# Medical literacy and medication adherence
Patient has poor literacy of her medications. Attempted to
address while inpatient, but it was not clear she had
understanding. Will probably need to have her bring all her pill
bottles in to a primary clinic visit to ensure accuracy and
safety of medication use.
Specific med rec issues identified include:
- She is filling two beta blockers (atenolol and propranolol).
We discharged her off atenolol.
- Patient says she is taking oral diclofenac, but there is no
record of this in pharmacy history or outpatient med list
(possibly purchased OTC in ___. While non-prescribed NSAIDs
are worrisome with her CKD, this particular NSAID has a high
risk of gastric ulcerations and possibly a higher risk of
cardiovascular events, which is why you cannot get it easily in
the US.
# Hypothyroidism:
- Continued home Synthroid
- note that she reports an intolerance of generic levothyroxine,
but received this throughout the admission without issue
# HTN
- Continued home propranolol 40 BID
- held atenolol
# Severe insomnia
- Continued home Ativan 1mg PO BID PRN
# GERD
- Ordered for omeprazole as home Nexium is non-formulary
TRANSITIONAL ISSUES:
[] please follow her transaminitis on discharge with repeat LFTs
in 1 week
[] please follow CBC in one week to ensure WBC has improved
[] Please reconcile home medications with patient. She did not
know her home medications and was unaware of what she was
taking. She has active scripts for both propranolol and
atenolol. We discharged her only on propranolol.
[] Ensure safe use of NSAIDS (diclofenac, ibuprofen) in this
patient with CKD and HTN.
[] Her husband is in the ICU in serious condition; please
continue to offer social and emotional support.
#CODE: FC
#CONTACT: ___) - ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Magnesium Oxide 400 mg PO BID:PRN constipation
2. Polyethylene Glycol 17 g PO DAILY:PRN constipation
3. Lidocaine 5% Patch 1 PTCH TD QAM
4. LORazepam 1 mg PO BID:PRN anxiety
5. Propranolol 40 mg PO BID
6. Levothyroxine Sodium 150 mcg PO DAILY
7. vitamin B complex-folic acid 0.4 mg oral DAILY
8. Vitamin D ___ UNIT PO DAILY
9. OSELTAMivir 75 mg PO Q12H
10. Atenolol 25 mg PO DAILY
11. Esomeprazole 40 mg Other BID
12. melatonin 6 mg oral QHS
13. Atorvastatin 10 mg PO QPM
14. Glucosamine (glucosamine sulfate) 150 mg oral DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever
2. Benzonatate 100 mg PO TID
3. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
4. OSELTAMivir 30 mg PO BID Duration: 3 Doses
5. Atorvastatin 10 mg PO QPM
6. Esomeprazole 40 mg Other BID
7. Glucosamine (glucosamine sulfate) 150 mg oral DAILY
8. Levothyroxine Sodium 150 mcg PO DAILY
9. Lidocaine 5% Patch 1 PTCH TD QAM
10. LORazepam 1 mg PO BID:PRN anxiety
11. Magnesium Oxide 400 mg PO BID:PRN constipation
12. melatonin 6 mg oral QHS
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Propranolol 40 mg PO BID
15. vitamin B complex-folic acid 0.4 mg oral DAILY
16. Vitamin D ___ UNIT PO DAILY
17. HELD- Atenolol 25 mg PO DAILY This medication was held. Do
not restart Atenolol until seen by your primary care doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
- influenza
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with the flu.
You received medications to help treat the flu. By day of
discharge you were walking with your cane and supporting
yourself well enough to go home.
Continue Tylenol as needed every 8 hours for pain. Continue the
Tamiflu medication twice a day until ___ night. You have
cough medicine to take too. These medications have been
delivered to you at discharge!
Follow up with your primary care doctor! We suggest going
through your medications with your primary care doctor.
It was a pleasure taking care of you.
Your ___ Care team
Followup Instructions:
___
|
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DS
| 10 |
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2138-05-14 16:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
decreased hearing; altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y/o M with a PMH significant for NPH who
presents to the emergency department with c/o decreased hearing
bilaterally and altered mental status. He presents to the ED at
___ for evaluation. He denies any headaches, dizziness,
shortness of breath, chest pain, abdominal discomfort.
Past Medical History:
Past Medical History: Diabetes, the hydrocephalus, and
hypertension.
Past Surgical History: Appendectomy, vasectomy, a VP shunt
placement in ___ and ___ removal of the shunt about four days
later.
Social History:
___
Family History:
Diabetes
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
T: 97.1 BP: 126/65 HR: 76 R: 17 O2Sats 98% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3-2.5mm bilaterally. EOMs intact throughout.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person only.
Language: Speech fluent with fair comprehension.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested.
II: Pupils equally round and reactive to light, 3 to 2.5
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.
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.
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
PHYSICAL EXAMINATION ON DISHCARGE
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3-2mm bilaterally. EOMs intact throughout.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, but
needed repetition to follow commands, flat affect.
Orientation: Oriented to person only.
Language: Speech fluent with fair comprehension.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested.
II: Pupils equally round and reactive to light, 3 to 2.5
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength 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.
Pertinent Results:
___ 12:40PM GLUCOSE-157* UREA N-19 CREAT-1.0 SODIUM-137
POTASSIUM-5.1 CHLORIDE-99 TOTAL CO2-24 ANION GAP-19
___ 12:40PM estGFR-Using this
___ 12:40PM WBC-10.5 RBC-4.43* HGB-13.2* HCT-38.4* MCV-87
MCH-29.8 MCHC-34.5 RDW-14.2
___ 12:40PM NEUTS-72.9* LYMPHS-16.7* MONOS-5.7 EOS-4.3*
BASOS-0.4
___ 12:40PM ___ PTT-32.1 ___
___ 12:40PM PLT COUNT-377
Non-Contrast Head CT: ___
No acute intracranial hemorrhage.
Ventriculomegaly. Unknown if this is the patient's baseline or
if the
ventricles are larger than the patient's baseline in the absence
of prior studies.
Brief Hospital Course:
Mr. ___ was admitted to the neurosurgery service with c/o
decreased hearing and altered mental status bilaterally. He
underwent a head CT which showed stable size of the ventricles
bilaterally. His shunt pressure was adjusted from 1.5 to 2.5
while in the emergency department. Otolaryngology was consulted
and implanted bilateral liquid colase for removal of ear wax,
the removal of which was accomplished on ___. IV
antibiotics were started for a UTI and a PICC was placed.
Audiogram showed age related hearing loss and it was determined
that his hearing loss was not a result of the shunt. His shunt
was dialed back to 1.5. He was seen by ___ on HD #2 who
recommended he be discharged back to the assisted living
facility he originally came from.
Medications on Admission:
Colace 100 PO BID; Remeron 30mg
PO QHS; Amantadine 50mg PO BID; Thiamine 100mg PO daily; Folic
Acid 1mg QAM; Metformin 850mg TID; Januvia 50mg PO BID;
Lopressor
12.5mg PO daily; Zocor 10mg PO QHS: Miralax 17g PO QD; Tylenol
___ PO Q6H prn.
Discharge Medications:
1. CefePIME 1 g IV Q12H Duration: 7 Days
RX *cefepime 2 gram 2 grams Q24H Disp #*14 Gram Refills:*0
2. Amantadine 50 mg PO BID
3. Simvastatin 10 mg PO DAILY
4. Thiamine 100 mg PO DAILY
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Mirtazapine 30 mg PO HS
7. Metoprolol Tartrate 12.5 mg PO DAILY
8. MetFORMIN (Glucophage) 850 mg PO TID
9. FoLIC Acid 1 mg PO DAILY
10. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Normal Pressure Hydrocephalus
Urinary Tract Infection
Cerumen Impaction
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
Followup Instructions:
___
|
10641888-DS-9
| 10,641,888 | 28,086,936 |
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| 9 |
2152-08-27 00:00:00
|
2152-08-27 15:30:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Aspirin
Attending: ___.
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Per ED: This patient is a ___ year old male who complains of
SHORTNESS OF BREATH. The patient admits to alcohol. He was
walking and fell down 7 or 8 steps. He denies hitting his head.
He was noted to have a blank stare at the bottom of the stairs.
He then went to bed and then developed left-sided rib pain and
shortness of breath. There is no history of abdominal pain.
There's no headache or back pain or neck pain. He does have left
rib pain
Past Medical History:
Past Medical History: coagulopathies/ ___'s
Social History:
Tobacco: None.
Alcohol: Occasional.
Recreational Drugs: None.
Positive for Alcohol
Physical Exam:
On admission:
Temp: 97.4 HR: 108 BP: 132/85 Resp: 20 O(2)Sat: 92 Low
Constitutional: Comfortable, collar and backboard
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light
Neck is nontender
Chest: Clear to auscultation, left posterior rib tenderness
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender
Extr/Back: There is no back tenderness or extremity
tenderness
Neuro: Speech fluent A/O X 3, CN ___ intact, normal
sensory, normal motor, normal cerebellar function, downgoing
toes, DTRs normal
On discharge:
VS: T 98.2 HR 100 BP 140/86 RR 18 02 94%RA
Constitutional: NAD
Neuro: Alert and oriented x 3
Cardiac: RRR
Lungs: CTA B
Abd: Soft, non-distended, + BS, no rebound tenderness/guarding
Ext: No edema
Pertinent Results:
___ 11:35PM BLOOD WBC-10.9# RBC-4.71 Hgb-14.5 Hct-42.5
MCV-90 MCH-30.7 MCHC-34.0 RDW-13.9 Plt ___
___ 06:27AM BLOOD WBC-8.1 RBC-4.46* Hgb-13.6* Hct-39.7*
MCV-89 MCH-30.5 MCHC-34.2 RDW-13.9 Plt ___
___ 08:40AM BLOOD Hct-36.8*
___ 05:15PM BLOOD Hct-35.3*
___ 12:38AM BLOOD Hct-33.9*
___ 03:35AM BLOOD Hct-35.5*
___ 07:20AM BLOOD Hct-36.0*
___ 03:00PM BLOOD Hct-33.5*
___ 06:10AM BLOOD Hct-37.1*
IMAGING:
___: CHEST (PORTABLE AP):
FINDINGS: Portable AP chest radiograph demonstrates low lung
volumes, but no focal consolidation, pleural effusion, or
pneumothorax. The cardiomediastinal silhouette is stable. Left
lower rib fractures are better seen on CT-Torso.
___: CT HEAD W/O CONTRAST:
IMPRESSION: No acute intracranial abnormality.
___ CT ABD & PELVIS WITH CONTRAST:
IMPRESSION:
1. Splenic laceration for roughly 4 cm without perisplenic
hematoma or
hemoperitoneum.
2. Left sixth-tenth rib fractures. The eighth rib fracture is
segmental.
___: CT CHEST W/CONTRAST:
IMPRESSION:
1. Splenic laceration for roughly 4 cm without perisplenic
hematoma or
hemoperitoneum.
2. Left sixth-tenth rib fractures. The eighth rib fracture is
segmental.
___ CT C-SPINE W/O CONTRAST:
IMPRESSION:
1. No fracture or malalignment of the cervical spine.
2. Mild degenerative changes at C6-7.
Brief Hospital Course:
Mr. ___ was admitted to the trauma surgical service a ___
after suffering an witnessed fall. Imaging obtained upon
presentation included a chest x-ray, Head CT, Spine CT, Chest
CT, Abd/Pelvic CT which were revealing for left-sided rib
fractures (___) and a splenic laceration without
hemoperitoneum. He was initially admitted to the TSICU, but he
was doing well, tolerating a diet and his hcts were stable so he
was transferred to the floor on HD1.
On the floor, the patient's pain regimen was transitioned from a
dilaudid PCA to oral prn oxycodone with effective pain control.
He remained stable from both a cardiovascular and pulmonary
standpoint; incentive spirometry and frequent ambulation were
strongly encouraged. The patient continued to tolerate a
regular diet and voided adequate amounts. His hematocrit
remained stable and was noted to be 37.1 on day of discharge on
HD3. He will follow-up in the ___ clinic within 2 weeks.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H Duration: 3 Days
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. 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
Discharge Disposition:
Home
Discharge Diagnosis:
Left-sided rib fractures: ___
Splenic laceration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after falling during which you
sustained multiple left-sided rib fractures and a laceration of
your spleen. You recovered in the hospital and are now
preparing for discharge to home with the following instructions:
* Your injury caused multiple rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).
Also, due to your splenic injury:
AVOID contact sports and/or any activity that may cause injury
to your abdominal area for the next ___ weeks.
*If you suddenly become dizzy, lightheaded, feeling as if you
are going to pass out go to the nearest Emergency Room as this
could be a sign that you are having inernal bleeding from your
liver or spleen injury.
*AVOID any blood thinners such as Motrin, Naprosyn, Indocin,
Aspirin, Coumadin or Plavix for at least ___ days unless
otherwise instructed by the MD/NP/PA.
Followup Instructions:
___
|
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2191-03-21 20:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Bradycardia, AMS, Shock, ___, Hyperkalemia
Major Surgical or Invasive Procedure:
___: Central line placement
History of Present Illness:
[Per CCU Admission Note]
Mr. ___ is a ___ yo M with history of atrial fibrillation, vocal
cord carcinoma s/p surgery, who presented with respiratory
distress and was found to have severe bradycardia (slow AFib)
and hypotension.
Patient was in his usual state of health until earlier on the
day of admission, when he was tired, sleepy, and increasingly
anxious. He was noted to have respiratory distress by his wife,
who called ___. At time of the evaluation, he was cold and in
slow Afib with heart rate in 20's and SBP in 50's. Lactate was
up to 9.1. Upon arrival to ED, temp wire placement was attempted
with no success. He was subsequently started on dopamine drip
with improvement in his hemodynamics with HR in ___ and MAP in
______. His lactate improved down to 6.7.
He was also agitated in the ED, for which he received zyprexa 5
mg IM and Ativan 1 mg IV. He also received 1 L NS in ED.
According to the wife, patient denied CP, and endorsed SOB and
lightheadedness. He denied n/v, abdominal pain, fever, chills.
He has been having abdominal discomfort and was supposed to get
endoscopy as outpatient. He also has difficulty swallowing
attributed to ___ infection.
Summary of ED course:
Labs/studies notable for:
WBC 10.8 H/H 14.9/45.0 platelets 121
Creatinine 2.6
___: 18.0 PTT: 28.8 INR: 1.6 Fibrinogen: 292
Na:138 K:5.5 Cl:100 TCO2:19 Glu:123
Lactate:9.1
Tox screen negative
Patient was given: Dopamine, 1 L NS
On arrival to the CCU: Patient was hemodynamically stable HR in
___ and MAP in ___. He was sleeping after being agitated in ED
s/p Ativan and zyprexa. His wife confirmed the history detailed
above.
Past Medical History:
[Per CCU Admission Note]
Atrial fibrillation
Vocal cord cancer in ___ s/p surgery in ___
___ infection of stoma
Blindness
Left eye cornea transplant in ___
Social History:
___
Family History:
[Per CCU Admission Note]
Father died of MI in ___
Brother died ___ years ago from a heart issue, he has a pacemaker
placed for unclear reasons
Mother died after choking with food
Physical Exam:
ADMISSION:
==========
VS: T afebrile BP 94/53 HR 83 RR O2 SAT 91% RA
GENERAL: Patient is sleeping and refusing to wake up, unable to
assess orientation.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. JVP not elevated.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Irregular rhythm. Normal S1, S2. No murmurs, rubs, or
gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm upper extremities, well perfused. Cold feet.
No clubbing, cyanosis, or peripheral edema. Chronic skin changes
noted bilaterally.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
----------
DISCHARGE:
==========
VS: Afebrile, BP 130s/60s, HR 110s, O2 SAT 95% RA
GENERAL: Comfortably sitting in chair, AOx3
NECK: JVP not elevated. Stoma without discharge.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Irregular rhythm. variable S1, S2. No murmurs, rubs, or
gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. Upper airway sounds
transmitted bilaterally.
EXTREMITIES: LUE hematoma, not tender to palpation, full ROM and
neurovascularly intact in L hand. No clubbing, cyanosis or
edema.
SKIN: Chronic skin changes noted bilaterally hands and legs.
Also L elbow with purple patch that extends form from proximal
forearm to distal ___ of upper arm.
Pertinent Results:
ADMISSION LABS:
---------------
___ 10:36PM BLOOD WBC-10.8* RBC-4.64 Hgb-14.9 Hct-45.0
MCV-97 MCH-32.1* MCHC-33.1 RDW-13.3 RDWSD-47.5* Plt ___
___ 10:36PM BLOOD Plt ___
___ 10:36PM BLOOD ___ PTT-28.8 ___
___ 02:20AM BLOOD Glucose-132* UreaN-50* Creat-2.7* Na-137
K-4.8 Cl-97 HCO3-20* AnGap-25*
___ 02:20AM BLOOD ALT-444* AST-458* LD(LDH)-980*
AlkPhos-151* TotBili-1.5
___ 10:36PM BLOOD Lipase-47
___ 02:20AM BLOOD CK-MB-3 cTropnT-<0.01
___ 02:20AM BLOOD Calcium-8.4 Phos-7.4* Mg-2.2
___ 10:36PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:30PM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative HAV Ab-Positive*
___ 02:20AM BLOOD TSH-3.5
___ 02:30PM BLOOD HCV Ab-Negative
___ 02:40AM BLOOD ___ pO2-48* pCO2-43 pH-7.29*
calTCO2-22 Base XS--5
___ 10:28PM BLOOD Glucose-123* Lactate-9.1* Na-138 K-5.5*
Cl-100 calHCO3-19*
OTHER IMPORTANT LABS:
Peak transaminases: ___ 07:05AM BLOOD ALT-995* AST-1495*
LD(LDH)-1579* AlkPhos-150* TotBili-1.2
Peak bilirubin: ___ 04:32AM BLOOD ALT-526* AST-141*
LD(LDH)-225 AlkPhos-126 TotBili-2.0*
MICROBIOLOGY:
-------------
___ Lyme IgM, IgG: Negative
___ Blood culture: No growth (final)
___ Urine culture: No growth (final)
IMAGING:
--------
___: RUQ Ultrasound
1. Cholelithiasis. No sonographic evidence of cholecystitis.
2. Normal ultrasound appearance of the liver however assessment
of the hepatic parenchyma is limited by a restrictive
sonographic window and poor sonographic penetration. No biliary
dilatation.
___: ___ dilated; no left atrial mass/thrombus seen (best
excluded by transesophageal echocardiography).
Mild symmetric LVH with normal cavity size and regional/global
systolic function (LVEF>55%).
RV cavity is dilated.
The aortic valve leaflets (?#) appear structurally normal with
good leaflet excursion, no stenosis, no regurgitation
The mitral valve appears structurally normal with trivial MR.
___ PASP is normal.
An anterior space which most likely represents a prominent fat
pad.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global systolic function.
Right ventricular cavity dilation.
___: CXR
Low lung volumes with probable bibasilar atelectasis. Small
right pleural
effusion.
DISCHARGE LABS:
---------------
___ 04:32AM BLOOD WBC-6.3 RBC-4.05* Hgb-12.8* Hct-37.8*
MCV-93 MCH-31.6 MCHC-33.9 RDW-13.3 RDWSD-45.0 Plt Ct-91*
___ 04:32AM BLOOD Plt Ct-91*
___ 04:32AM BLOOD ___ PTT-33.4 ___
___ 04:32AM BLOOD Glucose-147* UreaN-15 Creat-1.0 Na-140
K-3.8 Cl-103 HCO3-26 AnGap-15
___ 04:32AM BLOOD ALT-526* AST-141* LD(LDH)-225 AlkPhos-126
TotBili-2.0*
___ 04:32AM BLOOD Calcium-8.8 Phos-3.6 Mg-1.6
Brief Hospital Course:
SUMMARY: Mr. ___ is a ___ yo with history of afib on apixaban,
who presented with shortness of breath, and was found to have
bradycardia in ___ and hypotension with altered mental status
and ___.
ACUTE ISSUES:
=============
#Shock: Patient presented with elevated lactate (9.1) and end
organ ischemia ___, transaminitis, altered mental status).
Thought to be due to medication toxicity as patient was on
multiple nodal agents and had ___ (as below). Received
dopamine, 1L NS in ER and HR in ___ and MAP ___. In the CCU,
dopamine was discontinued on hospital day 2. No further pressor
support. No pacing ever required. The patient remained
hemodynamically stable on subsequent days and metoprolol was
resumed. Creatinine, transaminases, mental status and lactate
trended down. Discharge lactate was 1.7.
#Bradycardia: Presented with HR in ___. As above, thought to be
due to medication toxicities, especially atenolol in setting of
___. Lyme titer negative and TSH normal. HR responded to
dopamine in the ER and after ___ hours, HR returned to ___
fibrillation with rates in the 130s. Subsequently, HR controlled
with metoprolol, as below (#Atrial fibrillation). Patient
discharged on new rate control medication.
#Acute toxic-metabolic encephalopathy: Patient altered on
presentation as per HPI. Thought to be due to shock. Required
sedation in ER. Returned to AOx3 after ___ hours and was
cooperative. On discharge, AOx3.
___: Presented with creatinine elevated at 2.6, no known prior
kidney disease. Thought to be caused by poor PO intake in prior
week with his tracheitis causing nausea/anorexia per wife,
exacerbated by bradycardia observed on day of admission. With
return to normal HR and BP, creatinine trended down, ___
resolved. On discharge, Cr was 1.0.
#Atrial fibrillation: Patient presented with bradycardia thought
to be due to medication toxicity, as above. Initially, home
nodal agents were held. After 48 hours, HR returned to ___.
Metoprolol tartrate was started at 6.25 mg and uptitrated on
subsequent days. Anticoagulation as below. Patient on metoprolol
succinate 200 mg PO BID with rates in ___ at discharge, no
symptoms of CP, palpitations, or SOB.
#Thrombocytopenia: Presented with platelets 90k. Unclear
etiology, possible medication side effect, possibly shock liver,
possibly inflammation suppressing bone marrow. No acute bleeding
events during hospitalization. No direct interventions. Platelet
count uptrending at time of discharge.
#Hyperkalemia: Labs on presentation showed K+ 5.5. Thought to be
related to multiple factors including ___, volume contraction
and home potassium supplementation. Home supplements were held.
Daily electrolytes were followed. K+ corrected on HOD 1 after
hydration and was stable throughout. Discharge K+ was 3.8.
#Transaminitis: Labs on presentation showed elevated
transaminases. Thought to be secondary to hypoperfusion, but
acetaminophen level was sent, hepatitis panel was sent and RUQ
ultrasound was ordered. Tox screen negative, hepatitis panel
negative for acute infection and RUQ ultrasound showed
cholelithiasis but no biliary dilation or inflammation.
Transaminases peaked on HOD1 and downtrended for the remainder
of hospitalization.
CHRONIC ISSUES:
===============
#Anticoagulation: Initially, patient placed on heparin drip,
home anticoagulant held. H&H stabilized and fecal occult blood
negative. On HOD2, home apixaban was resumed. Patient discharged
on apixaban.
#Depression/Anxiety: Initially altered. After resolution,
patient denied symptoms of depression or anxiety. Mood stable
during hospitalization. No medication. Sertraline resumed on
discharge.
#Hypertension: Initially bradycardic. Treated with metoprolol as
above. On discharge, discontinued atenolol because renally
cleared; using metoprolol instead. Held home diltiazem during
hospitalization and until follow-up with a cardiologist.
#Candidiasis of trach: Trach discharge on admission. Continued
fluconazole from pre-hospitalization. Evaluated by ENT. Symptoms
improved by discharge with instructions to finish fluconazole
regimen, last dose ___.
#Insomnia: Initially, not a concern for patient. Home trazodone
resumed on HOD3 with little effect. On discharge, patient
looking forward to sleeping at home.
#GERD: Initially treated with ranitidine. Resumed home
omeprazole day of discharge.
#COPD: Treated with ipratropium.
TRANSITIONAL ISSUES:
-If ever requires intubation, obligate neck breather, INTUBATE
THROUGH NECK
-This patient presented with ___. In future, avoid renally
cleared medications that are renally cleared.
-Atrial fibrillation rate control. Discharged with rates
___ on maximum metoprolol doses; was previously on CCB and
may require restart
-New medication: fluconazole
-Medication change: atenolol to metoprolol
-Medication stopped: diltiazem
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluconazole 200 mg PO Q24H
2. Diltiazem 60 mg PO TID
3. LORazepam 1 mg PO Q12H:PRN Anxiety
4. TraZODone 200 mg PO QHS
5. Lisinopril 40 mg PO DAILY
6. Atenolol 200 mg PO DAILY
7. Hydrochlorothiazide 25 mg PO DAILY
8. Apixaban 5 mg PO BID
9. Sertraline 125 mg PO DAILY
10. Potassium Chloride 20 mEq PO DAILY
11. Omeprazole 40 mg PO DAILY
12. Fluticasone Propionate 110mcg 2 PUFF IH BID
13. salmeterol 50 mcg/dose inhalation Q24H
Discharge Medications:
1. Metoprolol Succinate XL 400 mg PO DAILY atrial fibrillation
RX *metoprolol succinate 200 mg 2 tablet(s) by mouth once a day
Disp #*60 Tablet Refills:*0
2. Apixaban 5 mg PO BID
3. Fluconazole 200 mg PO Q24H Duration: 7 Days
You started taking this medication on ___ and need to continue
taking it until ___. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Hydrochlorothiazide 25 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. LORazepam 1 mg PO Q12H:PRN Anxiety
8. Omeprazole 40 mg PO DAILY
9. Potassium Chloride 20 mEq PO DAILY
10. Salmeterol 50 mcg/dose INHALATION Q24H
11. Sertraline 125 mg PO DAILY
12. TraZODone 200 mg PO QHS
13. HELD- Diltiazem 60 mg PO TID This medication was held. Do
not restart Diltiazem until you see a cardiologist
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Bradycardia
- Shock
- Acute Kidney Injury
- Atrial Fibrillation
- Hyperkalemia
- Candidiasis (affecting stoma)
- Thrombocytopenia
SECONDARY DIAGNOSIS:
- Depression/Anxiety
- Insomnia
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 ___. Please find
below answers to some questions and answers regarding your
admission:
Why did you come to the hospital?
You came to the hospital because you were confused and short of
breath.
What did we do for you?
- You had a slow heart rate (bradycardia). We gave you medicines
to make your heart go more quickly. We put a central line in
your neck in case we needed to electrically pace your heart.
Thankfully, the medicine worked and the line was pulled quickly.
We also did not give your home medications for two days. Your
heart rate returned to normal.
- You had low blood pressure. This was caused by your slow heart
rate. Your blood pressure returned to normal as we sped your
heart rate up.
- You had a kidney injury. We gave you fluids and increased your
heart rate. Your kidneys recovered.
- Your irregular heart beat (atrial fibrillation) returned and
your heart was going fast. We gave you medication to slow your
heart rate to the normal range.
- You had some discharge from your stoma. Because you are on a
blood thinner at home, we were concerned you may be bleeding.
You were seen by the ear, nose and throat surgical team. There
was no bleeding. We continued to treat the fungal infection in
the stoma. We restarted your home anticoagulant medication,
apixaban.
- For the fungal infection you will continue taking this
medication until ___.
- You had a low platelet count, which can put you at risk for
bleeding. We monitored your platelet count. During your
hospitalization, as the rest of your problems improved, your
platelet count improved, too.
What should you do when you go home?
- You should not take atenolol. We are switching you to
metoprolol.
- Continue taking fluconazole, last dose ___.
- You should follow-up with the new Cardiologist.
- You should take your other home medications.
Medication changes
STOP TAKING THE FOLLOWING MEDICATIONS UNTIL YOU SEE A DOCTOR:
- Atenolol
- Diltiazem
NEW MEDICATIONS:
- Metoprolol succinate 400 mg by mouth once each day
- Fluconazole 200 mg by mouth once every day. Take this
medication for a total of 2 weeks. Last dose is on ___.
Followup Instructions:
___
|
10641947-DS-18
| 10,641,947 | 25,118,337 |
DS
| 18 |
2192-06-28 00:00:00
|
2192-06-28 18:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
shortness of breath, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old male with history of laryngeal cancer
s/p total laryngectomy & tracheostomy (total neck breather),
afib
on apixaban, HTN, CHF, and emphysema presents with new dyspnea,
cough, hemoptysis, and fever.
Patient reports a 1 week history of cough associated with
increasing dyspnea. Cough has been productive of sputum. Over
the
last four days he has also had a small amount of blood mixed ___
with the sputum. He endorses chills. Of note, over the past
month
he has had coughing associated with eating. Patient has a
tracheo-esophageal prosthesis (puncture with 1 way valve) that
allows him to vocalize. He and his wife report good care of
prosthesis per instructions, but the coughing with eating is new
for him. He denies having any sick contacts. His wife reports
that he has been more unsteady over the last few days. He has
also had 1 episode of diarrhea this AM. No n/v. No chest pain,
palpitations, orthopnea or PND.
___ this setting, he presented to ___, where CXR
showed RUL PNA. He received IV CTX, PO azithro x1 and was
transferred ___ ED.
___ the ED, initial vitals: 101.5 110 160/84 22 98% trach mask
- Exam notable for: RUL & bibasilar crackles, occasional ronchi
Mild blood around stoma
- Labs notable for: CBC: no leukocytosis, neutrophilic ___,
no left shift; Thrombocytopenia, chronic. Flu negative. Lactate
1.9
- Chem7: wnl
- Imaging notable for: CXR with Multifocal pneumonia
- ENT was consulted for blood ___ stoma who recommended:
-- CTA neck eval fistula
-- Unlikely, but if present c/s ___ for embolization
-- No ENT admit unless recent surgery by ENT - not applicable
here
- Pt given: CTX and Azithromycin at ___, olanzapine for
confusion
___ ED.
On the floor, patient reports feeling anxious and tired, but
otherwise is feeling better. Denies dyspnea at rest. No more
bloody cough.
Past Medical History:
Laryngeal (vocal cord) carcinoma s/p laryngectomy/XRT ___
(previous trach site and he uses a speaking valve per his
family)
Atrial fibrillation (on apixaban)
HTN
prior EtOH use d/o
___ infection of stoma
Blindness s/p corneal transsplant
depression/anxiety
Emphysema
Ingrown toe nail - sees podiatry
PAST SURGICAL HISTORY:
- laryngectomy ___
- left eye corneal transplants
- Right eye complete vision loss, unknown cause, attempted
injections
Social History:
___
Family History:
Father died of MI ___ ___
Brother died from a heart issue, he had a pacemaker placed for
unclear reasons
Mother died ___ her ___ after choking on food
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 99.1 171 / 102 L Lying 95 18 99 TM
GENERAL: AOx3, NAD
HEENT: Normocephalic, atraumatic. R eye not reactive to light,
complete vision loss. L eye reactive to light with limited
vision. Extraocular muscles intact. Sclera anicteric and without
injection. Moist mucous membranes, no teeth, uses dentures
occasionally. Oropharynx is clear.
NECK: Thyroid is normal ___ size and texture, no nodules. No
cervical lymphadenopathy. dried blood around stoma, discharge
through TEP valve
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops. No JVD.
LUNGS: RU-Field crackles and rhonchi, left lung base crackles
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation ___ all four quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema, no sign of
atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally.
SKIN: No evidence of ulcers, rash or lesions suspicious for
malignancy. Dry scaly skin over lower extremities and dorsal
feet
bilaterally
NEUROLOGIC: CN2-12 intact. ___ strength througout. Normal
sensation. No disdiadochokinesia.
DISCHARGE PHYSICAL EXAM:
=========================
VITALS: 170 / 100R ___ RA
GENERAL: AOx3, NAD
HEENT: Normocephalic, atraumatic. R eye not reactive to light,
complete vision loss. L eye reactive to light with limited
vision. Extraocular muscles intact. Sclera anicteric and without
injection. Moist mucous membranes, no teeth, uses dentures
occasionally. Oropharynx is clear.
NECK: stoma without bleeding or discharge
CARDIAC: Distant heart sounds, irregular, no obvious
murmurs/rubs/gallops
LUNGS: poor effort, poor air movement, bilateral crackles R>L,
comfortable without accessory muscle use
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation ___ all four quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: Dry scaly hyperpigmented skin over lower extremities and
feet bilaterally
NEUROLOGIC: alert, oriented, moving all extremities. vocalizing
short phrases but difficult to understand
Pertinent Results:
ADMISSION LABS:
===============
___ 12:44PM BLOOD WBC-9.1 RBC-4.92 Hgb-14.6 Hct-43.6 MCV-89
MCH-29.7 MCHC-33.5 RDW-13.1 RDWSD-42.6 Plt ___
___ 12:44PM BLOOD Neuts-91.8* Lymphs-3.1* Monos-4.4*
Eos-0.0* Baso-0.1 Im ___ AbsNeut-8.31*# AbsLymp-0.28*
AbsMono-0.40 AbsEos-0.00* AbsBaso-0.01
___ 12:44PM BLOOD Glucose-147* UreaN-12 Creat-1.2 Na-142
K-4.1 Cl-102 HCO3-24 AnGap-16
___ 01:10PM BLOOD Lactate-1.9
INTERVAL LABS:
==============
___ 05:35AM BLOOD WBC-10.7* RBC-4.60 Hgb-13.8 Hct-41.2
MCV-90 MCH-30.0 MCHC-33.5 RDW-13.3 RDWSD-43.6 Plt ___
___ 05:25AM BLOOD WBC-7.5 RBC-4.23* Hgb-12.6* Hct-37.9*
MCV-90 MCH-29.8 MCHC-33.2 RDW-13.4 RDWSD-43.8 Plt ___
___ 05:35AM BLOOD Glucose-98 UreaN-15 Creat-1.2 Na-147
K-4.1 Cl-105 HCO3-23 AnGap-19*
DISCHARGE LABS:
===============
___ 12:56PM BLOOD WBC-6.9 RBC-4.23* Hgb-12.7* Hct-37.8*
MCV-89 MCH-30.0 MCHC-33.6 RDW-13.3 RDWSD-43.6 Plt ___
___ 05:25AM BLOOD Glucose-95 UreaN-14 Creat-1.0 Na-141
K-3.6 Cl-101 HCO3-25 AnGap-15
___ 05:25AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.0
MICROBIOLOGY:
=============
neg legionella ag
___ blood culture pending
___ 2:20 pm SPUTUM Site: EXPECTORATED
Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ ___ per 1000X FIELD): BUDDING YEAST.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
YEAST. SPARSE GROWTH.
STAPH AUREUS COAG +. RARE GROWTH.
IMAGING:
========
___ CXR
FINDINGS:
AP upright and lateral views of the chest provided.
Airspace consolidation is noted ___ the right upper lower lobes
concerning for
pneumonia. Additional opacity ___ the left lower lobe may also
represent
pneumonic consolidation. No large effusion or pneumothorax.
Cardiomediastinal silhouette appears normal. Imaged bony
structures are
intact.
IMPRESSION:
Multifocal pneumonia.
CTA NECK W&W/OC & RECONS
___
1. Status post laryngectomy and tracheostomy. Thin anterior
wall just below the tracheostomy site without clear evidence for
dehiscence. No evidence of an arterial fistula. No evidence of
a venous fistula although the venous structures are suboptimally
___ the arterial phase.
2. Approximately 40% stenosis of the proximal right ICA by
NASCET criteria.
3. Atherosclerosis of the distal left CCA, with approximately
75-80% absolute stenosis, and approximately 60% stenosis by
NASCET criteria relative to the distal ICA lumen.
4. Moderate stenosis of the left vertebral artery origin. Mild
stenosis of the right distal V3/proximal V4 segments.
5. Increased bilateral superior mediastinal lymphadenopathy
inferior to the tracheostomy. Stable enlarged prevascular lymph
node.
6. Partially visualized large consolidation ___ the included
right lung, also seen on same-day chest radiographs, most likely
pneumonia. Underlying emphysema.
7. Chronic right maxillary sinusitis with osseous remodeling.
CXR
___
Overall, interval improvement of the consolidation within the
mid right lung.
The remainder of the consolidations bilaterally are unchanged.
Brief Hospital Course:
___ year old male with history of laryngeal cancer s/p total
laryngectomy with tracheoesophageal puncture prosthesis (TEP),
afib on apixaban, HTN, COPD, who presented with dyspnea,
hemoptysis and fever, found to have multifocal pneumonia with
suspicion for aspiration ___ the setting of malfunctioning TEP.
ACUTE ISSUES:
=============
#Multifocal pneumonia
#Aspiration
Patient with fever, productive cough and dyspnea on
presentation. CXR showed multifocal pneumonia, primarily RUL and
RLL. He was treated for CAP with IV CTX and azithromycin for 2
days (___), transitioned to PO augmentin and azithromycin
the day of discharge for 3 additional days (total 5 days). There
was strong suspicion for aspiration, with history of coughing
with swallowing. He was evaluated by speech and swallow, who
found his tracheoesophageal puncture prosthesis to be leaking
and malfunctioning, needing replacement. (Last replaced
___ He was planned to have TEP exchanged at Mass Eye and
Ear the day of discharge.
#Hemoptysis
#Stoma bleed
Patient had blood tinged sputum and small amount of bleeding
around stoma noted ___ the ED. He was evaluated by ENT ___ the ED,
who recommended a CTA that was negative for a tracheo-arterial
fistula. He did not have further bleeding from stoma. He did
have trace hemoptysis. His hemoglobin decreased to 12.6 from
13.8 overnight but was stable on recheck likely ___ the setting
of IVF, therefore his home apixaban was restarted. He should
have his hemoglobin rechecked at PCP ___.
CHRONIC ISSUES:
===============
#Atrial fibrillation: Home apixaban was initially held given
concern for bleeding, but restarted by discharge, with stable
hemoglobin, no further stoma bleeding, and only trace hemoptysis
___ the setting of pneumonia. Home metoprolol was continued.
#HTN: Was hypertensive this admission. Transitional issue to
address antihypertensive regimen. This admission, home
lisinopril was continued. Home furosemide was held. He was
instructed to restart furosemide the day after discharge, once
he was able to take PO.
#COPD: Continued home inhalers.
#Depression/anxiety: Continued home sertraline, trazodone;
restarted home mirtazapine for discharge.
#Vision loss: Continue ophthalmic meds, including bacitracin
ointment and prednisolone drops.
TRANSITIONAL ISSUES:
====================
- He is to have TEP replaced as an outpatient on the day of
discharge at Mass Eye and Ear (contact ___.
- Wears a ___ Extra Seal valve ___ place
tracheoesophageal puncture prosthesis, size 22.5 ___ (width)
and 8mm ___.
- Planned 5-day course of antibiotics (augmentin and azithro)
ending on: ___
- Hypertensive this admission, please readdress antihypertensive
regimen if hypertensive after restarting home regimen
- Had Atherosclerosis of the distal left CCA, with approximately
75-80% absolute
stenosis, and approximately 60% stenosis by NASCET criteria.
Please consider initiation of ASA81, high dose statin, measure
lipids, repeat imaging ___ 6 months
- Labs to be drawn on ___. Please follow up hemoglobin.
- Hgb on discharge 12.7
- New medications: augmentin, azithromycin
- Changed medications: none
- Held medications: none (to restart home Lasix the day after
discharge once taking PO)
#Code status: Full (presumed)
#Health care proxy/emergency contact: ___ (wife):
___, home phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Potassium Chloride 20 mEq PO DAILY
4. Apixaban 5 mg PO BID
5. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
6. Ranitidine 300 mg PO DAILY
7. Metoprolol Tartrate 100 mg PO BID
8. Lisinopril 10 mg PO DAILY
9. Furosemide 20 mg PO DAILY
10. Senna 17.2 mg PO BID:PRN cosntipation
11. Thiamine 100 mg PO DAILY
12. Sertraline 150 mg PO DAILY
13. TraZODone 100 mg PO QHS
14. Fluticasone Propionate 110mcg 2 PUFF IH BID
15. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
16. Mirtazapine 90 mg PO QHS
17. Bacitracin Ophthalmic Oint 1 Appl BOTH EYES TID
18. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES
Frequency is Unknown
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every 12 hours Disp #*7 Tablet Refills:*0
2. Azithromycin 250 mg PO Q24H
RX *azithromycin 250 mg 1 tablet(s) by mouth every 24 hours Disp
#*3 Tablet Refills:*0
3. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES BID
4. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
5. Apixaban 5 mg PO BID
6. Bacitracin Ophthalmic Oint 1 Appl BOTH EYES TID
7. Docusate Sodium 100 mg PO BID:PRN constipation
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. FoLIC Acid 1 mg PO DAILY
10. Furosemide 20 mg PO DAILY
11. Lisinopril 10 mg PO DAILY
12. Metoprolol Tartrate 100 mg PO BID
13. Mirtazapine 90 mg PO QHS
14. Potassium Chloride 20 mEq PO DAILY
15. Ranitidine 300 mg PO DAILY
16. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
17. Senna 17.2 mg PO BID:PRN cosntipation
18. Sertraline 150 mg PO DAILY
19. Thiamine 100 mg PO DAILY
20. TraZODone 100 mg PO QHS
21.Outpatient Lab Work
ICD-10: D64.9 Anemia. Lab: CBC. Date: ___. Contact:
___: ___ Phone: ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Pneumonia
Aspiration
Hemoptysis
Stoma bleeding
SECONDARY DIAGNOSIS:
Atrial fibrillation
Hypertension
COPD
Depression
Vision loss
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you at ___
___.
WHY WERE YOU ADMITTED?
- You had cough and shortness of breath, with coughing up small
amounts of blood.
WHAT HAPPENED THIS ADMISSION?
- You were diagnosed with pneumonia.
- Your TEP (tube ___ the stoma) was found to be loose and needing
replacement. This malfunction was causing you to aspirate
(inhale saliva and food).
- You were treated with antibiotics.
- You should get the TEP replaced at Mass Eye and Ear upon
discharge today.
WHAT SHOULD YOU DO ON DISCHARGE?
- PLEASE go to Mass Eye and Ear today (day of discharge) to get
your TEP replaced. They have appointments available for you
until 5PM. Please call them at ___. They know of you
but please let them know you are coming.
- Please DO NOT EAT OR DRINK anything until your TEP is
exchanged.
- If you have more bleeding from the stoma, if you cough up much
more blood, please STOP your apixaban and seek medical care.
- Restart your apixaban tonight.
- Restart your furosemide (Lasix) tomorrow.
- Please finish your course of antibiotics (see below).
- Please take your medicines as directed.
- Please go to your follow up appointments as scheduled.
We wish you the best,
Your ___ team
Followup Instructions:
___
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|
2132-09-08 07:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Transfer for SDH and ___ edema
Major Surgical or Invasive Procedure:
Paracentesis (___)
History of Present Illness:
___ year old female with history of recurrent metastatic colon
cancer (hepatic and pulmonary mets) s/p partial resection,
Avastin, currently on bevacizumab/FOLFIRI (last ___
presenting for evaluation of a subdural hematoma.
Per partial ___ records, patient's last chemotherapy was
___ and she had prolonged hospitalization from ___ for
hypercalcemia of malignancy, details unclear. Per patient, she
actually presented to ___ for ___ weakness and edema, and
was
not told of a diagnosis.
Since then, she notes that she had really not been doing well at
home, noting higher heart rates as well as progressive dyspnea
on
exertion for the past 3 weeks or so, such that she feels that
she
is unable to even walk to the door from the hospital bed, which
she thought was maybe a combination of being short of breath and
having ___ weakness/swelling. As such, she notes that her fiancé
had really been helping her with cooking/cleaning at home. She
denies any history of heart failure, PND, orthopnea. She denies
any increased abdominal girth.
Prior to presentation, she reached over to pick a shirt off the
bed when she lost her balance, stumbled backwards, and hit her
head on the carpeted floor. There was no preceding dizziness/
lightheadedness/ palpitations/ chest pain. Her boyfriend went to
assist her up, and it was at that time that she started to feel
dizzy. She presented to ___, where she received 10
mg vitamin K and FFP for an INR of 2.0 (not on chronic
anticoagulation) and was transferred for neurosurgery
evaluation.
Of note, she had had increasing bilateral ___ edema that started
with her most recent hospitalization, with reportedly negative
___
ultrasounds.
Of note, she has a history of recurrent metastatic colon
adenocarcinoma, s/p partial colonic resection, Avastin and
currently on bevacizumab/FOLFIRI (last ___ . She recently
received Neulasta She receives her oncologic care at ___.
In the ED, initial vitals were: 98.6 F, HR 118, BP 110/70s, RR
16, 95% RA
- Exam notable for: no focal neuro deficits, 4+ pitting edema
- Labs notable for:
WBC 27.5, Hgb 7.5, plts 141, neutrophils 89%, INR 1.7 (after
FFP), BNP 494, lytes WNL, LFTs showing ALT 28, AST 105, AP 542,
tibili 3.8, lipase 13, UA grossly positive, lactate 5.5
- Imaging was notable for: Stable to marginal increase in size
of
a small right cerebral subdural hematoma.
- Patient was given: 10 mg IV vitamin K, CTX, 500 cc NS
ROS: Positive per HPI. Remaining 10 point ROS reviewed and
negative. Notable for: No recent fevers or chills, no cough,
+mild abdominal pain without nausea or diarrhea. No urinary
hesitancy, frequency, dysuria. Decreased appetite recently.
Past Medical History:
Metastatic colon cancer (to the lung and liver)
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
___ 0027 Temp: 99.0 BP: 122/75 HR: 115 RR: 20 O2 sat: 92%
O2
delivery: Ra
GENERAL: Thin, pleasant lady in no acute distress
HEENT: Anicteric sclerae, MMM, no JVD appreciated
NECK: No cervical ___
CARDIAC: Tachycardic but regular, no m/r/g
LUNGS: CTA anteriorly, decreased BS in bilateral bases
ABDOMEN: Soft, mildly tender in epigastrium and LLQ without
rebound or guarding
EXTREMITIES: 3+ pitting edema in bilateral legs to level of
thighs
NEUROLOGIC: AO x 3, strength ___ in L deltoid, ___lse ___ throughout, per patient chronic, no pronator
drift
SKIN: No rashes appreciated
DISCHARGE EXAM:
Pertinent Results:
ADMISSION LABS:
===============
___ 02:25PM BLOOD WBC-27.5* RBC-2.53* Hgb-7.5* Hct-25.3*
MCV-100* MCH-29.6 MCHC-29.6* RDW-22.2* RDWSD-76.7* Plt ___
___ 02:25PM BLOOD Neuts-89* Bands-0 Lymphs-3* Monos-4*
Eos-0 Baso-0 ___ Metas-2* Myelos-2* NRBC-3* AbsNeut-24.48*
AbsLymp-0.83* AbsMono-1.10* AbsEos-0.00* AbsBaso-0.00*
___ 02:25PM BLOOD ___ PTT-35.6 ___
___ 02:25PM BLOOD Glucose-72 UreaN-8 Creat-0.4 Na-141 K-3.8
Cl-96 HCO3-26 AnGap-19*
___ 02:25PM BLOOD ALT-28 AST-105* AlkPhos-542* TotBili-3.8*
___ 02:25PM BLOOD Lipase-13
___ 02:25PM BLOOD proBNP-494*
___ 02:25PM BLOOD Albumin-2.7* Calcium-9.1 Phos-1.5* Mg-2.1
___ 10:21AM BLOOD ___ pO2-244* pCO2-38 pH-7.45
calTCO2-27 Base XS-3
___ 06:30PM BLOOD Lactate-5.5*
___ 09:00PM BLOOD Lactate-5.5*
___ 03:50PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 03:50PM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-TR* Bilirub-SM* Urobiln-2* pH-6.0 Leuks-TR*
___ 03:50PM URINE RBC-1 WBC-12* Bacteri-FEW* Yeast-NONE
Epi-1
___ 03:50PM URINE Hours-RANDOM Creat-71 TotProt-81
Prot/Cr-1.1*
___ 03:25PM ASCITES TNC-460* RBC-390* Polys-22* Lymphs-58*
___ Mesothe-1* Macroph-19*
___ 03:25PM ASCITES TotPro-2.1 Albumin-0.8
MICRO LABS:
===========
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ SCREENMRSA SCREEN-PENDINGINPATIENT
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ FLUIDGRAM STAIN-FINAL; FLUID
CULTURE-PRELIMINARY; ANAEROBIC CULTURE-PRELIMINARYINPATIENT
___ CULTUREBlood Culture,
Routine-PENDINGEMERGENCY WARD
___ CULTURE-FINALEMERGENCY WARD
IMAGING:
========
NCCTH (___): Stable to marginal increase in size of a small
right cerebral subdural
hematoma.
CTA torso (___): 1. No evidence of pulmonary embolus or
mesenteric ischemia. Numerous
pulmonary metastases and malignant pleural effusions.
Ground-glass opacities in the upper lobes are likely
infectious/inflammatory. 2. Hepatomegaly secondary to almost
complete replacement of the liver by numerous metastases as well
as abdominal adenopathy and mesenteric mass along the right
colic vasculature. 3. Moderate amount of ascites, extensive
subcutaneous soft tissue edema and compression fracture of T10
of uncertain chronicity.
DISCHARGE LABS:
===============
___ 04:26AM BLOOD WBC-30.0* RBC-2.63* Hgb-7.7* Hct-26.6*
MCV-101* MCH-29.3 MCHC-28.9* RDW-24.0* RDWSD-83.9* Plt ___
___ 04:26AM BLOOD Glucose-51* UreaN-7 Creat-0.4 Na-143
K-3.8 Cl-101 HCO3-23 AnGap-19*
___ 04:26AM BLOOD ALT-25 AST-74* LD(LDH)-1633* AlkPhos-290*
TotBili-5.0*
___ 04:26AM BLOOD Albumin-2.2* Calcium-8.8 Phos-1.3* Mg-1.9
Brief Hospital Course:
PATIENT SUMMARY:
================
___ w/ metastatic colon cancer (hepatic and pulmonary mets) s/p
partial resection, currently with progression on
bevacizumab/FOLFIRI (last on ___ presented as a transfer for
___ and worsening lower extremity edema subsequently
transitioned to comfort care and discharged home with hospice
services.
ACTIVE ISSUES:
==============
#Metastatic colon cancer:
#History of hypercalcemia of malignancy:
Last dose of FOLFOX ___ at ___. Corrected Ca on admission
10.1, not on bisphosphonate at home. Progressive metastatic
disease (lungs, liver) on CTA with ascites, b/l pleural
effusions, and mesenteric LN conglomerate likely causing lower
extremity edema. Given worsening symptoms and acute liver
failure, she was made CMO after discussions with her and her
family. Continued on higher doses of oxycodone upon discharge.
#Acute liver failure:
#Ascites:
#Hepatic encephalopathy:
#Coagulopathy:
#Hyperbilirubinemia/mild transaminitis:
Patient with known metastases to liver which may result in
hyperbilirubinemia and transaminitis, baseline unclear.
Paracentesis w/o e/o SBP. INR worsening while on IV vitamin K.
She was started on lactulose for mild confusion.
#Subdural hematoma:
3mm, subacute R frontoparietal subdural hematoma. She is s/p FFP
at ___. Repeat ___ showed slight interval increase. Per
neurosurgery, no need for management. She received IV vitamin K
w/o improvement.
#Leukocytosis:
#Tachycardia:
Patient reportedly received Neulasta (timing unclear), which may
explain at least part of her leukocytosis, although it has been
3 weeks since her last dose. CXR at ___ without evidence of
PNA. UCx negative. Also has ascites and pleural effusions on
imaging. s/p para on ___ w/o e/o SBP. Likely related to
worsening malignancy. She was originally started on broad
spectrum antibiotics, but these were discontinued as she had no
growth on cultures and her leukocytosis remained stable.
#Elevated lactate:
HDS, but elevated lactate to ___ concerning and not responsive
to IVF. Could be related to decreased clearance with hepatic
infiltration. CTA torso w/o ischemic process.
#Lower extremity weakness/edema:
Patient recently hospitalized at ___. Progressive, in the
setting of worsening edema, may be related to hypoalbuminemia,
venous compression, lymphedema, side effects of chemo, general
deconditioning. Phos level also noted to be low. Patient without
back pain, urinary retention, or difficulty with bowels to
suggest spinal cord involvement, also per patient no known mets
to spine.
#Anemia:
Patient with macrocytic anemia, appears to be at recent baseline
compared to ___ at ___ (7.1). Retic elevated, normal
B12/folate.
#Poor PO intake:
#Hypophosphatemia:
#Hypokalemia:
Likely related to poor PO and hypermetabolic state due to
metastatic colon cancer. She was given ensure TID, MVI, and lyte
repletion.
TRANSITIONAL ISSUES:
==================
#Follow-up: Palliative care at home
#New medications:
-Lactulose
-Sarna lotion
#Changed medications:
-OxyCODONE SR (OxyconTIN) 30 mg PO Q12H hold for sedation or RR
< 12 AND
-OxyCODONE (Immediate Release) ___ mg PO/NG Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
hold for sedation or RR < 12
-Code status: DNAR/DNI
-Contact/HCP: ___ (fiance) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dipyridamole 75 mg PO BID
2. Magnesium Oxide 400 mg PO TID
3. oxyCODONE 10 mg oral Q4H:PRN
4. Vitamin D ___ UNIT PO 1X/WEEK (SA)
5. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
Discharge Medications:
1. Lactulose 30 mL PO Q4H
2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
3. Sarna Lotion 1 Appl TP TID:PRN rash
4. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
==================
Subdural hematoma
Metastatic colon cancer
Secondary diagnosis:
====================
Acute liver failure
Acute hypoxemic respiratory failure
Leukocytosis
Sinus tachycardia
Bilateral pleural effusions
Ascites
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear ___,
You were admitted for trouble breathing and worsening metastatic
colon cancer. You were given medications to help treat your pain
and given other medications to treat your symptoms. You met with
our palliative care team to arrange for you to go home as soon
as possible with hospice care.
It was a pleasure caring of you,
Your ___ medical care team
Followup Instructions:
___
|
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|
2158-10-10 12:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___ Cardiac catheterization
___ Coronary artery bypass graft x 4
History of Present Illness:
___ year old male who presented with atypical chest pain. While
in ___ on vacation he was running along the beach and ___ mile
into his run felt chest pain that was associated with left arm
pain and diaphopresis. He stopped running and the pain went away
and would run again and felt his symptoms again. He felt these
episodes on and off during his vacation and when he returned
home he walked up 3 flights of stairs and felt these symptoms
and came to the ED to be seen. While in ED trop neg, D dimer 495
and EKG showed q wave II, aVf, twi iii, T wave flattening avF no
ST changes. He was admitted for further evaluation and a cardiac
catheterization where he was found to have multivessel disease.
He is now being referred to cardiac surgery for
revascularization.
Past Medical History:
Diverticulitis
s/p Tonsillectomy
Social History:
___
Family History:
Premature coronary artery disease-Father w MI in his mid ___,
multiple cardiac procedures
Physical Exam:
Pulse:86 Resp:18 O2 sat:100/RA
B/P Right:140/88 Left:152/81
Height:5'7" Weight:82.6 kg
General:WDWN, NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x] Edema:none [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 2+ Left:2+
___ Right: 2+ Left:2+
Radial Right: 2+ Left:2+
Carotid Bruit Right: NONE Left:NONE
Pertinent Results:
___ CHEST CTA: IMPRESSION:
1. No evidence of aortic dissection or pulmonary embolism.
2. Mild compression deforities of T3, T4, T6 vertebrae of
uncertain chronicity.
3. The presence of a few calcified left hilar lymph nodes and
calcified
pulmonary granulomas is suggestive of prior granulomatous
infection.
4. Hypodense, rounded lesion in the dome of the liver with
peripheral nodular enhancement is consistent with a hemangioma.
Ultrasound could be obtained for confirmation if clinically
indicated.
5. Hiatal hernia.
.
___ ABD US: IMPRESSION: 3.0 cm right hepatic hemangioma,
corresponding to the previously seen lesion on most recent chest
CTA.
.
___ CARDIAC CATH
Coronary angiography: right dominant
LMCA: No angiographically apparent CAD
LAD: Mid vessel long 60% disease. Serial plaques. Large
diagonal has diffuse disease with serial 50-70% stenoses.
LCX: Proximal diffuse 70% into large OM1 which has 80%
stenosis.
RCA: Proximal 40% with distal total occlusion with collaterals
showing large PL from LCA
.
___ TTE
The left atrium is elongated. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF = 65%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are structurally
normal. Mild (1+) mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
.
___ TEE: report pending
Brief Hospital Course:
Mr. ___ was admitted on ___ with chest pain for work-up while
receiving medical management. On ___ underwent cardiac cath
which revealed severe three vessel coronary artery disease. On
___ he was brought to the operating room where he underwent
a coronary artery bypass graft x 4. Please see operative note
for surgical details. Following surgery he was transferred to
the CVICU for invasive monitoring in stable condition. Later
this day he was weaned from sedation, awoke neurologically
intact and extubated.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD 4 the patient was ambulating freely, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged home in good condition with
appropriate follow up instructions.
Medications on Admission:
Vitamin B 12 unknown dose
Vitamin E unknown dose
Vitamin C unknown dose
Fish oil unknown dose
Flaxseed oil unknown dose
Gingsing unknown dose
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Metoprolol Tartrate 12.5 mg PO BID
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*0
4. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth
every four (4) hours Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 4
Past medical history:
Diverticulitis
s/p Tonsillectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg -Left - healing well, no erythema or drainage
Edema- none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
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2156-02-11 16:37:00
|
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
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o M with hx of pernicious anemia presents with 2 weeks of
breathing difficulties.
Patient reports a few weeks of heavy breathing. He denies any
chest pain or chest tightness. He says the heavy breathing is
worse with laying down. He does not notice it when he exercises.
It is intermittent in nature. Also, 2 weeks ago he started a new
supplement "force factor" which he thinks may be contributing.
Has some nasal congestion and had a mild cough last week. Denies
fevers or chills. Also reports snoring at night which is new but
denies waking from sleep or daytime somnolence. He denies any
lower extremity swelling, calf pain, recent travel.
In the ED, initial vitals were 99.6 106 173/87 16 100% RA
Exam significant for CTAB, RRR, S1S2, no ___ edema
Labs significant for WBC of 16.9 and trop negative x 1.
ECG showed SR 91. NA/NI. extensive TWI. slight STE in aVR and
V1.
CXR showed no acute process
Cardiology evaluated the patient and felt that ECG changes were
probably due to LVH rather than ACS. Exam concerning for LVOT
murmur.
Patient was given 200 mg po labetalol
Vital prior to transfer 98.1 88 107/50 16 98% RA
On arrival to the floor, he has no complaints.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No dysuria. Denies arthralgias
or myalgias. Ten point review of systems is otherwise negative.
Past Medical History:
Pernicious anemia
Social History:
___
Family History:
Mother has anemia, on further questioning, has B12 deficiency.
No CAD, HTN, DM.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.0 138/59 75 18 96% RA
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, no JVD
CV: regular rhythm, ___ systolic murmur at ___.
Lungs: CTAB, no w/r/r
Abdomen: soft, NT/ND, BS+
Ext: WWP, no c/c/e, 2+ distal pulses bilaterally
Neuro: moving all extremities grossly
DISCHARGE EXAM:
VS: 98.6 137/72 120s-50s/70s-90s 80 70s-90s 18 95RA
GENERAL: NAD, alert, interactive
HEENT: NC/AT, sclerae anicteric
LUNGS: CTAB, no w/r/r
HEART: RRR, normal S1, S2. ___ systolic murmur at ___
ABDOMEN: NABS, soft/NT/ND.
EXTREMITIES: WWP
NEURO: awake, A&Ox3
Pertinent Results:
ADMISSION LABS:
___ 07:05PM GLUCOSE-103* UREA N-15 CREAT-1.1 SODIUM-137
POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-27 ANION GAP-15
___ 07:05PM estGFR-Using this
___ 07:05PM cTropnT-<0.01
___ 07:05PM WBC-16.9*# RBC-5.85 HGB-16.4 HCT-50.7 MCV-87
MCH-28.0 MCHC-32.3 RDW-11.9
___ 07:05PM NEUTS-68.6 ___ MONOS-6.4 EOS-1.0
BASOS-1.2
___ 07:05PM PLT COUNT-376
___ 07:05PM ___ PTT-33.6 ___
TROPONINS/CARDIAC ENZYMES:
___ 07:05PM cTropnT-<0.01
___ 10:05AM BLOOD CK(CPK)-278
___ 03:47AM BLOOD CK(CPK)-320
___ 10:05AM BLOOD CK-MB-6 cTropnT-<0.01
___ 03:47AM BLOOD CK-MB-6 cTropnT-<0.01
DISCHARGE LABS:
___ 07:50AM BLOOD WBC-11.1* RBC-5.53 Hgb-15.4 Hct-48.5
MCV-88 MCH-27.9 MCHC-31.8 RDW-11.9 Plt ___
___ 07:50AM BLOOD Plt ___
___ 07:50AM BLOOD Glucose-86 UreaN-14 Creat-0.9 Na-137
K-4.5 Cl-101 HCO3-29 AnGap-12
STUDIES:
___ ECHO
Findings
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size.
Normal regional LV systolic function. Hyperdynamic LVEF >75%.
Estimated cardiac index is normal (>=2.5L/min/m2). False LV
tendon (normal variant). Mild resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. No 2D or Doppler evidence of distal
arch coarctation.
AORTIC VALVE: ?# aortic valve leaflets. Mildly thickened aortic
valve leaflets. No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets. ___ of mitral valve
leaflets. Trivial MR. ___ LV inflow pattern for age.
TRICUSPID VALVE: Normal tricuspid valve leaflets. No TR.
Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
No PS. No PR.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is normal in size. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). The
estimated cardiac index is normal (>=2.5L/min/m2). There is a
mild resting left ventricular outflow tract obstruction. Right
ventricular chamber size and free wall motion are normal. The
number of aortic valve leaflets cannot be determined. The aortic
valve leaflets are mildly thickened (?#). There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are structurally normal. There is systolic
anterior motion of the mitral valve leaflets. Trivial mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: Moderate symmetric left ventricular hypertrophy with
hyperdynamic systolic function and mild outflow tract gradient.
Mild systolic anterior motion of the mitral valve leaflet and
trivial regurgitation. Findings may be consistent with
hypertrophic obstructive cardiomyopathy.
___ CXR
FINDINGS: PA and lateral views of the chest provided
demonstrate no focal consolidation, effusion, or pneumothorax.
No pulmonary edema.
Cardiomediastinal silhouette is normal. Bony structures are
intact. No free air below the right hemidiaphragm.
IMPRESSION: No acute findings in the chest.
Brief Hospital Course:
___ yo M with hx of pernicious anemia presents with dyspnea of
recent onset.
# Dyspnea: Patient had recent episodes of "heavy" breathing
prior to admission. No known risk factors for PE, no pleuritic
CP, no tachycardia or EKG changes suggestive of PE. CXR was
reassuring for infection. Troponins were negative x2. Patient
was found to have LVH and possible hypertrophic obstructive
cardiomyopathy on Echo (see below).
# LVH: An ECHO showed moderate symmetric LVH with hyperdynamic
systolic function and mild outflow tract gradient. Mild systolic
anterior motion of the mitral valve leaflet and trivial
regurgitation. Findings may be consistent with hypertrophic
obstructive cardiomyopathy. Patient is to followup at ___
___.
# Hypertension - Records show Pt previously normotensive at
clinic, but was hypertensive in ED with good response to 200 mg
labetalol with SBP to 100-130s and 130s-150s/60s-80s on floor.
Patient was discharged home on metoprolol and lisinopril.
#Leukocytosis: Resolved. Patient with WBCs of 16.9, but had
improved to 11.1 at discharge.
# Pernicious anemia: Patient was continued on his home B12.
TRANSITIONAL ISSUES:
# Follow up with ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyanocobalamin Dose is Unknown PO DAILY
Discharge Medications:
1. Cyanocobalamin 1000 mcg PO DAILY
2. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet extended release 24
hr(s) by mouth daily Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertension
Left Ventricular Hypertrophy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted with shortness of breath and new EKG
changes. The shortness of breath resolved with treatment of your
blood pressure and the EKG changes are likely due to left
ventricular hypertrophy (thickening of the heart) caused by high
blood pressure. It is possible that this may have lead to a
condition known as hypertrophic obstructive cardiomyopathy, but
this is unclear. It is important that you take your new blood
pressure lowering medications.
Followup Instructions:
___
|
10642913-DS-17
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| 17 |
2158-05-14 00:00:00
|
2158-05-14 17:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Benazepril / Advil / Losartan
Attending: ___.
Chief Complaint:
Vision Loss
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with HTN and DM who presents
with multiple episodes of a right visual field cut.
This past ___, she was walking around her house when all of a
sudden, she lost vision in both her eyes for several seconds.
She
had to hold on to the wall, unclear if she felt like she was
going to faint. She may have been referring to the loss of
vision
as "dizziness." Denies any loss of consciousness. No
diaphoresis,
did not feel lightheaded, did not have tunnel vision or a shade
coming down over her eye. Happened in the early afternoon, never
happened before. Vision returned to baseline when this happened.
On ___, she was traveling to ___. While she was eating
lunch with her friends, she was unable to see out of her right
eye. She covered one eye and the other, and there was no vision
in her right eye. She rubbed her eye and some other areas around
her head, and after a few minutes, her vision returned albeit a
bit blurry. Unsure if her peripheral vision or her central
vision
came back first, was able to see color. Did not notice a shade
coming down over her eye. Had some head pressure associated with
the episode at the top of her head but no actual headache. At
dinner time, she felt like it was about to happen again, but she
did not lose her sight.
No further episodes. Went to see her PCP, who found that her
blood pressure was 178/90, so she was sent to the ED for further
evaluation. Denies urinary incontinence or neck pain.
Past Medical History:
DM, HTN, ear surgery
Social History:
___
Family History:
no family history of stroke or miscarriages,
father had CAD
Physical Exam:
Vitals: T: 98.8F HR: 71 BP: 152/56 RR: 16 SaO2: 99% RA
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR
Pulmonary: breathing comfortably on RA
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive, speech is fluent with
full
sentences, intact repetition, and intact verbal comprehension.
Naming intact. No paraphasias. No dysarthria. Normal prosody.
No
apraxia. No evidence of hemineglect. No left-right confusion.
Able to follow both midline and appendicular commands.
- Cranial Nerves: Pupils dilated by ophthalmology during exam.
VF
full to number counting. Visual acuity L ___, R ___ per
nursing prior to dilation. Optic discs crisp bilaterally. EOMI,
no nystagmus. V1-V3 without deficits to light touch bilaterally.
No facial movement asymmetry. Hearing intact to finger rub
bilaterally. Palate elevation symmetric. SCM/Trapezius strength
___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone in arms and legs, some thenar
atrophy bilaterally
[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1]
L 4 5- 4 5- 4 5- 5 5 5 5
R 4 4+ 4 4+ 4 4+ 5 5- 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 3+ 3+ 3+ 3+ 2
R 3+ 3+ 3+ 3+ 2
Plantar response flexor bilaterally
- Sensory: No deficits to light touch or pin throughout
- Coordination: No dysmetria with finger to nose testing
bilaterally.
- Gait: deferred
=
=
=
================================================================
Discharge Exam:
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive, speech is fluent with
full
sentences, intact repetition, and intact verbal comprehension.
No paraphasias. No dysarthria. Normal prosody. No apraxia. No
left-right confusion. Able to follow both midline and
appendicular commands.
- Cranial Nerves: Pupils 3->2 bilaterally. EOMI, no nystagmus.
VFFC. V1-V3 without deficits to light touch bilaterally. No
facial movement asymmetry. Hearing intact to finger rub
bilaterally. Palate elevation symmetric. SCM/Trapezius strength
___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone in arms and legs,
[Delt] [Tri] [ECR] [IP] [Ham] [TA] [Gas]
L 5 5 5 5- 5 5 5
R 5 5 5 5- 5 5 5
DTR:
___ response flexor bilaterally
- Sensory: No deficits to light touch throughout
- Coordination: No dysmetria with finger to nose testing
bilaterally.
Pertinent Results:
___ 05:10AM BLOOD WBC-7.9 RBC-4.16 Hgb-12.8 Hct-38.2 MCV-92
MCH-30.8 MCHC-33.5 RDW-11.9 RDWSD-40.2 Plt ___
___ 02:35PM BLOOD Neuts-72.5* Lymphs-18.5* Monos-6.5
Eos-1.6 Baso-0.6 Im ___ AbsNeut-4.57 AbsLymp-1.17*
AbsMono-0.41 AbsEos-0.10 AbsBaso-0.04
___ 02:35PM BLOOD ___ PTT-25.0 ___
___ 02:35PM BLOOD Glucose-255* UreaN-14 Creat-0.8 Na-141
K-3.8 Cl-102 HCO3-26 AnGap-13
___ 02:35PM BLOOD ALT-13 AST-13 AlkPhos-75 TotBili-0.3
___ 02:35PM BLOOD Albumin-4.2 Calcium-9.1 Phos-3.6 Mg-1.9
Cholest-177
___ 06:49PM BLOOD %HbA1c-6.8* eAG-148*
___ 05:10AM BLOOD Triglyc-288* HDL-48 CHOL/HD-3.6
LDLcalc-66
___ 02:35PM BLOOD TSH-0.66
___ 02:35PM BLOOD CRP-1.3
___ 02:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:19PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 06:19PM URINE Color-Straw Appear-Clear Sp ___
___ 06:19PM URINE Blood-SM* Nitrite-NEG Protein-NEG
Glucose-300* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 06:19PM URINE RBC-5* WBC-2 Bacteri-NONE Yeast-NONE
Epi-0
Brief Hospital Course:
Ms. ___ is a ___ year old woman past medical history of diabetes
and hypertension who is admitted to the Neurology stroke service
with vision loss secondary to an acute ischemic stroke in the L
Occipital Lobe. Her stroke was most likely secondary to a
cardioembolic event given embolic appearance of the stroke as
well as minimal atherosclerosis in her extracranial and
intracranial arteries. We started her on Aspirin 81 mg daily.
Her neurologic exam prior to discharge was normal. She had no ___
or OT needs.
Her stroke risk factors include the following:
1) DM: A1c 6.8%
2) Hyperlipidemia: LDL 62, ___ 288. Started on Fenofibrate
An echocardiogram did not show a PFO on bubble study and had a
normal EF.
Inpatient telemetry did not reveal atrial fibrillation.
She should follow up with dermatology for her R medial ankle
skin lesion. She should follow up with PCP for DM,
___, and BP management. She should follow up
with Neurology in ___ months. She will have a 30 day holter for
evaluation of paroxysmal atrial fibrillation.
=
=
=
=
=
=
=
=
=
=
=
=
================================================================
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 62) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (x) No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ x] LDL-c less than 70 mg/dL
]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
() Yes - (x) No
9. Discharged on statin therapy? () Yes - (x) No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[x ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - (x) No - () N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. MetFORMIN (Glucophage) 500 mg PO BID
4. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Fenofibrate 48 mg PO DAILY
RX *fenofibrate nanocrystallized 48 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
3. amLODIPine 5 mg PO DAILY
4. Atenolol 25 mg PO DAILY
5. MetFORMIN (Glucophage) 500 mg PO BID
6. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
L Occipital Stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of Right vision loss
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
Diabetes
High Blood Pressure
High Triglycerides
We are changing your medications as follows:
START Aspirin 81 mg daily
START Fenofibrate 48 mg daily
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10642913-DS-18
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| 18 |
2158-05-21 00:00:00
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2158-05-23 10:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Benazepril / Advil / Losartan
Attending: ___
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Neurology Resident Stroke Admission Note
Time/Date the patient was last known well: ___ at 0800
Pre-stroke mRS ___ social history for description): 0
t-PA Administration
No - Reason t-PA was not given/considered: NIHSS 0, symptoms
resolved by the time of my assessment
Endovascular intervention: No
I was present during the CT scanning and reviewed the images
within 20 minutes of their completion.
___ Stroke Scale - Total 0
1a. Level of Consciousness -0
1b. LOC Questions -0
1c. LOC Commands -0
2. Best Gaze -0
3. Visual Fields -0
4. Facial Palsy -0
5a. Motor arm, left -0
5b. Motor arm, right -0
6a. Motor leg, left -0
6b. Motor leg, right -0
7. Limb Ataxia -0
8. Sensory -0
9. Language -0
10. Dysarthria -0
11. Extinction and Neglect -0
HPI: Ms. ___ is a ___ year old woman with history of
recent left occipital stroke (presumed cardioembolic in
etiology,
on aspirin 81mg daily) during hospitalization 1 week ago,
hypertriglyceridemia, HTN and T2 DM non-insulin dependent who
presents following an episode of dizziness. History provided by
patient and daughter at bedside.
Ms. ___ was recently hospitalized at ___ Neurology from
___ due to having multiple episodes of loss of right sided
visual field cut and dizziness. Examination on admission was
notable for bilateral upper extremity weakness in a lower motor
neuron pattern and hyperreflexia, but no other focal deficits
and
normal ophthalmologist examination. She was admitted to the
Stroke service for further evaluation, and was found to have an
acute ischemic stroke in the left occipital lobe. Stroke
etiology
was presumed cardioembolic given embolic appearance of the
stroke, and minimal atherosclerosis in her extracranial and
intracranial vessels. She was started on aspirin 81mg daily. Her
neurologic exam prior to discharge was normal. Stroke risk
factor
screening included hemoglobin A1c 6.8%, LDL 62, triglyceride 288
(started on Fenofibrate). TTE did not show a PFO on bubble
study
and had a normal EG. Inpatient telemetry did not reveal any
evidence of arrhythmias. She was discharged with a 30 day holter
monitor for evaluation of paroxysmal Afib.
Since being discharged on 1 week ago, she initially felt at her
baseline for about 24 hours. On ___ (4 days ago) she woke up
and was able to go about her day feeling well until dinner time.
She sat down to eat dinner with her family. In the middle of
eating dinner, she developed acute onset of dizziness, which she
describes as a sensation of "everything going down." She was
seated upright in a chair when this occurred. She asked her
daughter for a piece of chocolate because she wanted "something
sweet" to help. She took the chocolate, stepped aside from the
dinner table and felt better. She denies any symptoms of
diaphoresis, lightheadedness, numbness/tingling, weakness, room
spinning vertigo, chest pain and shortness of breath. She
measured her blood pressure at home and it was 167/64. The
feeling resolved in a few minutes, but she remained with
generalize malaise, which has been ongoing since that time. She
went to sleep.
She woke up on ___ morning (3 days ago) with ongoing malaise,
but no dizziness. Over the last 3 days, she has had intermittent
dizziness that has been "less severe" lasting just several
seconds to a minute at a time. It seems to occur when she is
seated upright and not in other positions. There have been no
clear provoking factors.
This morning, patient woke up with her ongoing malaise but
otherwise no dizziness. She went into the kitchen to prepare
oatmeal. She completed cooking the oatmeal and reached into the
refrigerator to get blueberries. As this happened she notes that
both hands became "weak" which she clarifies as a sensation of
hands feeling extremely cold, out of proportion to temperature.
She also had a sensation of her head feeling "hot" with pressure
on top of her head, a sensation that she experienced a week ago
prior to her stroke. She then sat down to relax; the hand and
head sensations resolved. She then developed her dizziness,
similar to what was described above on ___ (feeling like
"everything is going down"). This lasted for a few minutes and
then resolved. She did not have any visual symptoms, no
weakness,
no sensory changes, no vertigo, no hearing loss, no tinnitus.
EMS
was called and blood pressure was 160/90. She was transferred
to
___ ED for further management.
At ___ Ed, vitals were notable for T 98.1F, HR 75, BP 177/69,
RR 18, O2 100% on room air. Per ED team, she reported dizziness
on arrival but patient denies this, saying she has been at her
baseline since arrival. She has no complaints at this time.
She denies recent illness. Denies any medication changes or new
medications. Denies fevers/chills. Denies recent stressors.
Denies any changes to her oral intake.
Past Medical History:
Recent left occipital ischemic infarct s/p hospitalization
___
Hypertriglyceridemia
Diabetes mellitus, non-insulin dependent, on metformin
HTN
History of ear surgery
Cervical Spondylosis
Social History:
___
Family History:
No family history of stroke or miscarriages. Her
father had coronary artery disease.
Physical Exam:
Vitals: T 98.1F, HR 72-76, BP 160-179/69-90, RR 18, O2 100% RA
General: Awake, alert, in no acute distress
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: warm, well perfused; regular on telemetry
Pulmonary: breathing non labored on room air
Abdomen: Soft, NT, ND, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. She is mildly inattentive and
requires some prompting to maintain attention to tasks on the
exam. Speech is fluent with full sentences, intact repetition,
and intact verbal comprehension. Naming intact. No paraphasias.
No dysarthria. Normal prosody. Names all objects on stroke card
except for "hammock." No apraxia. No evidence of hemineglect. No
left-right confusion. Able to follow both midline and
appendicular commands.
- Cranial Nerves: PERRL 3->2 brisk. VF full to number counting.
Gaze conjugate with no nystagmus on primary gaze or on EOM.
Funduscopic exam performed and crisp disc margins noted. No
skew.
Negative head impulse test. EOMI, no nystagmus. V1-V3 without
deficits to light touch and pinprick bilaterally. No facial
movement asymmetry. Hearing intact to finger rub bilaterally.
Palate elevation symmetric. SCM/Trapezius strength ___
bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
[___]
L 4+* 5 5 5 4+* 5 5 5 5 5 5 5
R 5 5 5 5 4+* 5 5 5 5 5 5 5
*difficult to assess if true weakness or due to inattention
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 3 3 3 3 2
R 3 3 3 3 2
Plantar response flexor bilaterally
- Sensory: No deficits to light touch, pin, or proprioception
bilaterally. No extinction to DSS.
- Coordination: No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait: Normal initiation. Narrow base. Normal stride length and
arm swing. Stable without sway. Negative Romberg. Negative
Unterberger test.
=====================================================
DIscharge Exam unchanged.
Also notable for + occiput tenderness to palpation, paraspinal
tenderness, and decreased cervical spine ROM
Pertinent Results:
___ 09:25AM BLOOD WBC-5.4 RBC-4.58 Hgb-14.0 Hct-41.3 MCV-90
MCH-30.6 MCHC-33.9 RDW-11.9 RDWSD-38.9 Plt ___
___ 05:00AM BLOOD WBC-5.7 RBC-4.26 Hgb-13.2 Hct-38.9 MCV-91
MCH-31.0 MCHC-33.9 RDW-12.1 RDWSD-40.0 Plt ___
___ 09:25AM BLOOD Neuts-69.8 ___ Monos-7.0 Eos-1.1
Baso-0.4 Im ___ AbsNeut-3.78 AbsLymp-1.14* AbsMono-0.38
AbsEos-0.06 AbsBaso-0.02
___ 05:00AM BLOOD ___ PTT-25.9 ___
___ 05:00AM BLOOD Glucose-95 UreaN-11 Creat-0.7 Na-143
K-4.0 Cl-103 HCO3-25 AnGap-15
___ 09:25AM BLOOD ALT-17 AST-16 AlkPhos-68 TotBili-0.9
___ 09:25AM BLOOD cTropnT-<0.01
___ 05:00AM BLOOD Calcium-8.7 Phos-4.3 Mg-1.9
___ 09:25AM BLOOD Albumin-4.5 Cholest-193
___ 01:12PM BLOOD %HbA1c-6.9* eAG-151*
___ 09:25AM BLOOD Triglyc-182* HDL-58 CHOL/HD-3.3
LDLcalc-99
___ 09:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:40AM URINE Color-Straw Appear-Clear Sp ___
___ 10:40AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-TR*
___ 10:40AM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE
Epi-<1 TransE-<1
___ 10:40AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Urine CUlture:
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
MRI Brain ___
1. Evolving small left occipital lobe subacute infarction. No
new infarct is
identified.
2. Minimal scattered periventricular and deep white matter
T2/FLAIR
hyperintensities are nonspecific but can be seen with chronic
small vessel
disease.
CTA H/N ___
1. Re-demonstration of foci of hypodensity in the left occipital
lobe, which
is better visualized on prior MR head performed ___.
Otherwise there
is no evidence of infarction, hemorrhage, edema, or mass.
2. Normal head and neck CTA, grossly unchanged when compared to
prior CTA head
and neck performed ___.
Brief Hospital Course:
___, ___ of recent admission for L occipital lobe
infarct was admitted for dizziness and headache. Upon further
history, her dizziness was described as lightheadedness, with
worsening upon standing. She was given IVF overnight, and
Orthostatics on HOD2 were negative. It was felt that her
lightheadedness was either cervicogenic from underlying cervical
spondylosis or orthostatic in nature. Furthermore, her headaches
were described as a "head pressure", and on exam, she had
subtle UMN pattern of weakness, hyperreflexia, decreased
cervical ROM, and occiput notch tenderness. Her headaches are
likely cervicogenic in nature given underlying cervical
spondylosis. She was given a soft collar. Her MRI negative for
new infarcts. Lastly, During hospital stay, noted to have an
hives ___ adhesive. Adhesive removed and given sarna/Benadryl.
She was discharged home.
Transitional Issues:
- Outpt Dermatology as previously scheduled
- Outpt Stroke as previously scheduled
- c/w Holter
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Omeprazole 20 mg PO DAILY
6. Fenofibrate 48 mg PO DAILY
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. Fenofibrate 48 mg PO DAILY
5. MetFORMIN (Glucophage) 500 mg PO BID
6. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Cervicogenic Headache
Non-specific Lightheadedness
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 dizziness and headaches. Your headaches
are likely a result of cervical spondylosis, which is arthritis
of your neck. For this we would recommend you wear a soft collar
nightly while you sleep. Your dizziness was described as
lightheadedness, which may be secondary to low blood pressure
upon standing and/ or related to your arthritis in your neck. We
recommend you continue to stay hydrated, eat well and wear your
soft collar at night.
Your MRI Brain did not show any new strokes.
Your medications were not changed.
Please follow up with your PCP and ___ as
previously scheduled.
Thank you,
Your ___ Neurology Team
Followup Instructions:
___
|
10642913-DS-19
| 10,642,913 | 23,526,783 |
DS
| 19 |
2158-12-23 00:00:00
|
2158-12-24 12:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Benazepril / Advil / Losartan
Attending: ___
Chief Complaint:
L arm and leg weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
EU Critical ___ aka ___ (MRN ___ is a ___
year old woman with history of prior L PCA infarct with no
residual symptoms, HTN, type 2 DM who presents with a several
hour history of dizziness, and a 30 minute history of left arm
and leg sensorimotor symptoms. History provided by patient,
daughter and husband, with ___ interpreter assisting.
Ms. ___ was in her usual state of health until approximately 2PM
today, when she developed acute onset of dizziness. She was
sitting down on the couch at the time. By dizziness, she
clarifies to mean a lightheadedness or pre-syncopal sensation.
She laid down to take a nap, thinking it could be related to a
new herbal tea she had just prior to that. Her daughter (who is
an ___) did measure her blood pressure and it was 182/78, which
is
increased from her baseline. When she woke up 1 hour later,
systolic blood pressure improved to 138. She took another nap
and woke up at 5:30PM feeling in her usual state of health.
At approximately 7:30PM, while sitting in the kitchen with her
husband, she then had acute onset of left arm and leg weakness
and numbness. She reports that she had numbness throughout the
left arm and leg (sparing the face), as well as weakness of L
leg>arm. She could still lift both antigravity, but not sustain.
Her husband contacted her daughter who advised her to go to the
ED.
On arrival to ___ ED about 30 minutes later, vitals were
notable for BP 149/119. Code stroke was called. Initial NIHSS
performed by ED was 5, scoring for left arm and leg drift, with
left leg barely antigravity, as well as L arm and leg numbness.
On my assessment within 5 minutes, L leg weakness improved
somewhat and NIHSS was 3, scoring for L leg drift, L nasolabial
fold flattening and left arm/leg mild sensory loss. CTA
Head/Neck
revealed RIGHT PCA occlusion, and otherwise no large vessel
occlusion.
After discussion of risks/benefits, decision made to give TPA.
Bolus given at 20:57 on ___.
With respect to her prior neurologic history:
-Was hospitalized at ___ Neurology from ___ due
to
having multiple episodes of loss of right sided visual field cut
and dizziness. Examination on admission was notable for
bilateral upper extremity weakness in a lower motor neuron
pattern and hyperreflexia, but no other focal deficits and
normal ophthalmologist examination. She was admitted to the
Stroke service for further evaluation, and was found to have an
acute ischemic stroke in the left occipital lobe. Stroke
etiology was presumed cardioembolic given embolic appearance of
the stroke, and minimal atherosclerosis in her extracranial and
intracranial vessels. She was started on aspirin 81mg daily. Her
neurologic exam prior to discharge was normal. Stroke risk
factor screening included hemoglobin A1c 6.8%, LDL 62,
triglyceride 288 (started on Fenofibrate). TTE did not show a
PFO on bubble study and had a normal EF. Inpatient telemetry did
not reveal any evidence of arrhythmias. She was discharged with
a
30 day holter monitor for evaluation of paroxysmal Afib, which
was unrevealing.
-She was re-admitted briefly in late ___ with headache and
dizziness. Neuro exam was at baseline (4+ effort dependent L
deltoid and bilateral finger extensor strength). MRI negative
for
new infarct, headache was treated symptomatically with
improvement.
- Since then is followed by Dr. ___ who feels that
stroke etiology remains unclear. He has expressed concern for
underlying hypercoagulability and is considering malignancy
screening. He ordered screening D-dimer which was elevated at
683, ESR which was 6. Considering CT torso. Remains on aspirin
81mg daily.
Currently patient reports left arm and leg strength and numbness
is improving, but not back to baseline. Prior to above, only
change in her routine is that she has been having increasing low
grade headaches over the last ___ weeks, without any elevated
ICP
features. Otherwise denies recent illness, denies recent
fevers/chills, denies any recent medication changes.
Past Medical History:
Recent left occipital ischemic infarct s/p hospitalization
___
Hypertriglyceridemia
Diabetes mellitus, non-insulin dependent, on metformin
HTN
History of ear surgery
Cervical Spondylosis
Social History:
___
Family History:
No family history of stroke or miscarriages. Her
father had coronary artery disease.
Physical Exam:
ADMISSION EXAM:
Vitals: Afebrile, HR 79 (sinus), BP 149/119, RR 17, O2 100% RA
Glucose 242
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. She is mildly inattentive, requiring
prompting a few times to maintain attention to examiner.
Language
is fluent with intact repetition and comprehension. Normal
prosody. There were no paraphasic errors. Pt was able to name
both high and low frequency objects. Able to read without
difficulty. Speech was not dysarthric. Able to follow both
midline and appendicular commands. There was no evidence of
apraxia or neglect. No evidence of neglect on line bisection
task.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation via finger
wiggling and number couting.
V: Facial sensation intact to light touch and pinprick
VII: Mild left nasolabial fold flattening with mildly reduced
activation.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 4 ___ ___ 4 5 5 5
R 4+* ___ 4+* ___ 5 5 5
*limited by poor effort and inattention
-Sensory: Reduced but not absent sensation in L arm and leg to
pinprick and light touch. No deficits to proprioception
throughout. No extinction to DSS. Romberg absent.
-DTRs:
___ Tri ___ Pat Ach
L ___ 2 2
R ___ 2 2
Plantar response was flexor on R, extensor on L.
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF or HKS bilaterally.
-Gait: deferred
=========================
DISCHARGE EXAM:
Pertinent Results:
___ 05:35AM BLOOD WBC-8.0 RBC-4.26 Hgb-12.9 Hct-38.4 MCV-90
MCH-30.3 MCHC-33.6 RDW-12.2 RDWSD-40.1 Plt ___
___ 05:35AM BLOOD Glucose-134* UreaN-14 Creat-0.7 Na-140
K-4.0 Cl-98 HCO3-25 AnGap-17
___ 05:35AM BLOOD ___ PTT-24.1* ___
___ 08:04PM BLOOD ALT-19 AST-38 AlkPhos-67 TotBili-0.4
___ 05:35AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.9 Cholest-179
___ 05:35AM BLOOD %HbA1c-7.4* eAG-166*
___ 05:35AM BLOOD Triglyc-224* HDL-50 CHOL/HD-3.6
LDLcalc-84
___ 05:35AM BLOOD TSH-1.6
___ 11:05PM BLOOD CRP-7.4*
___: ___ 254 (slightly elevated)
___: D-Dimer 683 (slightly elevated)
TEE ___:
Good image quality. No spontaneous echo contrast or thrombus in
the left atrium/left
atrial appendage/right atrium/right atrial appendage. No atrial
septal defect or patent forament ovale
identified by 2D, Doppler or intravenous saline with maneuvers.
Echo TTE ___:
The left atrium is normal in size. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF =
70%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
MRI Brain ___:
1. Mulltiple scattered late acute to subacute infarcts involving
the right
thalamus, medial right occipital lobe, right medial temporal
lobe and right
cerebellum.
2. Evidence of hemorrhagic transformation along the posterior
aspect of the
right medial temporal lobe.
3. Minimal white matter small vessel disease.
4. Mild generalized parenchymal volume loss, likely age related.
5. Additional findings described above.
CTA head and neck ___:
1. Occlusion/high-grade stenosis of the right PCA at the distal
P1/proximal P2
segment.
2. No evidence of a large territorial infarction.
3. CT perfusion images demonstrated mismatch volume of 27 mL of
ischemic
penumbra in the right PCA distribution without definite sign of
an infarct
core.
Brief Hospital Course:
___ year old woman with history of prior L PCA infarct
(scattered, multifocal infarcts within the left PCA territory),
HTN, DM2, who presents with several hour history of
lightheadedness and transient left arm and leg
weakness/numbness, found to have R P2 occlusion and sluggish
flow in the right SCA on CTA and received tPA. MRI showed
multiple scattered ischemic infarctions including the right
cerebellum and the right thalamocapsular areas as well as at
least three areas within the right PCA territory. Course
complicated by small area of hemorrhagic transformation within
the ischemic areas (after tPA). Workup has not shown clear
etiology of recurrent strokes (stroke of unknown etiology),
including normal TTE, TEE, 30day cardiac monitor, and
hypercoagulability workup (antiphospholipid antibodies were
negative, D-Dimers were slightly elevated); she has not had
genetic testing done (Factor V leiden, Prothrombin Gene
Mutation).
# Ischemic Stroke: Patient presented with NIHSS 3 and tPA was
given within 1.5 hours of time last seen well. CTA showed R PCA
cutoff, and MRI showed multiple small strokes in the right
medial right occipital lobe, right medial temporal lobe
consistent with PCA distribution, but there was also an acute
stroke in the right cerebellum and in the right thalamocapsular
region, which is not PCA distribution. MRI was performed ~24
hours after tPA and showed small area of hemorrhagic
transformation in the R temporal lobe and in the right posterior
cingulate/retrosplenial region. Subsequent CT 2 days later was
stable without further hemorrhage. Patient had normal TTE and
TEE during admission without findings of PFO. Hypercoagulability
workup including lupus anticoagulant, cardiolipin, beta-2
glycoprotein, Protein C/S were all negative. She had previously
a slightly positive D-Dimer at 683 (done on ___.
We added an LDH to her lab and it came back slightly elevated at
254. Furthermore her CRP was slightly elevated. She also had
more than 1% atypical lymphocytes in her Diff.
We decided to increase her ASA81 to 162mg and started her on a
statin for secondary stroke prophylaxis. We discussed continuing
aspirin versus switching plavix meanwhile, and decided to
increase aspirin to 81mg twice daily. As 20% of Asians have a
mutation rendering plavix ineffective, it was felt to be high
risk to switch to plavix despite current stroke while on
aspirin.
We also anticipate that patient might be placed on Apixaban for
secondary stroke prophylaxis and suggested this to her
outpatient Neurologist (she does not require prior
authorization, has $45 copay) but should not start until ___
weeks after discharge due to recent intracranial hemorrhage. She
also had a Linq device placed while in the hospital to monitor
her for paroxysmal AFib.
We had a further discussion with her outpatient Neurologist.
Considering that all tests for any embolic source or any hyper
coagulable state have been either negative or marginal, but that
she has at last 8 separate small strokes over the last 8 months,
we were wondering whether or not other etiologies need to be
excluded further such as an Intravascular Lymphoma. She does
have some atypical lymphocytes in her blood smear, she has
slightly elevated CRP and slightly elevated D-dimers and she has
an elevated LDH. Of course an IVL diagnosis is very difficult to
make without a brain biopsy. We discussed the possibility of
doing a large volume LP to see if she has abnormal lymphocytes.
The LP and a possible brain biopsy was not discussed with the
patient yet.
# Hypertriglyceridemia: Her LDL was 84, and she was started on
atorvastatin 40mg. Triglycerides were in the 200s, elevated out
of proportion to other medications, and we recommended
nutritional intervention and starting fish oil.
==========
Transitional Issues:
- Patient to get mutational sequencing for Prothrombin gene and
Factor V as an outpatient
- Patient should be transitioned to apixaban ___ weeks after
discharge per outpatient neurologist (does not require prior
authorization)
- Patient with elevated triglycerides, please continue to
monitor
- Patient had LinQ cardiac monitor placed to evaluate for atrial
fibrillation, requires follow up with cardiology.
- Further discussion with PCP and ___ about
more rare etiologies of her multiple strokes and the appropriate
work-up for this.
===========
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day
2? () Yes - () No
4. LDL documented? (x) Yes (LDL = 84) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. Fenofibrate 48 mg PO DAILY
5. MetFORMIN (Glucophage) 250 mg PO BID
6. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*5
2. Aspirin 81 mg PO BID
RX *aspirin 81 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*5
3. amLODIPine 5 mg PO DAILY
4. Atenolol 25 mg PO DAILY
5. Fenofibrate 48 mg PO DAILY
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Ischemic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of dizziness resulting
from an ACUTE ISCHEMIC STROKE, a condition where a blood vessel
providing oxygen and nutrients to the brain is blocked by a
clot. The brain is the part of your body that controls and
directs all the other parts of your body, so damage to the brain
from being deprived of its blood supply can result in a variety
of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
Your risk factors are currently unknown.
We are changing your medications as follows:
Please start taking atorvastatin.
Please call your neurologist in ___ weeks to discuss starting
apixaban (blood thinner). Continue increased dose of aspirin
until otherwise instructed.
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10643269-DS-14
| 10,643,269 | 29,246,051 |
DS
| 14 |
2158-10-05 00:00:00
|
2158-10-06 11:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Vistaril / Biaxin / aspirin / Ceclor / Cardura
Attending: ___.
Chief Complaint:
Weight gain, dyspnea, orthopnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ with history of asthma, IDDM, OSA
(on CPAP), who presented to the ED complaining of 1 month of
chest pain which has become worse over the past 3 days.
Associated with increased DOE and orthopnea. She presented to
her ___ appointment earlier today and was c/o chest
heaviness. EKG showed AFib so she was sent in to the ___ Unit
for evaluation, however the ___ felt that an inpatient
admission would be more appropriate for workup so she was
admitted through the ED. She received ASA 325mg en route.
In the ED, initial vitals were: T 98.4, HR 98, BP 132/77, RR 20,
O2Sat 100%RA
- EKG: Atrial fibrillation w/ rate of 93bpm. NANI. T wave
flattening in I, aVF, V6. No prior for comparison. No STEMI.
- Labs notable for: BNP 976, CBC and Chem-7 wnl (K hemolyzed,
whole blood was 4.2). TSH 0.38. Trop < 0.01 x1. UA wnl. Coags
wnl. No prior labs for comparison.
- Imaging was notable for: CXR with cardiomegaly without
superimposed acute cardiopulmonary process per formal read.
However, by interpretation there is increased pulmonary vascular
congestion perhaps suggestive of mild heart failure.
- Patient was given: 120mg PO Lasix, 21u insulin, pravastatin,
pregabalin 150mg, metformin 1000mg
Upon arrival to the floor, patient reports about 1 month of
worsening orthopnea, chest tightness not responsive to albuterol
or nitroglycerin without radiation to jaw or arm. She has had
substantial weight gain over several months. She was also
recently started about 1 month ago on Lasix for increasing
bilateral ___ edema (80mg qAM and 100mg at noon) but without
improvement.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
- HFpEF
- Pulmonary hypertension
- Asthma/COPD
- IDDM (A1c 8.5%, seen at ___
- OSA (on CPAP)
Social History:
___
Family History:
Heart failure on her mother's side. The patient's daughter died
of an MI at age ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital Signs: T 98.3, 118/78, 100, 20, 94%RA
Weight: 327.7 lbs (standing)
General: Alert, oriented, no acute distress, morbidly obese
HEENT: Sclerae anicteric, MMM.
Neck: JVP elevated ~12 cm
CV: Irregularly irregular. No murmur.
Lungs: Diminished at bilateral bases. No wheezes or crackles.
Abdomen: Soft, non-tender, non-distended, obese.
GU: No foley
Ext: Warm, well perfused. 1+ bilateral ___ edema at least.
DISCHARGE PHYSICAL EXAM:
- VITALS: T 98.1 ___ 18 91-97RA
- I/Os: 24HR 1730/2350 | 8HR 100/350
- WEIGHT: ___ kg ___ kg ___ kg ___ kg
- WEIGHT ON ADMISSION: 149.0 standing
GENERAL: Alert, oriented, no acute distress, morbidly obese
HEENT: Sclerae anicteric, MMM.
NECK: Supple, JVP flat
HEART: Regular rate. No murmur.
LUNGS: Diminished at bilateral bases, otherwise clear
ABDOMEN: Soft, non-tender, non-distended, obese.
EXTREMITIES: Warm, well perfused. Minimal pretibial edema in the
bilateral lower extremities
Pertinent Results:
_______________________
ADMISSION LABS:
___ 12:39PM BLOOD WBC-8.6 RBC-4.52 Hgb-12.1 Hct-39.2 MCV-87
MCH-26.8 MCHC-30.9* RDW-16.0* RDWSD-50.5* Plt ___
___ 12:39PM BLOOD Neuts-66.1 ___ Monos-6.9 Eos-2.2
Baso-0.6 Im ___ AbsNeut-5.66 AbsLymp-2.06 AbsMono-0.59
AbsEos-0.19 AbsBaso-0.05
___ 12:39PM BLOOD ___ PTT-29.3 ___
___ 12:39PM BLOOD Glucose-139* UreaN-21* Creat-0.9 Na-138
K-8.3* Cl-98 HCO3-27 AnGap-21*
___ 12:39PM BLOOD proBNP-976*
___ 12:39PM BLOOD Calcium-9.3 Phos-4.2 Mg-1.9
___ 12:39PM BLOOD VitB12-299
___ 12:39PM BLOOD TSH-0.38
___ 12:39PM BLOOD T3-143
_______________________
STUDIES/IMAGING:
___ Cardiovascular ECHO:
The left atrium is elongated. 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. There is considerable
beat-to-beat variability of the left ventricular ejection
fraction due to an irregular rhythm/premature beats. Right
ventricular chamber size and free wall motion are normal. The
aortic valve is not well seen. Trace aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. Mild
(1+) mitral regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is an anterior space which
most likely represents a prominent fat pad.
IMPRESSION: Very suboptimal image quality. Normal biventricular
cavity sizes with preserved global biventricular systolic
function. Moderate pulmonary artery systolic hypertension. Mild
mitral regurgiattion. Left atrial enlargementr.
_______________________
DISCHARGE LABS:
___ 07:40AM BLOOD Glucose-124* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-98 HCO3-28 AnGap-18
___ 07:40AM BLOOD Calcium-9.6 Phos-4.9* Mg-2.0
Brief Hospital Course:
Outpatient Providers: ___ with history of asthma, IDDM, OSA (on
CPAP), who presented to the ED from outpatient ___
appointment with chest pressure and dyspnea on exertion, found
to have acute diastolic CHF exacerbation as well as new atrial
fibrillation. CXR significant for cardiomegaly without
superimposed acute cardiopulmonary process. proBNP upon
admission was 976. EKG significant for coarse atrial
fibrillation without ST changes. Troponins negative x 3. TTE was
suboptimal, especially in the setting of atrial fibrillation,
but significant for normal biventricular cavity sizes with
preserved global biventricular systolic function, with moderate
pulmonary artery systolic hypertension and mild MR. ___ was
diuresed using IV furosemide 100 mg TID and subsequently
transitioned to PO torsemide 40 mg daily and instructed to take
torsemide 40 mg BID for weight gain or dyspnea. Initially, plan
was for TEE/cardioversion for her newly diagnosed atrial
fibrillation, however, she spontaneously converted and
subsequently remained in sinus rhythm. She was started on
rivaroxaban for anticoagulation given paroxysmal atrial
fibrillation.
ACTIVE ISSUES:
====================================
#ACUTE HFpEF EXACERBATION (LVEF >55%):
Patient presented with orthopnea, dyspnea on exertion,
previously on outpatient diuretics, with prior known diagnosis
of HFpEF. TTE here with suboptimal image quality but with EF
>55%. BNP is likely spuriously low due to morbid obesity.
- PRELOAD: Discharged with diuretic regimen of torsemide 40 mg
daily and instructed to take 40 mg BID if develops lower
extremity edema, weight gain, difficulty breathing
- NHBK: Continued metoprolol succinate 25 mg daily
- AFTERLOAD: Continue spironolactone 25 mg daily and losartan
100 mg daily and amlodipine 10 mg daily
#CHEST PAIN/PRESSURE:
Likely heart failure +/- acid reflux as the patient had another
episode ___ ___ that resolved with Maalox and ginger-ale. EKG
and enzymes reassuring.
- Continued Pravastatin 40mg QHS
- Maalox PRN
#NEWLY DIAGNOSED PAROXYSMAL ATRIAL FIBRILLATION :
Rates controlled in ___ on arrival. CHADS-VASC score
elevated to 5 (age, sex, CHF, HTN, DM). On DOAC. Spontaneously
converted back to sinus ___ ___.
- Continued Xarelto 20 mg DAILY
- Discharged on metoprolol 25 mg XL daily
TRANSITIONAL ISSUES:
====================================
CONTACT: ___ (daughter, ___
DISCHARGE/DRY WEIGHT: 145.6 kg (320.9 lbs)
DISCHARGE DIURETIC DOSING: Torsemide 40 mg daily, with
instructions for torsemide 40 mg BID prn weight gain, dyspnea
- The patient was going to be cardioverted but spontaneously
converted back to sinus rhythm the evening before planned ___.
She was discharged on rivaroxaban for anticoagulation
- Please repeat BMP at follow up appointment to ensure stable
creatinine and electrolytes; Cr of 0.9 on the day of discharge
- Discharged with diuretic regimen of torsemide 40 mg daily and
instructed to take 40 mg BID if develops lower extremity edema,
weight gain, difficulty breathing
- Aspirin 81 mg daily for primary prevention was discontinued as
patient was initiated on rivaroxaban as above
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pregabalin 150 mg PO TID
2. Aspirin 81 mg PO DAILY
3. amLODIPine 10 mg PO DAILY
4. Allopurinol ___ mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. Furosemide 80 mg PO QAM
9. Furosemide 120 mg PO NOON
10. Montelukast 10 mg PO DAILY
11. Losartan Potassium 100 mg PO DAILY
12. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
13. Restasis 0.05 % ophthalmic QHS
14. MetFORMIN (Glucophage) 1000 mg PO BID
15. Trulicity (dulaglutide) 0.75 mg/0.5 mL subcutaneous 1X/WEEK
16. Spironolactone 25 mg PO DAILY
17. Pravastatin 40 mg PO QPM
18. Ranitidine 150 mg PO BID
19. Metoprolol Succinate XL 25 mg PO DAILY
20. Fluticasone Propionate NASAL 1 SPRY NU DAILY
21. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
DAILY
22. Lidocaine 5% Patch 1 PTCH TD QAM
23. Levemir 16 Units Breakfast
Levemir 36 Units Bedtime
Insulin SC Sliding Scale using Novolog Insulin
Discharge Medications:
1. Rivaroxaban 20 mg PO DINNER
RX *rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth at bedtime
Disp #*30 Tablet Refills:*0
2. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
3. Torsemide 40 mg PO ASDIR
prn weight gain, shortness of breath, lower extremity swelling
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
5. Allopurinol ___ mg PO DAILY
6. amLODIPine 10 mg PO DAILY
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
DAILY
10. Glargine 16 Units Breakfast
Glargine 36 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
12. Lidocaine 5% Patch 1 PTCH TD QAM
13. Losartan Potassium 100 mg PO DAILY
14. MetFORMIN (Glucophage) 1000 mg PO BID
15. Metoprolol Succinate XL 25 mg PO DAILY
16. Montelukast 10 mg PO DAILY
17. Multivitamins 1 TAB PO DAILY
18. Pravastatin 40 mg PO QPM
19. Pregabalin 150 mg PO TID
20. Ranitidine 150 mg PO BID
21. Restasis 0.05 % ophthalmic QHS
22. Spironolactone 25 mg PO DAILY
23. Trulicity (dulaglutide) 0.75 mg/0.5 mL subcutaneous 1X/WEEK
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Paroxysmal Atrial Fibrillation
Acute Diastolic CHF Exacerbation
Secondary Diagnosis:
Diabetes
Hypertension
Hyperlipidemia
Obstructive Sleep Apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
You first came to the hospital because you were experiencing
some chest pressure. You have a condition called congestive
heart failure which can cause fluid to back up into your lungs.
You were also diagnosed with a heart arrhythmia called atrial
fibrillation. Your heart rhythm returned to normal. However,
because people with atrial fibrillation have an increased risk
of stroke, we started on you blood thinning medications to
prevent clots from forming to help reduce your risk of stroke.
Please continue to take these medications.
We also started a medication called torsemide which you should
take to remove fluid from your body.
Please weigh yourself daily using the same scale everyday. Your
weight today was 145.6 kg (321 lbs). This is also called your
dry weight, or your weight when you have no extra fluid in your
body. You should take torsemide 40 mg in the morning. You should
monitor your weight and symptoms. If you notice your weight is
increasing, or if you have shortness of breath or lower
extremity edema, take a second dose of torsemide 40 mg in the
afternoon. If your weight increases by more than 2 pounds per
day or by more than 5 pounds in one week, you should call the
heart failure clinic here at ___ or call your
cardiologist. If you notice you are losing weight too quickly,
more than 2 lbs in one day or more than 5 lbs in one week,
please call your cardiologist.
Please seek medical attention if you develop fevers, chills,
shortness of breath, chest pressure, swelling in your legs, or
if your weight increases or decreases by more than 2 lbs in one
day or by more than 5 lbs per week.
We wish you all the best of health,
Your ___ healthcare team
Followup Instructions:
___
|
10643286-DS-17
| 10,643,286 | 24,693,844 |
DS
| 17 |
2187-05-06 00:00:00
|
2187-05-06 21:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Respiratory Distress
Major Surgical or Invasive Procedure:
Cricothyroidotomy, open tracheostomy
History of Present Illness:
Per ED report, patient presents with diffuse swelling of her
lips, oropharynx, and face. Patient is able to give yes/no
answers with the phone interpreter, but is unable to speak full
sentences to provide further history. Patient is never had
symptoms like this before. No known history of angioedema. She
has never been intubated. Patient has an empty bottle of
diphenhydramine in her purse.
On transfer to the internal medicine floor, the following
history was relayed by the ICU team: this is a ___ with h/o
HTN who presented to the ED on
___ with facial swelling and angioedema. Upon questioning
in the SICU, patient reported that she had been eating at a
restaurant when she suddenly started to feel her face swell and
she became short of breath. Her friend then brought her to the
ED. She is unable to relay further history at this time given
trach and unable to write at present. Of note, she reportedly is
primarily ___ but understands ___. She has
received prior care at ___ and ___ has requested
records. She is being transferred to medicine for workup of
angioedema and ongoing SLP evaluation, given she no longer
requires ICU level care and she no longer has an acute surgical
needs.
Past Medical History:
Unknown
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Constitutional: Uncomfortable, awake and alert
HEENT: Normocephalic, atraumatic
Symmetric swelling of upper and lower lips as well as face
and eyelids, tongue swelling, prominent uvula, no stridor
Chest: Clear to auscultation, mild tachypnea
Cardiovascular: Normal first and second heart sounds,
tachycardic
Abdominal: Soft, Nontender, Nondistended
Extr/Back: no lower extremity edema, warm and well perfused
Skin: No rash, Warm and dry
Neuro: able to say yes/no, follows commands, moving all
extremities
DISCHARGE PHYSICAL EXAM:
========================
VITALS: T 97.8 BP 118/76 HR 87 RR 16 SpO2 98% RA
GENERAL: Sitting up in bed eating breakfast, awake and alert
HEENT: Normocephalic, atraumatic. Moist mucous membranes. Speaks
in slightly hoarse voice.
NECK: No neck edema. Folded 4x4 gauze dressing clean, dry, and
intact.
CARDIAC: RRR. S1, S2 normal. NMRG.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales.
ABDOMEN: Soft, nontender to palpation, nondistended, no masses.
EXTREMITIES: No edema
NEURO: AOX3, moves all extremities spontaneously, able to follow
commands
Pertinent Results:
ADMISSION LABS:
===============
___ 09:32AM BLOOD WBC-19.3* RBC-4.66 Hgb-14.1 Hct-43.1
MCV-93 MCH-30.3 MCHC-32.7 RDW-14.8 RDWSD-49.7* Plt ___
___ 01:30PM BLOOD WBC-37.5* RBC-4.13 Hgb-12.5 Hct-39.2
MCV-95 MCH-30.3 MCHC-31.9* RDW-14.8 RDWSD-51.3* Plt ___
___ 09:32AM BLOOD Neuts-79.2* Lymphs-15.0* Monos-4.2*
Eos-0.8* Baso-0.3 Im ___ AbsNeut-15.33* AbsLymp-2.89
AbsMono-0.81* AbsEos-0.15 AbsBaso-0.05
___ 12:47AM BLOOD ___ PTT-23.7* ___
___ 12:47AM BLOOD Plt ___
___ 01:39AM BLOOD Glucose-195* UreaN-12 Creat-0.8 Na-140
K-4.1 Cl-109* HCO3-20* AnGap-11
___ 09:32AM BLOOD Glucose-110* UreaN-8 Creat-1.0 Na-142
K-3.8 Cl-107 HCO3-21* AnGap-14
___ 09:32AM BLOOD AST-14 AlkPhos-69 TotBili-0.2
___ 09:32AM BLOOD Lipase-17
___ 09:32AM BLOOD cTropnT-<0.01
___ 01:39AM BLOOD Calcium-8.0* Phos-2.0* Mg-2.5
___ 09:48PM BLOOD HBsAg-NEG
___ 09:48PM BLOOD HIV Ab-NEG
___ 09:48PM BLOOD HCV Ab-NEG
___ 08:31AM BLOOD ___ pO2-34* pCO2-37 pH-7.36
calTCO2-22 Base XS--3
___ 10:31AM BLOOD pO2-52* pCO2-42 pH-7.36 calTCO2-25 Base
XS--1 Comment-SAMPLE TYP
___ 10:15AM BLOOD Lactate-1.7
___ 11:41AM BLOOD Lactate-4.1*
___ 10:31AM BLOOD Glucose-110* Creat-0.9 Na-143 K-3.4*
Cl-106 calHCO3-23
___ 11:41AM BLOOD Hgb-12.2 calcHCT-37
___ 10:31AM BLOOD Hgb-14.4 calcHCT-43
DISCHARGE LABS:
===============
___ 08:34AM BLOOD WBC-9.9 RBC-3.51* Hgb-11.0* Hct-34.3
MCV-98 MCH-31.3 MCHC-32.1 RDW-15.9* RDWSD-57.0* Plt ___
___ 05:45AM BLOOD ___ PTT-27.4 ___
___ 08:34AM BLOOD Glucose-156* UreaN-15 Creat-0.8 Na-138
K-4.4 Cl-100 HCO3-23 AnGap-15
___ 05:55AM BLOOD ALT-35 AST-17 AlkPhos-100
___ 08:34AM BLOOD Calcium-9.6 Phos-4.5 Mg-2.0
___ 01:11PM BLOOD Lactate-1.5
Test Result Reference
Range/Units
COMPLEMENT COMPONENT C1Q 8.1 5.0-8.6 mg/dL
Test Result Reference
Range/Units
C1 ESTERASE INHIBITOR, 60 L >=68 %
FUNCTIONAL
Reference Range:
> or = 68%: Normal
41-67%: Equivocal
< or = 40%: Abnormal
Less than 40% of the reference functional activity
indicates a likely diagnosis of hereditary angioedema
or acquired C1 Inhibitor deficiency.
IMAGING:
========
___ LIVER/GALLBLADDER US
No sonographic explanation for abdominal pain is identified.
___ CT NECK W CONTRAST
1. No evidence of mass lesion within the neck or along the
aerodigestive
tract.
2. No acute findings. Intact tracheostomy.
___ VIDEO OROPHARYNGEAL SWALLOW
Penetration. No aspiration.
Please note that a detailed description of dynamic swallowing as
well as a
summative assessment and recommendations are reported separately
in a
standalone note by the Speech-Language Pathologist (OMR, Notes,
Rehabilitation
Services).
___ CHEST (PORTABLE AP)
Feeding tube terminating in the stomach. No evidence of acute
cardiopulmonary disease.
MICROBIOLOGY:
=============
___ 11:28 am URINE CATHETER.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 1:15 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 3:25 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
TRANSITIONAL ISSUES:
====================
[ ] OUTPATIENT FOLLOWUP: The patient has appointments with a
newly established PCP, ___, and Allergy clinic. Consider
sending RAST allergy testing though this may be difficult if
patient does not have insurance.
[ ] Please have patient follow up with patient financial
services and social work for ongoing help obtaining resources.
[ ] The patient's new PCP is ___, who is a resident
and works under Dr. ___. For billing purposes,
insurance needs to name ___ as the Primary Care
Physician. Please do this before the PCP appointment or this can
incur out of pocket costs.
[ ] The patient may also benefit from an outpatient sleep study
(CO2 retention during sleep) though this is not an urgent issue.
[ ] The patient should have LFTs repeated at PCP follow up as
she had transaminitis that resolved during admission.
BRIEF SUMMARY:
==============
___ with unknown PMH who presented to the ED on ___ with
facial swelling and angioedema, transferred from the TSICU s/p
emergent crichothyrotomy (failed first attempt, successful
second attempt), now s/p open tracheostomy (___), and
decannulated on ___.
ACUTE/ACTIVE ISSUES:
====================
# Angioedema
Patient presented with acute onset facial swelling and SOB. s/p
open tracheostomy (___), IV decadron, epinephrine and
famotidine. Etiology remains unclear, differential includes food
allegry, medication-induced angioedema (used supplement Bone
Essence with Kolla2), idiopathic vs. food allergy, as she
reported chicken allergy however lack of recovery from treatment
makes it seem unlikely. Work-up unremarkable including CT
sinus/neck, ___, tryptase, C3/C4. Equivocal C1 esterase may
suggest bradykinin-mediated process. Allergist consulted who
recommended sending off RAST allergy test; was delayed because
of lack of insurance. The patient had poor speaking valve
tolerance and significant pain initially, which resolved with
trach downsize. Because underlying etiology assumed to be
bradykinin-mediated, Allergy did not feel strongly that PO
steroids help manage the long-term course for this patient; the
patient underwent a steroid taper which ended on ___. Tolerance
of the speaking valve was initially slow and felt to be due to
patient anxiety surrounding the trauma of the trach. With
calming exercises and meditation, this improved, with the help
of SLP. Trach decannulated on ___. Patient received tube feeds
during admission and were continued after decannulation until
she was advanced to a regular diet and took in adequate PO. Pt
continued to experience discomfort and cough, which improved
with Tylenol and guaifenesin; ENT scoped and found no evidence
of ulcers from NG tube though found evidence of reflux. On
discharge, the stoma site is healing well, with no blood,
drainage, erythema, or edema. The patient is eating a regular
diet and uses Chloraseptic throat spray for comfort. She will
continue her omeprazole, fexofenadine, Tylenol, ibuprofen,
guaifenesin, dextromethorphan.
# Cough, improved
# Blood-tinged sputum (resolved)
Patient with significant cough s/p trach. The most likely
etiology is iatrogenic from tracheostomy tube. Also with likely
contributions from glycopyrrolate drying her secretions, leading
to increased cough, as her cough has improved off the
glycopyrrolate. WBC and CXR unremarkable, making infection,
inflammation, malignancy less likely. After stopping
glycopyrrolate and starting guaifenesin-codeine, patient
reported significantly improved cough. Patient received
acetylcysteine nebs and duonebs with good effect. They were
discontinued as cough improved. On discharge, the patient will
continue guaifenesin, dextromethorphan.
# Nutrition:
# Throat pain:
Patient was NPO per SLP recs s/p trach and received tube feeds
through Dobhoff until she was able to tolerate speaking valve
and demonstrate controlled swallow function. Her diet was
advanced as tolerated per SLP recs, first with PO food trials
with RN. Initially, the pt was not taking adequate PO on soft
solids diet and TF were continued overnight. Viscous lidocaine
and chloraseptic throat spray were used before meals with good
effect. 6-day trial of mirtazapine was given for appetite
stimulation. Per above, ENT did not find any evidence of ulcers
from DH tube but evidence of reflux. Pt was motivated to take
out DH and increased PO intake once upgraded to regular diet. On
discharge, the patient is eating regular meals and uses
Chloraseptic throat spray for comfort. She will continue her
omeprazole for reflux.
CHRONIC/STABLE/RESOLVED ISSUES:
===============================
#C. difficile colitis (resolved)
Patient had positive C diff PCR and toxin on ___, likely
mild-moderate infection as stools are slightly well formed. She
received full 2-week course of PO vancomycin. Denies abdominal
pain and reports improvement in symptoms. The patient's
abdominal exam was routinely benign, bowel sounds present, and
no concern for toxic megacolon. Vital signs are reassuring. KUB
unremarkable and RUQ U/S unremarkable. On discharge, the patient
has WBC of 9.9 and is having normal formed BMs.
#Leukocytosis (resolved)
Persistent leukocytosis to the ___, likely in the setting of
decadron vs stress reponse. No infectious symptoms, afebrile.
Resolved with discontinuation of steroids. s/p PO vanc for C
diff. No localizing symptoms for infection at this time; CBC
monitored weekly after WBC stabilized. On discharge, patient's
WBC is 9.9.
#Anemia
No signs of active bleeding; likely in s/o frequent lab draws,
hospital diet/suboptimal eating. CBC was monitored daily and
then weekly after H/H stabilized. On discharge, the patient is
asymptomatic (negative pallor, dyspnea, fatigue, weakness); her
Hgb was 11 and Hct 34.3.
#Respiratory acidosis (resolved)
___ on ___ was pH 7.25, pCO2 69, BE 0. Repeat ABG showed
pO2:
88 pCO2: 46* pH: 7.37 calTCO2: 28 Base XS: 0. Pt had no s/sx of
SOB, respiratory distress. No signs of neck edema. ENT paged
after ___ ___, given recent decannulation. Suggested following
up
ABG before scoping, as pt did not have signs of respiratory
distress or airway compromise -- repeat ABG reassuring. Pt
likely retains CO2 during sleeping; outpatient sleep study can
help determine etiology though not an urgent issue.
#Tachycardia
HR has ranged ___ during her stay though pt not symptomatic
- denies palpitations, chest pain, lightheadedness/dizziness,
presyncope/syncope, nausea. Likely due to her scheduled
albuterol
nebs. Other causes include pain (likely contributing factor), or
hypovolemia (unlikely). Albuterol nebs made PRN and discontinued
ultimately. EKG obtained showed sinus tachycardia. On discharge,
patient's vitals are stable; HR 87.
___ infection (resolved)
White spots noted by ENT near trach site on trach downsize. s/p
8 day course of fluconazole (___) per ENT recs. Resolved
with fluconazole.
#Transaminitis (resolved)
Slightly elevated LFTs, likely in s/o C. diff although no
convincing explanation. Resolved as of ___.
#Elevated lactate (resolved)
Elevated lactate to peak 5.2 on admission, downtrended to 1.7
after IVF without further uptrending of lactate.
Medications on Admission:
Unknown
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6)
hours Disp #*360 Tablet Refills:*0
2. Chloraseptic Throat Spray 1 SPRY PO Q8H:PRN throat pain
before meals
RX *phenol [Chloraseptic Throat Spray] 1.4 % three times a day
Disp #*2 Spray Refills:*0
3. Dextromethorphan Polistirex ___ mg PO Q12H:PRN Cough
RX *dextromethorphan polistirex ___ mg/5 mL 10 mL by mouth every
twelve (12) hours Refills:*0
4. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 Duration: 1 Dose
Use if severe trouble breathing, wheezing, hives, skin rash,
swelling of tongue, lips, or throat
RX *epinephrine 0.3 mg/0.3 mL 1 injection IM ONCE Disp #*1
Syringe Refills:*0
5. Fexofenadine 360 mg PO BID Angioedema
RX *fexofenadine 180 mg 2 tablet(s) by mouth twice a day Disp
#*180 Tablet Refills:*0
6. GuaiFENesin ___ mL PO Q6H:PRN cough
RX *guaifenesin 100 mg/5 mL ___ ml by mouth every six (6) hours
Refills:*0
7. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
Please do not use for more than 7 days in one month period.
RX *ibuprofen 400 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*270 Tablet Refills:*0
8. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth once a day Disp #*90
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses: angioedema s/p tracheostomy and
decannulation;
Secondary diagnoses: C. difficile colitis, ___ infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
==========================
- You came into the hospital because you face and lips were
swollen and you had trouble breathing and speaking.
WHAT HAPPENED TO ME IN THE HOSPITAL?
====================================
- Because you had trouble breathing and speaking, we performed a
procedure to open up your airway to help you breath. We then
inserted a tube into your neck (tracheostomy), that made sure
your airway remained open. We gave you medications to treat your
allergic reaction. You improved and we were able to take the
tube out. You are now breathing normally on your own.
- You had a tube placed down your nose into your stomach to help
feed you when you were unable to eat. Your diet was slowly
advanced and you slowly ate more food. You are now eating normal
meals.
WHAT SHOULD I DO WHEN I GO HOME?
=================================
- Please continue to take all of your medications as directed.
- Please follow up with all the appointments scheduled with your
doctor.
- Please go to the Emergency Room immediately if you experience:
* face/neck swelling
* difficulty breathing or speaking
* worsening pain or difficulty with swallowing
* chest pain/palpitations
* bleeding or drainage from your stoma site
* any other new or concerning symptoms
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Team
Followup Instructions:
___
|
10643342-DS-2
| 10,643,342 | 23,062,613 |
DS
| 2 |
2153-06-24 00:00:00
|
2153-06-25 17:25:00
|
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:
___ laparoscopic cholecystectomy
History of Present Illness:
___ year old Female status-post gastric bypass Feburary of ___,
transferred from ___, after presenting
with 1 day of RUQ abdominal pain.
The patient reports she was feeling well yesterday then
yesterday evening, after eating just a small amount of chicken,
she had acute onset of epigastric, RUQ abdominal pain. She took
some Peptol Bismol and felt a little better but her pain
persisted so she presented to ___. She denies nausea or
vomiting. No changes in bowel or bladder habits, although she
has noted that her urine is darker today. She presented to
___ and was found to have acute
cholecystitis on imaging. She was not febrile at ___, but given
the imaging was started on IV Zosyn (first dose 130am on
___
Initial vitals in the ED: 101.6, 113, 111/67, 18, 97%. Bariatric
Surgery/ACS were consulted who concurred that urgent ERCP was
warranted, prior to a surgical decision on cholecystectomy.
She has had no fever or chills since early this morning.She
currently complains of epigastric pain that raidates to her
right upper quadrant and is ___ in severity. She has no nausea
or vomiting currently.
ROS: Remainder of 12 point ROS negative
Past Medical History:
Gastric Bypass- Febrary ___
Pacemaker- Placed in ___ in post partum period for bradycardia
Diabetes
Hypertension
Social History:
___
Family History:
Mother:living in ___, diabetes, hypertension
Father: deceased age ___
Brother: ___ Lung cancer
Sister: Living, breast cancer
Physical Exam:
PHYSICAL EXAM:
VSS: 99.4 BP: 99/60 HR: 84 R: 16 O2: 99% RA
GEN: in some distress secondary to abdominal pain
Pain: ___
HEENT: + Scleral iceterus, MMM,no OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, No MRG
ABD: Soft, Tender on palpation epigastrum RUQ. No rebound or
guarding
EXT: CCE
NEURO: CAOx3, Non-Focal
Physical examination upon discharge: ___:
vital signs: 100.2, hr=85, bp=132/77, rr=18, oxygen
satuation=97%
CV: ns1, s2, -s3, -s4
LUNGS: diminished BS left base
ABDOMEN: soft, tender, hypoactive BS, port sites with DSD, no
erythema
EXT: no pedal edema bil., no calf tenderness bil
NEURO: via ___ interpreter, alert and oriented x 3
Pertinent Results:
___ 04:08AM BLOOD WBC-4.7 RBC-4.06* Hgb-12.9 Hct-37.1
MCV-92 MCH-31.9 MCHC-34.8 RDW-12.5 Plt ___
___ 04:08AM BLOOD Neuts-90.5* Lymphs-6.0* Monos-2.9 Eos-0.5
Baso-0.1
___ 04:08AM BLOOD ___ PTT-24.9* ___
___ 04:08AM BLOOD Glucose-244* UreaN-14 Creat-0.7 Na-141
K-3.3 Cl-105 HCO3-25 AnGap-14
___ 04:08AM BLOOD ALT-636* AST-1458* AlkPhos-181*
TotBili-3.0*
___ 04:08AM BLOOD Albumin-3.6 Calcium-8.8 Phos-1.8* Mg-1.5*
___ 04:25AM BLOOD Lactate-2.5*
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___
5:12 AM
Preliminary Report
IMPRESSION:
Thickened gallbladder wall with pericholecystic fluid and
cholelithiasis concerning for acute cholecystitis.
Report not finalized.
Logged in only.
PATHOLOGY # ___
GALLBLADDER
Brief Hospital Course:
___ year old female presented to the hospital with fever,
abdominal pain, and elevated liver enzymes. She was initially
seen at an outside hospital where a cat scan of the
abdomen-pelvis was done with findings concerning for a stone in
the common bile duct. The patient was given intravenous fluid
and started on zosyn. She was transferred here for ERCP. Blood
cultures were drawn upon admission and the patient was reported
to be growing E. Coli. The patient was started on a course of
ciprofloxacin and flagyl.
On HD #2, the patient underwent an ERCP with the removal of
sludge. Following the procedure, her liver enzymes were
monitored. After they trended downward, the patient was taken
to the operating room on HD #6 where she underwent a
laparoscopic cholecystectomy. The operative course was stable
with minimal blood loss. The patient was extubated after the
procedure and monitored in the recovery room.
The post-operative course was stable. The patient's incisional
pain was controlled with intravenous analgesia. After return of
bowel function, she was started on clear liquids and advanced to
a regular diet. She was transitioned to oral analgesia. Her
total bilirubin had trended down to 2.4. On HD # 8, the patient
was discharged home in stable condition. Post-operative
instructions were reviewed with the patient with the assistance
of a ___ interpreter. The patient was instructed to
complete a week course of ciprofloxacin. A follow-up
appointment was made with the acute care service.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. GlipiZIDE XL 5 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral daily
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
last dosse ___
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*12 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
3. 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
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Senna 8.6 mg PO QHS:PRN constipation
6. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral daily
7. Ferrous Sulfate 325 mg PO DAILY
8. GlipiZIDE XL 5 mg PO DAILY
9. Lisinopril 40 mg PO DAILY
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
?choledocholithiasis
cholecystitis
E.coli bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
___ were admitted to the hospital with right upper quadrant
pain. ___ underwent an ERCP where ___ had removal of sludge from
the common bile duct. After your liver function test
normalized, ___ were taken to the operating room to have your
gallbladder removed. ___ are now preparing for discharge home
with the following instructions:
___ were admitted to the hospital with acute cholecystitis. ___
were taken to the operating room and had your gallbladder
removed laparoscopically. ___ 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 ___ have stopped taking pain medicine and
feel ___ could respond in an emergency.
___ may climb stairs.
___ may go outside, but avoid traveling long distances until ___
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.
___ may start some light exercise when ___ feel comfortable.
___ will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when ___
can resume tub baths or swimming.
HOW ___ MAY FEEL:
___ may feel weak or "washed out" for a couple of weeks. ___
might want to nap often. Simple tasks may exhaust ___ may have a sore throat because of a tube that was in your
throat during surgery.
___ might have trouble concentrating or difficulty sleeping. ___
might feel somewhat depressed.
___ 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 ___ may shower and remove the gauzes over your
incisions. Under these dressing ___ 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.
___ 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 ___ were told
otherwise.
___ 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.
___ may shower. As noted above, ask your doctor when ___ may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, ___ may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. ___ can get both of these
medicines without a prescription.
If ___ 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 ___ find the pain is
getting worse instead of better, please contact your surgeon.
___ 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 ___ take it before your
pain gets too severe.
Talk with your surgeon about how long ___ 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 ___ are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when ___ cough
or when ___ are doing your deep breathing exercises.
If ___ 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 ___ were on before the operation just as
___ did before, unless ___ have been told differently.
If ___ have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if ___ 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:
___
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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:
abd pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
PCP:
Name: ___
Location: ___
Address: ___
Phone: ___
Fax: ___
___ ADMISSION NOTE
HPI:
Mr. ___ is a ___ yo M with h/o acute/chronic EtOH
pancreatitis with several hospitalizations, CBD stricture s/p
several ERCP at ___ and ___ with metal stent placement,
pancreatic stent placement, and pancreatic pseudocyst, who
presents with recurrent acute abd pain with radiation to the
back. patient states that the pain came yesterday, is severe,
epigastric with radiation to back, +n/v, nonbloody, no
fevers/rigors. He reports chronic constipation without
diarrhea. He reports decreased urination with burning. He has
occasional chronic cough. He denies HA, sore throat. He denies
leg swelling and has chronic neuropathy. he denies change in
medications, activity. He denies alcohol or trauma. He
presented to ___ and was transferred here.
given 3L in ED and Cipro/Flagyl.
Of note, he was last hospitalized here ___ and treated for a
pancreatitis flare with supportive care. GI and surgery
evaluated the patient at that time. He was subsequently
discharged and underwent follow up EUS on ___ showing chronic
pancreatitis and good positioning of the CBD stent which was
left in place. Plan was to follow up in surgery clinic here to
consider surgical interventions.
On arrival, he is in ___ pain
10 point review of systems reviewed, otherwise negative except
as listed above
Past Medical History:
Chronic EtOH pancreatitis with pseudocyst
Pancreatic and CBD stenting, several ERCP and EUS
Secondary Diabetes Mellitus
Depression per records
Migraines per records
Social History:
___
Family History:
Father and Mother with Pancreatic Cancer. Sister passed from
___ Ca
Physical Exam:
VS: 98.0 PO 135 / 93 71 18 100 RA
GEN: lying in bed uncomfortable, eyes closed
HEENT: MM dry, anicteric sclera, EOMI, OP clear
NECK: supple no LAD
HEART: RRR no mrg
LUNG: CTAB no wheezes or crackles
ABD: soft, + RUQ/epigastric/LUQ pain to palpation with
intermittent guarding no rebound, +BS
EXT: warm well perfused no pitting edema
SKIN: no rashes or bruising noted
NEURO: no focal deficits appreciated
Pertinent Results:
___ 06:25AM GLUCOSE-141* UREA N-7 CREAT-0.6 SODIUM-139
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-22 ANION GAP-17
___ 06:25AM estGFR-Using this
___ 06:25AM ALT(SGPT)-9 AST(SGOT)-11 ALK PHOS-81 TOT
BILI-0.3
___ 06:25AM LIPASE-98*
___ 06:25AM ALBUMIN-4.0
___ 06:25AM WBC-14.1* RBC-4.47* HGB-13.0* HCT-40.6 MCV-91
MCH-29.1 MCHC-32.0 RDW-13.3 RDWSD-44.7
___ 06:25AM NEUTS-75.3* LYMPHS-15.6* MONOS-6.3 EOS-1.9
BASOS-0.4 IM ___ AbsNeut-10.64*# AbsLymp-2.20 AbsMono-0.89*
AbsEos-0.27 AbsBaso-0.05
___ 06:25AM PLT COUNT-195
RUQ US:
IMPRESSION:
No acute process seen. Gallbladder sludge without evidence of
acute
cholecystitis. Normal CBD. No intrahepatic biliary ductal
dilation.
Pancreas not well visualized.
CXR, my review: No acute processes identified
Brief Hospital Course:
___ yo M with prior EtOH pancreatitis now with acute/chronic
pancreatitis, known pseudocyst, with pancreatic/CBD stents and
multiple ERCP and EUS, presents with recurrent acute epigastric
pain with radiation to the back, consistent with acute on
chronic pancreatitis.
Acute on chronic pancreatitis:
CBD stricture with CBD stent:
Pancreatic Pseudocyst:
Symptoms were consistent with a flare of his chronic
pancreatitis. Gastritis was also possible. There was no
evidence of cardiopulmonary processes, infection, or bleeding.
His LFTs were at his baseline. He has a known CBD stent which
was functioning well as of ___. He is scheduled to follow up
with HBS to consider surgical intervention. He denies alcohol
use. he was treated with supportive care and improved after 48
hrs. Advanced endoscopy reviewed the case and did not feel that
ERCP was necessary. He was discharged home without medication
change to follow up with Dr. ___ week and to follow up
with Dr. ___.
Leukocytosis:
Likely secondary to above. CXR neg. UA negative
Depression:
Expressed depressed mood and tearfulness without SI or HI. SW
consulted and resources provided for a partial/day program. He
was encouraged to follow up closely with his PCP as well as
psychiatrist
Secondary diabetes mellitus:
- Held metformin but resumed on discharge
Chronic constipation:
Aggressive bowel regimen
ADD:
Will hold home amphetamines during hospitalization and resume at
discharge.
Medications on Admission:
1. OxyCODONE (Immediate Release) ___ mg PO Q8H:PRN Pain -
Severe
2. Amphetamine-Dextroamphetamine 20 mg PO BID
3. MetFORMIN (Glucophage) 500 mg PO BID
4. Omeprazole 20 mg PO DAILY
5. Viokace (lipase-protease-amylase) 20,880-78,300- 78,300 unit
oral DAILY:PRN With Largest Meal
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
2. Polyethylene Glycol 17 g PO BID
RX *polyethylene glycol 3350 17 gram/dose 17 gram by mouth twice
a day Refills:*0
3. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Amphetamine-Dextroamphetamine 20 mg PO BID
5. MetFORMIN (Glucophage) 500 mg PO BID
6. Omeprazole 20 mg PO DAILY
7. OxyCODONE (Immediate Release) ___ mg PO TID:PRN
BREAKTHROUGH PAIN
8. Viokace (lipase-protease-amylase) 20,880-78,300- 78,300 unit
oral DAILY:PRN
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on chronic pancreatitis
Depression
Constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with a flare of your pancreatitis. Please
resume all of your home medications including the stool
softeners you are being prescribed. Please follow up with Dr.
___ as scheduled this week, as well as your PCP as scheduled.
Please call Dr. ___ to make an appointment ASAP as well.
You have been given a list of partial day programs to help with
your depression. Please call to join the program of your choice
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:
abdominal pain of 2 months duration
Major Surgical or Invasive Procedure:
ERCP ___
History of Present Illness:
Mr. ___ is a ___ male with the past medical
history noted below who presented with 2 months history of
worsening epigastric pain without radiation, mild to moderate,
associated with occasional nausea and vomiting but was able to
keep some food in last few days. Says his pain is similar to his
chronic pancreatitis pain. Says his appetite has been okay but
everything he eats gives him diarrhea and he can see undigested
food with stool. Says he lost more than 30 lbs in the last 8
weeks. Had some burning micturition 2 days ago with darker urine
color but now he improved. No fever, chills, or night sweats.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative except for mild
sore
throat and weakness (having no energy)
Past Medical History:
alcoholic cirrhosis
biliary stricture s/p metal biliary stent
alcohol-related chronic calcific pancreatitis
exocrine insufficiency of the pancreas
diabetes
chronic pain (on opiate analgesics)
ADHD (on amphetamines)
depression
single kidney (L renal agenesis)
Social History:
___
Family History:
both parents and one sister died of pancreatic
cancer.
Physical Exam:
ADMISSION EXAM
VITALS: ___ 0330 Temp: 97.6 PO BP: 136/87 L Lying HR: 66
RR:
18 O2 sat: 97% O2 delivery: RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, tender to palpation diffusely.
GU: No suprapubic fullness. 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,
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM
24 HR Data (last updated ___ @ 905)
Temp: 97.8 (Tm 98.6), BP: 132/79 (125-159/79-96), HR: 63
(53-74), RR: 18, O2 sat: 97% (97-98), O2 delivery: RA, Wt: 163.0
lb/73.94 kg
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
MMMs
CV: RRR no m/r/g
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, midl ttp similar to prior.
SKIN: No rashes or ulcerations noted
EXTR: wwp no edema
NEURO: Alert, interactive, face symmetric, gaze conjugate with
EOMI, speech fluent, motor function grossly intact/symmetric
PSYCH: pleasant, appropriate affect
Pertinent Results:
WBC 10.5 ---> ___
Hgb ___
Plt 140-210
BMP wnl (except hyperglycemic)
ALT ___
AST ___
Alk phos 1100s--->800s
TBili 1.1--->0.6
Lipase
GGT ___
albumin 3.7
vitamin B12 1494
Ferritin 81
TSH 1.1
Vitamin D 20
Cortisol 20.1
Ig subclasses pending
Vitamin B6 pending
RUQUS
1. Gallbladder sludge without evidence of acute cholecystitis.
2. Sequelae of chronic pancreatitis.
3. Persist moderate biliary dilatation.
MRCP ___. Slight interval increase in moderate intrahepatic biliary
ductal dilatation with an abrupt transition point in the
midportion of the common bile duct
compatible with a stricture related to chronic pancreatitis.
2. Slight interval worsening of focal main portal vein stenosis.
3. Otherwise similar sequelae of chronic pancreatitis including
pancreatic ductal dilatation and irregularity, pancreatic
parenchymal atrophy, multiple dilated side branches, and chronic
occlusion of the splenic vein with collateralization.
ERCP ___
CBD stricture s/p brushings and metal stent placement
Brief Hospital Course:
Mr. ___ is a ___ male with chronic pancreatitis
and pancreatic insufficiency, history of biliary stricture with
ERCPs and stent placements, alcoholic cirrhosis, DM on insulin
pump, who presented with subacute worsening of his chronic
abdominal pain and nausea, weight loss, and generalized
weakness, found to have recurrence of biliary stricture now s/p
ERCP with stent placement
# Recurrent biliary stricture
# Subacute on chronic abdominal pain and nausea
# Weight loss / malnutrition
# Generalized weakness
# Chronic pancreatitis/pancreatic insufficiency
# History of alcoholic cirrhosis
Patient found to have recurrence of biliary stricture which was
felt to be secondary to his chronic pancreatitis. He had severe
pain following the procedure, which seemed to be due to the
stent and which improved quickly. Soon he was back on his home
medication regimen and tolerating a full diet. Patient felt
optimistic based on prior experiences that this will help him
break his current cycle of worsening pain, weight loss, and
nausea. He will follow-up with Dr. ___ in ___ clinic and
will undergo repeat ERCP in follow-up for stent removal. He was
discharged on his prior narcotic regimen. Nutrition saw the
patient and provided supplement recommendations. Micronutrient
testing was sent, with high B12, low vitamin D at 20, and
vitamin B6 pending. It was recommended that patient establish
with a nutritionist. He left before the vitamin D level returned
so will need to be prescribed vitamin D in follow-up.
# Diabetes
Patient uses a daily disposable pump called V-GO, through which
he received 20 units of long acting and 4 units of short acting
with meals. However his glycemic control has been poor. ___
consulted and by discharge recommended that thepatient increase
his meal associated to 6 units per meal. These recommendations
were discussed with the patient and he also received a script
for additional V-GO units. He was offered an appointment at
___ and ___ consider this.
# ADHD: continued Amphetamine-Dextroamphetamine.
============================
TRANSITIONAL ISSUES:
- follow-up B6 level
- please prescribed patient vitamin D supplement in clinic in
follow-up given vitamin D level of 20
- patient to follow-up in primary care and GI clinic
- follow-up ERCP for stent removal
============================
>30 minutes in patient care and coordination of discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amphetamine-Dextroamphetamine 20 mg PO BID
2. OxyCODONE (Immediate Release) 20 mg PO TID:PRN pain
3. Viokace (lipase-protease-amylase) 4 tabs oral TID W/MEALS
4. Omeprazole 20 mg PO DAILY
5. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
6. VGO 20 (sub-q insulin device, 20 unit) miscellaneous QID
Discharge Medications:
1. Amphetamine-Dextroamphetamine 20 mg PO BID
2. Omeprazole 20 mg PO DAILY
3. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
4. OxyCODONE (Immediate Release) 20 mg PO TID:PRN pain
5. VGO 20 (sub-q insulin device, 20 unit) miscellaneous QID
20 units lantus, 6 units of meal associated (3 clicks) for each
meal
6. Viokace (lipase-protease-amylase) 4 tabs oral TID W/MEALS
7.V-GO 20, 56 units. Diagnosis: diabetes mellitus. Dose: 20 U
long acting daily and 6 U short acting with meals. Total: 30
units. Refills: 1
Discharge Disposition:
Home
Discharge Diagnosis:
Recurrent biliary stricture
Chronic pancreatitis
Cirrhosis
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 worsening abdominal pain,
nausea, weakness and weight loss. We found that your bile duct
stricture had come back, and you had a stent placed. After this
procedure you had some increase in your pain, but by the time of
discharge you reported that you were starting to feel better.
You will need to follow-up with Dr. ___ need
another ERCP procedure scheduled to remove the stent. The ERCP
team can be contacted at ___ if you haven't heard from
them about scheduling your procedure. You should also contact
them if you do not receive a letter about the results of the
pathology from your procedure.
You also expressed interest in possibly following-up in the
___. If so, here is the contact information:
Dr. ___
___
You can call anytime and request an appointment, letting the
schedulers know that you were seen by Dr. ___ as an inpatient
and she had requested to see you in clinic.
You received instructions from the diabetes team about your
insulin. In summary, they recommend setting your V-GO to
administer 20 units of lantus (glargine), as well as 6 units (3
clicks) of meal time short acting insulin for each meal.
Followup Instructions:
___
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|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
prednisone
Attending: ___.
Chief Complaint:
diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with DM, HTN and history of large ventral hernia admitted
with 7 days of diarrhea, decreased PO intake, and subacute
confusion/somnolence per family. She presented to ___
because of watery diarrhea q30m that started circa ___. She had
2 days of intermittent vomiting as well. She called her
outpatient provider who started on an antidiarrheal agent with
improvement but not resolution in symptoms. Her granddaughter,
who helps with meds, gave her 2 lomotil q5h for several days,
eventually spacing to 1q6h. During this time, her anterior
abdomen apparently developed "water blisters." On ___, she
became more somnolent, less conversant, with reduced appetite
x2-3 days and 1 additional episode of emesis. No blood seen in
diarrhea or emesis; no fever, chills. No sick contacts, recent
travel, exposure to small children, prior colonoscopies. She is
independent of ADLs and IADLs at baseline.
At BID-P her vitals were 96.5 rectal; (started on bair hugger) |
97/35 | 72 | 99%RA, Creatinine 13, BUN of 157, nd leukocytosis
to 23, lipase 253, VBG 7.05, CO2 37, bicarb 11. Negative
salicylates, acetaminophen, and alcohol. Noncontrast abdominal
CT showed ventral hernia containing portion of duodenum with
wall thickening and fat stranding and distension to 4cm, though
study was inhibited by habitus (artifact from abdomen pressing
against CT scan). No incarceration. She was given fluids and
started on a bicarbonate drip per OSH nephrology. Surgery was
consulted and recommended transfer to ___.
In the ED, initial vitals: 98.9 | 72 | 118/72 | 18 | 96% RA,
blood pressure as low as 97/41.
#ED EXAM notable for general "dry" appearance, large ventral
hernia, cyanotic dusky overlying abdominal skin. Mild diffuse
abdominal tenderness with no focal reducible hernia on exam
#INITAL LABS were notable for: Lactate 2.3, BUN/Cr 144/11.5,
HCo2 8, Anion Gap 35, ___ 23.6 (86%PMNs), H/H 11.2/33.3,
Platelets 360, Lipase 798, AP 181, ALT/AST ___, Tbili 0.5, Alb
3.3
Venous gas: pH 7.16/ pCO2 32 / pO2 26
UA yellow, hazy, pH 5.5, large leuk, mod blood, neg nitrates,
300 protein, 17 RBC, >182 ___. Negative for urobil, glu, ket. 2
epis.
#INITIAL IMAGING:
CXR without evidence of acute cardiopulmonary process
OSH CT uploaded and read for evidence of hydronephrosis -
reportedly negative
#PATIENT WAS GIVEN: 2L NS, Cefepime 2g, Metro 500mg, Vanc 1g,
1300mg Sodium bicarb.
#CONSULTS:
1) SURGERY: Low concern for incarceration given size of hernia
and absence of SBO symptoms. Dusky skin likely due to
hypoperfusion from size of hernia
2) RENAL: Determined likely pre-renal, recommended volume
resuscitation, 1300mg sodium bicarb TID and to start on isotonic
bicarb at 100cc/hr if pH is still dropping on q3-q4h checks.
On arrival to the MICU, patient is awake and alert feels "not
sick." She proceeded to have large melenic stool.
Review of systems: As above, (+) Per HPI
(-) Denies fever, chills, recent weight loss or gain. Denies
headache, congestion, shortness of breath. Denies chest pain. No
recent change bladder habits. No dysuria.
Past Medical History:
MEDICAL hx: Diabetes, Hypertension, Elevated BMI,
hyperlipidemia, GERD, large ventral hernia through surgical mesh
from prior abdominal procedures
SURGICAL hx: appendectomy, cholecystectomy, umbilical hernia
repair
Social History:
___
Family History:
Grandmother with diabetes. No family hx IBD. No family hx renal
disease or dialysis.
Physical Exam:
ADMISSION EXAM
Vitals: 98.5 | 89 sinus | 128/45 | ___ | 98%RA
HEENT: Dry mucous membranes, pupils equal and reactive,
anicteric sclera, dentures in place
CARDIAC: Limited due to habitus, RRR by pulses, apparent S1/S2
without no murmurs
LUNG: Limited due to habitus, CTAB, no wheezes, rales. Tachypnic
but no pursed lip breathing or use of accessory muscles.
ABDOMEN: Ventral hernia at least 25x25cm with dilated, +BS, no
tinkling. Nontender in all quadrants, no rebound/guarding,
cannot assess for hepatosplenomegaly due to habitus, hernia and
positioning. Vessels visible, skin breakdown (loss of overlying
dermis) in 3 areas with 1-3cm radius
EXTREMITIES: no cyanosis, clubbing or edema
PULSES: 2+ DP pulses bilaterally
SKIN: Dry but w/o increased turgor
NEURO: Oriented to location (___, ___ but not to year
___ even with options). Recognizes daughter and granddaughter.
NOT attentive to DOWB ___, stopped). Face
symmetric, moving all 4 extremities with purpose, ___ strength
to ankle plantar/dorsiflexion and elbow flexion/extension.
DISCHARGE EXAM:
VS: 98.2 71 142/76 18 94%RA
General: Well appearing, animated and interactive woman lying in
bed in NAD
Eyes: PERLL, sclera anicteric
ENT: MMM, oropharynx clear without exudate or lesions
Respiratory: CTAB without crackles, wheeze, rhonchi
Cardiovascular: RRR, normal S1 and S2, no murmurs, rubs or
gallops
Gastrointestinal: large ventral hernia, at least 25x25cm,
normoactive bowel sounds, non tender in all quadrants, no
rebound/guarding. Cannot assess for hepatosplenomegaly due to
hernia. Three discrete patches of violaceous purpuric rash, non
tender, contained within the demarcated borders, non blanching,
covered with dressing.
Extremities: Warm and well perfused, no peripheral edema
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
aside
from above
Neurological: Alert and oriented x3, interactive and animated,
motor and sensory exam grossly intact
Pertinent Results:
ADMISSION LABS
==============
___ 07:30PM BLOOD ___ RBC-3.60* Hgb-11.2 Hct-33.3*
MCV-93 MCH-31.1 MCHC-33.6 RDW-15.3 RDWSD-51.8* Plt ___
___ 07:30PM BLOOD Neuts-86* Bands-1 Lymphs-7* Monos-5 Eos-0
Baso-0 ___ Metas-1* Myelos-0 AbsNeut-20.53* AbsLymp-1.65
AbsMono-1.18* AbsEos-0.00* AbsBaso-0.00*
___ 07:30PM BLOOD ___ PTT-26.5 ___
___ 07:30PM BLOOD Glucose-122* UreaN-144* Creat-11.5*
Na-138 K-3.6 Cl-95* HCO3-8* AnGap-39*
___ 07:30PM BLOOD ALT-9 AST-12 AlkPhos-181* TotBili-0.5
___ 07:30PM BLOOD Lipase-798*
___ 07:30PM BLOOD Albumin-3.3* Calcium-7.1* Phos-11.4*
Mg-1.4*
___ 08:10PM BLOOD Lactate-2.3*
___ 08:00PM BLOOD ___ pO2-26* pCO2-32* pH-7.16*
calTCO2-12* Base XS--18
___ 01:55AM BLOOD Triglyc-405*
___ 01:55AM BLOOD Lipase-572*
___ 01:55AM BLOOD CK(CPK)-2423*
INTERVAL LABS
===============
___ 01:55AM BLOOD ___ RBC-3.27* Hgb-10.4* Hct-30.1*
MCV-92 MCH-31.8 MCHC-34.6 RDW-15.2 RDWSD-51.1* Plt ___
___ 09:00PM BLOOD ___ RBC-2.93* Hgb-9.4* Hct-26.4*
MCV-90 MCH-32.1* MCHC-35.6 RDW-14.9 RDWSD-49.0* Plt ___
___ 04:30AM BLOOD ___ RBC-2.77* Hgb-8.7* Hct-25.4*
MCV-92 MCH-31.4 MCHC-34.3 RDW-14.9 RDWSD-50.2* Plt ___
___ 07:30AM BLOOD ___ RBC-2.84* Hgb-8.8* Hct-27.4*
MCV-97 MCH-31.0 MCHC-32.1 RDW-15.7* RDWSD-54.7* Plt ___
___ 01:55AM BLOOD Glucose-99 UreaN-140* Creat-10.4*# Na-137
K-3.6 Cl-100 HCO3-8* AnGap-33*
___ 05:21AM BLOOD Glucose-94 UreaN-138* Creat-10.9* Na-139
K-3.6 Cl-104 HCO3-8* AnGap-31*
___ 04:51PM BLOOD Glucose-110* UreaN-129* Creat-8.9*#
Na-139 K-2.8* Cl-102 HCO3-10* AnGap-30*
___ 12:49AM BLOOD Glucose-116* UreaN-131* Creat-7.8*#
Na-139 K-3.0* Cl-104 HCO3-10* AnGap-28*
___ 04:55PM BLOOD Glucose-109* UreaN-117* Creat-6.3*#
Na-142 K-2.8* Cl-108 HCO3-13* AnGap-24*
___ 02:15AM BLOOD Glucose-113* UreaN-107* Creat-5.5* Na-141
K-3.5 Cl-108
___ 07:15AM BLOOD Glucose-105* UreaN-106* Creat-5.0* Na-143
K-3.2* Cl-108 HCO3-16* AnGap-22*
___ 04:30AM BLOOD Glucose-122* UreaN-88* Creat-3.7*# Na-140
K-3.5 Cl-106 HCO3-17* AnGap-21*
___ 02:35AM BLOOD Glucose-123* UreaN-72* Creat-2.9* Na-141
K-3.4 Cl-107 HCO3-18* AnGap-19
___ 09:11AM BLOOD Glucose-119* UreaN-69* Creat-2.5* Na-141
K-3.4 Cl-107 HCO3-19* AnGap-18
___ 07:30AM BLOOD Glucose-101* UreaN-57* Creat-2.3* Na-144
K-5.0 Cl-110* HCO3-23 AnGap-16
___ 01:55AM BLOOD CK(CPK)-2423*
___ 09:00PM BLOOD LD(___)-196 CK(CPK)-2818*
___ 12:49AM BLOOD ALT-12 AST-37 CK(CPK)-2547* AlkPhos-128*
TotBili-0.3 DirBili-<0.2 IndBili-0.3
___ 04:30AM BLOOD CK(CPK)-536*
___ 07:30PM BLOOD Lipase-798*
___ 01:55AM BLOOD Lipase-572*
___ 02:35AM BLOOD CK-MB-1 cTropnT-<0.01
___ 01:55AM BLOOD Calcium-6.7* Phos-10.7* Mg-1.3*
___ 04:51PM BLOOD Calcium-6.7* Phos-8.5* Mg-1.5*
___ 04:55PM BLOOD Calcium-7.1* Phos-6.5* Mg-1.9
___ 02:35AM BLOOD Calcium-7.7* Phos-3.9 Mg-1.6
___ 07:30AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.6
___ 04:55PM BLOOD ___
___ 05:39AM BLOOD ___ Temp-36.3 pO2-37* pCO2-28*
pH-7.14* calTCO2-10* Base XS--19 Intubat-NOT INTUBA
___ 01:05AM BLOOD ___ Temp-36.5 FiO2-21 pO2-38*
pCO2-26* pH-7.30* calTCO2-13* Base XS--12 Intubat-NOT INTUBA
___ 08:24AM BLOOD ___ pO2-37* pCO2-30* pH-7.31*
calTCO2-16* Base XS--9
___ 05:34PM BLOOD ___ pO2-58* pCO2-29* pH-7.32*
calTCO2-16* Base XS--9
___ 08:43AM BLOOD ___ pO2-112* pCO2-37 pH-7.25*
calTCO2-17* Base XS--10
___ 04:31AM BLOOD ___ pO2-138* pCO2-29* pH-7.38
calTCO2-18* Base XS--6 Comment-GREEN TOP
Stool rotavirus negative
DISCHARGE LABS
==================
___ RBC HgbHct
MCVMCHMCHCRDWRDWSDPlt Ct
___ 07:30
10.9*2.96*9.5*29.4*99*32.1*32.315.8*56.0*197
GlucoseUreaNCreatNaKClHCO3AnGap
___ 07:30 110* 44* 2.1* 145___.___* 23
18
IMAGING
========
___ CT ___
Evaluation of the abdomen is limited due to beam hardening
artifact related to arms down position during image acquisition.
Lung bases: There is hypoventilatory change/atelectasis within
the visualized lung bases.
Liver: There is a 1.5 cm cyst within the left hepatic lobe.
There are additional smaller low-attenuation structures within
the liver which
are too small further characterize may represent small cysts or
hemangiomas.
Gallbladder: Status post cholecystectomy.
Pancreas: Unremarkable
Spleen: Unremarkable
Adrenal glands: Unremarkable
Kidneys: There are multiple cysts identified arising from the
bilateral kidneys. Additionally there are multiple hyperdense
structures arising from the kidneys which may represent complex
cysts.
Mesentery and retroperitoneum: There is no intraperitoneal free
air,
free fluid, or formed fluid collections. There are no enlarged
mesenteric or retroperitoneal lymph nodes. There is no
aneurysmal dilatation of the abdominal aorta. There is
atherosclerotic change and mural wall calcifications of the
abdominal aorta and iliac arteries.
Bowel: There is a large ventral right-sided fat and bowel
containing hernia. Please note that the hernia is incompletely
visualized due to
patient's size contact with the CT gantry associated artifact.
There
appears to be a moderately sized segment of duodenum within the
hernia
with wall thickening and surrounding fat stranding. This segment
of
appears to be abnormally distended to a diameter approximately 4
cm.
The efferent and afferent loops of of the involved segment
appear to
be relatively decompressed.
There is diverticulosis of the distal colon and sigmoid colon.
Pelvis: Urinary bladder is contracted. Uterus is nonenlarged.
There
are no adnexal masses.
Overlying soft tissues and Axial skeleton: There is degenerative
change of the visualized osseous structures. There are surgical
clips along the inferior right pelvic wall compatible previous
hernia repair.
Impression:
There is a large right ventral fat and bowel containing hernia.
Limited evaluation the hernia sac due to patient body habitus
and contact with the CT gantry with associated artifact. Within
the hernia there is a moderately sized segment of
circumferential wall thickening of segment of duodenum with
surrounding fat stranding. The efferent and afferent loops of
the involved segment through the hernia are decompressed. These
findings are compatible with an incarcerated moderately sized
segment of duodenum within the ventral hernia sac. Findings
suggestive of polycystic kidneys. There are higher attenuation
structures arising from the kidneys which are indeterminate may
represent complex cysts.
Signed By: ___ on ___ 3:31 ___
___ CXR - No acute cardiopulm process
MICRO
======
___ URINE CX negative
FECAL CULTURE (Preliminary):
Reported to and read back by ___ @ ___,
___.
SALMONELLA SPECIES.
Presumptive identification pending confirmation by
___
___.
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.
MICROSPORIDIA STAIN (Final ___: NO MICROSPORIDIUM
SEEN.
CYCLOSPORA STAIN (Final ___: NO CYCLOSPORA SEEN.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
O&P MACROSCOPIC EXAM - WORM (Final ___: NO WORM
SEEN.
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.
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.
___ BLOOD CX x2 NGTD
___ C diff negative
Brief Hospital Course:
___ year old woman with history of NIDDM (on metformin), HTN, and
chronic ventral hernia who was transferred from ___ with 7
days of diarrhea found to be ___ salmonella leading to severe
___, AGMA, and AMS, with course c/b acute on chronic retiform
purpura with necrotic bullae overlying the chronic ventral
hernia.
# Acute on chronic kidney injury: Per prior records, most recent
Cr (checked as part of annual visit) was 2.16 in ___, no labs
since then. Presented with Cr elevated to 11.5 with significant
metabolic abnormalities suggestive of acute kidney injury.
Likely
prerenal etiology due to dehydration from profound diarrhea,
poor
PO, exacerbated by antihypertensive and ___. Also supported by
FeNa 0.89%. No suggestion of obstruction or hydronephrosis on CT
imaging. Cr improved to baseline 2.1 with good urine output
prior to discharge. Restarted on home antihypertensives on
discharge, metformin held until further discussion with PCP
given ___.
# METABOLIC ACIDOSIS: VBG on arrival to ICU: pH 7.17, pCO2 27,
HCO3 10 with anion gap 35, improved with improving kidney
function, IVF, and sodium bicarb 1300mg TID per renal to replace
GI losses from diarrheas to ___ on floor. Anion gap
closed ___ with bicarb up to 23. Most likely from ___ and GI
losses of bicarbonate from diarrhea, especially as lactate not
elevated and remained stable, though metformin in setting of
acute renal failure could have played a role. Initially received
bicarb drip prior to transition to PO. Bicarb discontinued on
day of discharge.
#Salmonella enteritis: Patient developed profuse watery
diarrhea q30min that started circa ___, responded partially to
Imodium, with a few episodes of emesis early in course. Diarrhea
concerning for infectious etiology e.g. norovirus given time
course and no recent antibiotics, travel, exposures. With
lactate improving ischemic bowel deemed unlikely. Stool samples
were sent on ___, C.diff was negative, O&P identified
charcot laden crystals with concern for parasitic infection,
worms and cryptosporidium, cyclopora and giardia tests were
added and were negative. Her
diarrhea improved over her course, with output notably less
liquid and even some fecoliths noted. Flexiseal was in
place in ICU and on transfer to floor but given solidifying
stool and patient discomfort removed ___. Stool cx
ultimately returned showing Salmonella infection. Rotavirus
negative. Initially treated with ceftriaxone/flagyl but upon
Salmonella diagnose switched to PO Cipro. Completed total ___. Diarrhea appears to be largely resolved at
time of discharge.
# SEPSIS: Presented with qSOFA>2, lactic acidosis,
leukocytosis.
Only infectious source that is evident is GI in
origin(significant acute diarrhea, likely infectious
enteritis/colitis). Lactate cleared with IVF, vitals improved.
___ improved significantly from 23 on
admission to 11. Ucx with <10K colonies, stool cx ultimately
showed Salmonella. s/p VANC, METRONIDAZOLE, CEFEPIME ___ x1),
then ceftriaxone/flagyl (through ___, with Cipro to finish
course ___.
#Acute toxic-metabolic encephalopathy: Presented with
somnolence, confusion and
decreased appetite x2-3 days, likely due toxic-metabolic
encephalopathy in setting of uremia to 144 from ___ above, with
possible contribution of sepsis. No focal neuro findings.
Resolved to baseline with improved kidney function.
# Purpuric rash/Necrotic bullae: Presented with violaceous
lesions on anterior abdomen for past several weeks. Per report,
fluid from the lesions was cultured and grew MSSA in ___. No
other signs of bleeding or bruising noted anywhere else. Per
derm
consult, common causes include vasculitis, protein C and S
deficiencies (labs sent), heparin necrosis (unlikely given time
course), warfarin necrosis (unlikely given time course),
antiphospholipid antibody syndrome (labs sent), disseminated
intravascular coagulation (not supported by labs),
cryoglobulinemia (labs sent), calciphylaxis (usually tender
lesions), and cholesterol embolization syndrome. Derm is most
concerned for a vasculopathic process, perhaps a hypercoagulable
state. After further collateral information from granddaughter,
it appears she has had these lesions intermittently for years
which self resolve and have no clear precipitant. She has seen
wound care as an outpatient in past. Currently holding off on a
biopsy given proximity of the lesions to the visceral organs
contained within the hernia. Bullae ruptured but rash
remained within demarcated area, remained painless, and
improved. Beta 2 glycoprotein, lupus anticoagulant
negative, ___ negative. Cryos, anti-cardiolipin abs,
protein C/S pending at time of discharge, will follow up with
derm as outpatient as well as home wound care specialist. Wound
care recs from derm:
-Generous Vaseline to all areas
-Areas with eschar, santyl to help with debridement
-Mepilex border lite to cover the areas, with care not to
stick
the border onto any necrotic areas as that will tear the skin
off
--Wound care daily
#Nonsustained ventricular tachycardia: Patient without known
history of cardiac disease though given diabetes and ___ is at
risk for CAD. Had one overnight 45 beat run of wide complex
tachycardia which does appear c/w VT given likely capture/fusion
beats. EKG at the time showed NSR rate 80 with nonspecific T
wave
flattening in anterolateral leads and low limb lead voltages
without clear evidence of ischemia. Troponins negative. No sx as
pt was sleeping at the time of event. ___ be related to
electrolyte abnormalities given K 3.4 and Mg 1.6 at the time,
repleted. No further episodes on tele with tele showing only
sinus rhythm subsequently.
# Anemia: Mildly guaiac positive stool with no BRBPR or black
tarry stools and Hgb gradually downtrending, though stable
___.
This could be a slow oozing GIB however given drop in all cell
counts, suspect this is more likely dilutional anemia given
aggressive fluid resuscitation so far. Per GI, unlikely to
represent GI bleeding. EGD in ___ showed reflux esophagitis but
no AVMs or ulcers. GI following, and no plan for endoscopy given
brown stool and anemia likely dilutional. Stable hgb 8.8 ___.
- Maintain active type and screen
- H/H daily
- Follow up GI recs
- PO PPI
# Ventral hernia/gait abnormality: Massive ventral hernia,
chronic over nearly ___ years. Seen by acute surgery service but
abd soft with no pain or evidence of strangulation on CT.
Evaluated by ___, SW given reduced mobility and functionality but
after improvement in kidney injury and diarrhea, appears to be
at baseline, able to move herself in and out of bed to chair.
Patient and family uninterested in additional services at this
time. Patient interested in manual wheelchair but it will likely
not be covered as she already has motorized scooter.
#ELEVATED LIPASE: No e/o acute pancreatitis on exam or chronic
pancreatitis on history/imaging. Other LFTs normal except for AP
to 181. Downtrended from 700's to 500's. No signs of acute
pancreatitis on imaging.
#ELEVATED CK: Not consistent with rhabdo given mildly elevated
levels. Most likely secondary to severe dehydration from
diarrhea, significantly downtrended after IVF.
#Vaginal bleeding: ___ patient experienced one episode of
clotted vaginal bleeding. Per patient's daughter and
granddaughter this is a chronic issue she has experienced past
several months. C/f endometrial hyperplasia or carcinoma in a
high estrogen stated ___ obesity. Patient should follow up with
gynecology for exam, ultrasound and biopsy in the outpatient
setting.
#DM: A1C 6.3% ___. FSGs in 100s prior to discharge.
Metformin held on discharge given good glycemic control and risk
of acidosis in setting of ___. Will need to discuss diabetes
management with PCP as outpatient.
#HTN: BPs stable during admission, home antihypertensives held
in the setting ___ but restarted on discharge.
#GOUT: Restarted allopurinol on discharge, held in the setting
___ during admission.
#GERD: Stable on PO PPI
Transitional issues:
-Given ___ and severe acidosis on admission, as well as well
controlled FSG in 100s during admission, will hold metformin at
this time until patient discusses ongoing diabetes care with PCP
-___ will need dermatology follow up (hypercoagulability
workup pending) for purpuric rash on ventral hernia
-Patient to have wound care follow up arranged by granddaughter
for healing bullae/rash
-Patient recommended for ___ and home ___ but refused additional
services at this time
-Patient is interested in manual wheelchair, should discuss with
PCP
-___ has had intermittent vaginal bleeding, should follow
with PCP
-___ care recs from derm:
Vaseline to all areas
-Areas with eschar, santyl to help with debridement
-Mepilex border lite to cover the areas, with care not to
stick
the border onto any necrotic areas as that will tear the skin
off
--Wound care daily
# Communication: Granddaughter (lives with her) ___
___ Daughter ___ (legal HCP) ___
# Code: Full Code
>30 min spent on discharge coordination on day of discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. propranolol-hydrochlorothiazid ___ mg oral DAILY
2. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
3. irbesartan 50 mg oral DAILY
4. Allopurinol ___ mg PO DAILY
5. diphenoxylate-atropine 2.5-0.025 mg oral Q6H:PRN diarrhea
6. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. irbesartan 50 mg oral DAILY
3. Omeprazole 20 mg PO DAILY
4. propranolol-hydrochlorothiazid ___ mg oral DAILY
5. HELD- MetFORMIN XR (Glucophage XR) 500 mg PO DAILY This
medication was held. Do not restart MetFORMIN XR (Glucophage XR)
until you discuss with your PCP
___:
Home
Discharge Diagnosis:
Primary: Salmonella enteritis
Secondary: Acute on chronic kidney injury, acidosis, purpuric
rash, 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:
Dear Ms. ___,
You were admitted to ___ with severe diarrhea which led to
severe kidney injury. The diarrhea was found to be caused by a
bacteria called Salmonella, which sometimes causes food
poisoning. During your admission the diarrhea improved and your
kidney function recovered. You were also found to have a rash on
your abdominal hernia for which you were evaluated by
dermatology. You should follow up with dermatology as an
outpatient as well as your home wound care specialist for care
of the healing rash.
It was a pleasure caring for you,
Your ___ Care Team
Followup Instructions:
___
|
10644128-DS-8
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DS
| 8 |
2114-12-29 00:00:00
|
2114-12-29 19:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors / alendronate sodium / Losartan
Attending: ___.
Chief Complaint:
L neck pain and dysphagia x 3 days
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is an ___ year old female with h/o DM, h/o HTN who
presents with L neck swelling and pain x 3 days. She is having
diffculty swallowing. She was at her baseline before this
started. Per patient she first noticed the swelling 6 months ago
but the pain became unbearable 3 days ago such that she could
not
sleep. No difficulties breathing. She does not reports chest
pain
or shortness of breath. She reported one subjective fever three
days ago. She did not tell her daughter and thus her temperature
was not checked. This happened to her once ___ years ago and
the swelling improved with abx. No recent weight loss. she had
lost 10 lbs and then she gained it back again
A ten point ROS is negative except as above.
.
In ER: (Triage Vitals: Yest 12:07 |7|98.2 |91| 157/76 |18 |98%
RA
115 )
Meds Given: Tylenol/unasyn/potassium
chloride/insulin/oxycodone/tylenol
Fluids given: None
Radiology Studies: CT neck
consults called: ENT called
.
PAIN SCALE: ___
Past Medical History:
HYPERTENSION
MEMORY LOSS
OSTEOPOROSIS (T fn = -2.6)
DIABETES TYPE II
COLONIC ADENOMA
GASTRIC INTESTINAL METAPLASIA
GERD
BILATERAL CATARACTS
H/O VITAMIN D DEFICIENCY
Social History:
___
Family History:
No family history of stones in her salivary glands. She does not
know what her parents died of.
Physical Exam:
ADMISSION
Vitals: ___ 2245 Temp: 101.2 PO BP: 159/83 L Lying HR: 91
RR: 18 O2 sat: 93% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain
Score:
___
CONS: she is moaning in pain
HEENT: ncat anicteric MMM
No stridor
R neck swelling with marked tenderness
L neck with swollen submandibular gland but is non-tender
CV: s1s2 rr soft SEM at LUSB
RESP: b/l ae no w/c/r
GI: +bs, soft, NT, ND, no guarding or rebound
GU:No foley
MSK:no c/c/e 2+pulses
SKIN: no rash
NEURO: R facial droop secondary to pain L neck when she opens
her
jaw
LAD: r submandibular jaw lymph node
Psychiatric [x] WNL
[X] Appropriate [] Flat affect [] Anxious [] Manic []
Intoxicated
[] Pleasant [] Depressed [] Agitated [] Psychotic
[] Combative
ADMISSION
VS: ___ 0754 Temp: 98.5 PO BP: 130/77 HR: 69 RR: 18 O2 sat:
100% O2 delivery: ra FSBG: 104
Gen - sitting up in bed, comfortable appearing
Eyes - EOMI
ENT - OP clear, R neck indurated/firm with moderate tenderness;
no associated fluctuance; R axillary lymphadenopathy; both
improved from day prior; L neck within normal limits
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft nontender, normal bowel sounds
Ext - no edema
Skin - no rashes
Vasc - 2+ DP/radial pulses
Neuro - AOx3, moving all extremities
Psych - appropriate
Pertinent Results:
ADMISSION
___ 02:30PM BLOOD WBC-9.2 RBC-4.76 Hgb-12.9 Hct-38.5
MCV-81* MCH-27.1 MCHC-33.5 RDW-14.0 RDWSD-40.9 Plt ___
___ 02:00PM BLOOD Glucose-108* UreaN-14 Creat-0.7 Na-134*
K-5.9* Cl-94* HCO3-21* AnGap-19*
___ 07:30AM BLOOD Calcium-8.9 Phos-2.4* Mg-1.7
DISCHARGE
___ 08:00AM BLOOD WBC-5.8 RBC-4.25 Hgb-11.4 Hct-34.8 MCV-82
MCH-26.8 MCHC-32.8 RDW-13.8 RDWSD-41.0 Plt ___
___ 08:00AM BLOOD Glucose-113* UreaN-6 Creat-0.5 Na-140
K-3.9 Cl-102 HCO3-23 AnGap-15
NECK CT:IMPRESSION:
1. Right submandibular gland sialadenitis with dilatation of the
right submandibular gland ducts due to two large calculi within
___ duct measuring 13 x 8 and 9 x 6 mm.
2. Additional branching calculi within the left submandibular
gland ducts which are dilated. Left submandibular gland however
does not appear acutely inflamed.
3. Reactive right submandibular lymphadenopathy.
Brief Hospital Course:
This is an ___ year old female with past medical history of
hypertension, admitted ___ with R sialadenitis, treated
with antibiotics, sialogogues, warm packs and massages with slow
clinical improvement, subsequently able to advance her diet
slowly to regular diet, able to maintain own nutrition and
hydration, able to be discharged home
# Sialadenitis:
# Acute severe protein calorie malnutrition
Patient was admitted with neck pain, swelling, and fever, with
CT demonstrating R
salivary gland stones with associated duct dilation and
inflammation concerning for concurrent infection. She had been
unable to eat or drink due to pain. Patient was seen by ENT
consult service, with fiberoptic scope demonstrating clear
posterior oropharynx and patent airway. The patient was started
on IV fluids and IV antibiotics, and recommended for warm
compresses, firm salivary gland massage and sialogogues. Over
the subsequent week her swelling and pain slowly improved and
she was able to have her diet gradually advanced. At time of
discharge she was safely tolerating a regular diet and
maintaining her own hydration and nutrition status. Per ENT
recommendations, she will ___ with them in clinic for
discussion regarding potential surgical intervention. At
discharge she was transitioned from IV unasyn to PO augmentin,
with planned total duration of therapy of 10d therapy (last day
= ___
# Hypertension
Initially held antihypertensives in setting of infection.
Restarted amlodipine, atenolol, chlorthalidone over course of
admission. Given normotension, held at doxazosin. Could
consider restarting at ___.
# Type 2 Diabetes
Held oral glypizide and metformin, restarted at discharge
# Hyperlipidemia
Continued statin, ASA
# GERD
Continued PPI
Transitional issues
- Discharged home with ___ services
- Has PCP and ENT ___ scheduled
- Discharged on PO augmentin with plan to complete total 10 day
course (last day = ___
- Given poor PO intake, initially held doxazosin; given
normotension at discharge, asked patient to continue to hold it;
would consider restarting at ___
> 30 minutes spent on this discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral QID:PRN
6. Chlorthalidone 25 mg PO DAILY
7. Doxazosin 1 mg PO HS
8. Fluticasone Propionate NASAL 2 SPRY NU BID
9. GlipiZIDE XL 5 mg PO DAILY
10. Loratadine 10 mg PO DAILY
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Omeprazole 20 mg PO DINNER
13. Potassium Chloride 10 mEq PO DAILY
14. Docusate Sodium 100 mg PO BID
15. Voltaren (diclofenac sodium) 1 % topical Other
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*30 Tablet Refills:*0
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
last day = ___
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*7 Tablet Refills:*0
3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*10 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily
Disp #*5 Packet Refills:*0
5. amLODIPine 10 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Atenolol 25 mg PO DAILY
8. Atorvastatin 40 mg PO QPM
9. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral QID:PRN
10. Chlorthalidone 25 mg PO DAILY
11. Docusate Sodium 100 mg PO BID
12. Fluticasone Propionate NASAL 2 SPRY NU BID
13. GlipiZIDE XL 5 mg PO DAILY
14. Loratadine 10 mg PO DAILY
15. MetFORMIN (Glucophage) 1000 mg PO BID
16. Omeprazole 20 mg PO DINNER
17. Potassium Chloride 10 mEq PO DAILY
18. Voltaren (diclofenac sodium) 1 % topical Other
19. HELD- Doxazosin 1 mg PO HS This medication was held. Do not
restart Doxazosin until you see your primary care doctor
20.Rolling Walker
Rolling Walker
Diagnosis: Gait instability
Prognosis: Good
Length of Need: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
#Sialadenitis
# Hypertension
# Type 2 Diabetes
# Hyperlipidemia
# Seasonal allergies
# 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:
Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
with inflammation and infection of the glands that make saliva.
This was caused by stones. You were started on antibiotics and
treated with heat and massage. You improved and were able to a
eat a normal diet.
You are now ready for discharge home.
After discharge, you should continue:
- Firm salivary gland massage at least ___ times a day
- Warm compresses q2h while awake to affected side as needed
- Sialogogues (foods that make you salivate, like lemon candy,
sour candy, chewing gum) at least four times daily
It will be important for you to see the ear/nose/throat
surgeons--we have made an appointment for you.
Followup Instructions:
___
|
10644222-DS-12
| 10,644,222 | 21,721,714 |
DS
| 12 |
2134-01-09 00:00:00
|
2134-01-12 17:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ibuprofen / tramadol
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ year old gentleman with known pituitary
lesion diagnosed ___ months ago by a neurosurgeon at ___ found during workup for 9 months of headaches. He was
instructed by his neurosurgeon to have an endocrinology workup
and was referred to an endocrinologist however he was unable to
be seen as he was ___ prior to the appointment. The
patient states that he was subsequently "fired" by all of his
providers and hence he has presented to us as a transfer from an
OSH for further management and care. Of note the patient is
known
to confabulate and his stories as to his current medical
sequence
of events changes depending on the provider he is speaking with.
Regardless of this, he has a known pituitary lesion and has yet
to have the appropriate work up to determine the best course of
treatment and as such neurosurgery was consulted for assistance
Past Medical History:
anxiety, aneurysm, pituitary lesion, substance abuse
Social History:
___
Family History:
NC
Physical Exam:
ON ADMISSION:
PHYSICAL EXAM:
Gen: acromegalic appearing, WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs intact without nystagmus
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4mm to
2mm bilaterally. Patient is not cooperative with visual field
testing but reports scattered visual disturbance
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.
Discharge physical exam:
Vitals-98.1 100s-120s/60s-90s ___ 18 98% RA
General- Alert, oriented, no acute distress, hands/feet/jaw
diffusely enlarged
HEENT- EOMI, visual fields full and in tact to confrontation,
Sclera anicteric, MMM, oropharynx clear
Neck- thyroid normal without nodules, supple, JVP not elevated,
no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, no nipple
discharge
GU- no foley
Ext- warm, well perfused, 2+ pulses, no cyanosis or edema, feet
and hands appear large
Neuro- CNs2-12 intact but blurry vision worsened with
extraocular eye movements, strength ___ bilaterally in
extremities, fine touch sensation in tact b/l
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally
Coordination: normal on finger-nose-finger
Pertinent Results:
ADMISSION LABS:
================
___ 09:15PM BLOOD WBC-7.3 RBC-4.31* Hgb-10.9* Hct-35.1*
MCV-81* MCH-25.3* MCHC-31.1* RDW-14.9 RDWSD-43.5 Plt ___
___ 09:15PM BLOOD ___ PTT-30.2 ___
___ 09:15PM BLOOD Glucose-89 UreaN-10 Creat-0.7 Na-142
K-3.1* Cl-106 HCO3-23 AnGap-16
___ 09:15PM BLOOD estGFR-Using this
___ 09:15PM BLOOD Calcium-9.2 Phos-3.1 Mg-2.1
___ 09:15PM BLOOD T3-140 Free T4-1.1
___ 09:15PM BLOOD Cortsol-57.6*
___ 09:15PM BLOOD INSULIN-LIKE GROWTH FACTOR-1-Test
___ 09:15PM BLOOD ACTH - FROZEN-Test
OTHER IMPORTANT LABS:
=====================
___ 12:50PM BLOOD Testost-382 SHBG-68*
___ 09:14AM BLOOD Cortsol-6.4
___ 12:50PM BLOOD FSH-4.7 LH-5.0 ___
___ 09:14AM BLOOD Prolact-PND
___ 09:14AM BLOOD ACTH - FROZEN-PND
___ 12:50PM BLOOD ALPHA SUBUNIT-PND
___ 09:15PM BLOOD ACTH - FROZEN-Test
___ 09:15PM BLOOD INSULIN-LIKE GROWTH FACTOR-1-Test
IMAGING:
========
MR PITUITARY WITH AND WITHOUT CONTRAST ___
FINDINGS:
Study is moderately degraded by motion.
There is heterogeneous T2 hyperintense, T1 isointense, hypo
enhancing
pituitary lesion measuring 1.2 (AP) x 1.6 (TV) x 1.2 (SI) cm .
The
infundibulum is displaced towards the left. There is no
suprasellar or
cavernous sinus invasion of the mass. The cavernous carotid
arteries appear unremarkable without any evidence of encasement
or narrowing. There is no mass effect on the optic chiasm.
The remaining visualized brain parenchyma appears unremarkable.
The
visualized intracranial flow voids are maintained. The
paranasal sinuses are clear.
IMPRESSION:
1. Study is moderately degraded by motion.
2. 1.2 x 1.6 x 1.2 cm pituitary mass without definite
suprasellar or cavernous
sinus extension, as described, suggestive of macroadenoma.
CTA HEAD ___ PRELIMINARY REPORT
IMPRESSION:
1. No acute intracranial hemorrhage.
2. A 2.5 mm aneurysm off of the proximal left A2 anterior
cerebral artery.
NOTIFICATION: A notification for the additional finding in
impression 2 was placed into the critical result finding.
DISCHARGE LABS:
===============
___ 07:16AM BLOOD WBC-5.6 RBC-3.81* Hgb-9.8* Hct-31.3*
MCV-82 MCH-25.7* MCHC-31.3* RDW-14.6 RDWSD-43.7 Plt ___
___ 07:16AM BLOOD Plt ___
___ 07:16AM BLOOD Glucose-121* UreaN-9 Creat-0.9 Na-138
K-4.5 Cl-100 HCO3-30 AnGap-13
___ 07:16AM BLOOD Calcium-8.9 Phos-4.4 Mg-2.0
___ 09:14AM BLOOD Prolact-PND
___ 09:14AM BLOOD Cortsol-6.4
___ 09:14AM BLOOD ACTH - FROZEN-PND
Brief Hospital Course:
___ yo M w/ hx of substance abuse and anxiety p/w pituitary
macroadenoma (diagnosed ___ months ago at ___
with lab evaluation revealing prolactinoma. He had not had an
adequate workup as of yet for this problem secondary to many
social issues and hospitalizations for psychiatric reasons.
# Pituitary Macroadenoma/Prolactinoma:
Patient endorsed constant right sided headaches for the past 9
months accompanied by bilateral blurry vision, however visual
fields were full and in tact on exam. MRI pituitary revealed no
suprasellar/cavernous sinus extension or optic chiasm
impingement. Given the MRI findings above and that his visual
complaints were not consistent with an optic chiasm lesion, the
endocrine and neurosurgery teams were not concerned about the
prolactinoma affecting his vision. He was evaluated by
Neurosurgery and Endocrine teams while in house who felt medical
management was the treatment of choice. He was started on
cabergoline 0.25mg once a week by the Encorine team, Day 1:
___. Patient had clinical features of acromegaly however IGF-1
levels were normal - given his enlarged hands/feet/jaw on exam
an IGF-1 level was repeated and pending on discharge. Other
hormonal levels were largely within normal limits except for TSH
that was 4.7 with a normal T3/T4. Patient was continued on his
home medication of Acetaminophen-Caff-Butalbital 1 TAB PO
Q8H:PRN for headache.
# History of brain aneurysm:
Patient was unsure whether he has a history of brain aneurysm
therefore CTA head was obtained - it was initially reviewed by
Neurosurgery and read as normal on the day of discharge without
aneurysm, however final radiology read returned after patient
was discharged and revealed a 2.5mm ACOM aneurysm. Neurosurgery
still feels this may simply be a bulging of the vessel and not a
true aneurysm. They called the patient after discharge and
informed him of the results, he will have a follow up
appointment scheduled with neurosurgeon ___ in ___ for
serial imaging/monitoring (see neurosurgery followup note dated
___.
# Psych: Anxiety/ADD/Substance Abuse/Personality Disorder NOS:
The patient's Haldol was discontinued during this admission as
patient was started on cabergoline which has an opposing
mechanism of action. There was theoretical concern that both
cabergoline and Haldol should not be prescribed at the same time
as per the Endocrine team. The in patient medicine team
attempted to contact the patient's psychiatrist ___ at
___ (___) without success, however the
patient's primary care physician stated that the patient does
not have schizophrenia/known indication for Haldol. It was felt
that the patient was most likely on Haldol for agitation and
that it was safe to discontinue on discharge with close out
patient psychiatry follow up. The patient was continued on his
other home psychiatric medications including klonipin,
trileptal, suboxone, benztropine and
amphetamine-dextroamphetamine. Patient became agitated and
threatening with staff throughout admission and intermittently
obstructed other ___ medical care. He received an extra
dose of 2.5mg Haldol X 1, however other times was re-directable
with considerable effort.
# ?Homelessness:
Patient was seen by social work during this admission to discuss
the possibility of obtaining disability and housing benefits. He
will follow up with his primary care physician as an out patient
regarding this issue.
TRANSITIONAL ISSUES:
=====================
- started on cabergoline 0.25mg once weekly, Day 1: ___
- needs out patient endocrine follow up with Dr. ___
(___), will need prolactin levels checked at follow up
appointment ___ weeks after discharge
- needs follow-up with outpatient neuroophthalmology for formal
visual field testing
- repeat AM cortisol, repeat IGF-1 and ACTH pnd on discharge.
Patient had AM cortisol + ACTH drawn previously during admission
however was on hydrocortisone at the time labs were drawn making
the results uninterpretable. Patient had IGF-1 previously drawn
on admission which was normal, however repeat level pending to
confirm given features of acromegaly on physical exam.
- CTA head is inconclusive for aneurysm. - follow up appointment
scheduled with neurosurgeon ___ in ___ for serial
imaging/monitoring of possible small ACOM aneurysm.
- Haldol 5mg QHS discontinued upon discharge given that patient
was initiated on cabergoline. In patient medicine team attempted
to contact the patient's psychiatrist ___ at ___
___ (___) without success, however the patient's
primary care physician stated that the patient does not have
schizophrenia. It was felt that the patient was most likely on
Haldol for agitation and that it was safe to discontinue on
discharge with close out patient psychiatry follow up. Patient
may need to be started on Seroquel as an out patient pending
medical indication for anti-psychotic treatment.
- follow up with patient regarding housing concerns
Medications on Admission:
fioricet 1 tab daily PRN
Adderall 20MG tabs TID
klonopin 1mg BID PRN
oxcarbazapine 600mg QHS
benztropine 1mg BID
Haldol 5mg at bedtime
suboxone ___ films BID
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO DAILY PRN migraine
2. Amphetamine-Dextroamphetamine 20 mg PO TID
3. Benztropine Mesylate 1 mg PO BID
4. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID
5. ClonazePAM 1 mg PO BID PRN anxiety
6. OXcarbazepine 600 mg PO QHS
7. cabergoline 0.25 mg oral 1X/WEEK
RX *cabergoline 0.5 mg 0.5 (One half) tablet(s) by mouth 1X/week
Disp #*8 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Pituitary macroadenoma - prolactinoma
SECONDARY DIAGNOSES:
ADD
Anxiety
History of substance abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to the hospital for a benign pituitary tumor
called a pituitary macroadenoma. You were evaluated by the
neurosurgical team who felt you were are not a surgical
candidate. You were started on a medication called cabergoline
which should shrink your pituitary macroadenoma over time. This
medication can cause nausea and dizziness as side effects, so
please take this medication close to bedtime once a week. Please
stop taking Haldol as it interacts with the new medication you
were started on - cabergoline. You had an imaging study called a
CTA that did not show any evidence of a brain aneurysm. Please
continue to take all your medications and follow up with your
PCP, ___, and endocrine physicians as an out patient.
It was a pleasure taking care of you.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10644222-DS-14
| 10,644,222 | 21,396,212 |
DS
| 14 |
2134-04-16 00:00:00
|
2134-04-18 08:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ibuprofen / tramadol
Attending: ___
Chief Complaint:
Worsening headaches.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This patient is a ___ year old male with history of pituitary
macroadenoma on bromocriptin 2.5 mg, 2.5mm A2 ACA aneurysm,
personality d/o NOS, substance abuse on suboxone, who initially
presented to ___ with HA x1 week with ___ c/f possible
increased size of pituitary macroadenoma. Patient transferred to
___ for neurosurgery evaluation. On admission to ___, MRI
head showed stable size pituitary macroadenoma when compared to
imaging from ___. Prolactin level elevated at 456 (451 in
___. Endocrine was consulted who recommended increasing
Bromocriptine to 5mg daily in hopes to avoid neurosurgery in the
future. Given that there was no need for surgical intervention,
plan to transfer to medicine for initiation of Bromocriptine
therapy and continued management of his chronic pain.
In regards to his pituitary macroadenoma, the patient was
initially diagnosed in ___ when he presented to ___
___ with HA. CT imaging at that time revealed 0.2 (AP) x
1.6 (TV) x 1.2 (SI)cm pituitary mass found to have prolactin
level 544. He was started on cabergoline with plans to ___
with Endocrine as an out-patient, however, he had a severe
bullous rash reaction to the Cabergoline and was therefore
re-admitted. At that time, his medication was switched to
Bromocriptine 2.5mg nightly. No signs of other pituitary hormone
deficiencies. The patient now represented with worsening HA x
1week. Per neurosurgery, no indication for surgical intervention
at this time as no e/o optic nerve compression and macroadenoma
stable in size. Per Endocrine, plan to increase Bromocriptine to
5mg nightly with plans to repeat prolactin level on ___.
Patient remains admitted at this time for pain control and
continued management of his HA. Chronic pain service involved
and recommended dialudid ___ Q4hrs prn, Amitriptyline 50 mg
qHS in addition to his suboxone 8mg daily. The patient is very
anxious about increasing his Bromocriptine medication given his
reaction to Carbergoline in the past (although has been stable
on bromocriptine 2.5mg daily) as well as his reported peripheral
visual field defects. The hope is to have visual field testing
performed as an in-patient and optimization of his pain regimen
with plans to ___ closely with Endocrine as an out-patient
for continued management of his macroadenoma.
Past Medical History:
- Anxiety
- Aneurysm
- Pituitary Macroadenoma
- Substance Abuse
- Personality D/O NOS
- Gastric bypass surgery
- Chronic pain
Surgery:
- Cervical fusion ___
- Gastric bypass ___
- Cholecystectomy
- Hernia repairs
Social History:
___
Family History:
non-contributory
Physical Exam:
On Admission:
VITALS: 97.7 ___ 59-63 100%RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear; pupils equal
and reactive.
NECK: Supple, JVP not elevated, no LAD
RESP: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
ABD: +BS, soft, nondistended, nontender to palpation. No
hepatomegaly.
GU: no foley
EXT: trace pitting edema; warm, well perfused, 2+ pulses, no
clubbing, cyanosis
NEURO: CNs2-12 intact, motor function grossly normal
On Discharge:
VITALS: 98.2, 123/66, 73, 20, 100RA
GENERAL: Alert, oriented, no acute distress
HEENT: EOMI, 2-3 cm raised contusion left medial scalp; sclerae
anicteric, MMM, oropharynx clear; pupils equal and reactive.
NECK: Supple, JVP not elevated, no LAD
RESP: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
ABD: +BS, soft, nondistended, slightly tender to palpation in
the LUQ, but no rebound or guarding. No hepatomegaly.
GU: no foley
EXT: trace pitting edema; warm, well perfused, 2+ pulses, no
clubbing, cyanosis
NEURO: CNs2-12 intact, motor function grossly normal; sensory
function grossly normal.
Pertinent Results:
Admission Labs:
___ 01:51AM BLOOD WBC-8.1# RBC-4.09* Hgb-9.7* Hct-32.5*
MCV-80* MCH-23.7* MCHC-29.8* RDW-15.0 RDWSD-43.7 Plt ___
___ 01:51AM BLOOD Neuts-45 Bands-0 ___ Monos-15*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-3.65 AbsLymp-3.24
AbsMono-1.22* AbsEos-0.00* AbsBaso-0.00*
___ 01:51AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL
___ 01:51AM BLOOD ___ PTT-32.1 ___
___ 01:51AM BLOOD Glucose-93 UreaN-9 Creat-0.8 Na-141 K-4.2
Cl-102 HCO3-28 AnGap-15
___ 07:25AM BLOOD ___ TSH-1.2
___ 07:25AM BLOOD calTIBC-378 Ferritn-14* TRF-291
___ 07:25AM BLOOD Calcium-8.9 Phos-4.3 Mg-2.1 Iron-21*
___ 07:25AM BLOOD Free T4-1.0
Discharge Labs:
___ 05:50AM BLOOD WBC-5.2 RBC-3.35* Hgb-8.0* Hct-25.9*
MCV-77* MCH-23.9* MCHC-30.9* RDW-15.2 RDWSD-42.7 Plt ___
___ 05:50AM BLOOD ___ PTT-32.2 ___
___ 05:50AM BLOOD Glucose-100 UreaN-9 Creat-0.9 Na-139
K-4.7 Cl-104 HCO3-27 AnGap-13
___ 05:50AM BLOOD ALT-17 AST-25 AlkPhos-121 TotBili-<0.2
___ 05:50AM BLOOD Calcium-8.7 Phos-5.2* Mg-2.2
Imaging:
MR ___ and w/o contrast:
FINDINGS:
MRI brain: There is no evidence of acute intracranial
hemorrhage, mass effect or large territorial infarction. A
mucous retention cyst is seen in the right maxillary sinus. The
visualized paranasal sinuses are otherwise unremarkable. The
sphenoid sinuses, ethmoid air cells, and frontal sinuses are
clear. The globes are unremarkable. The principal flow voids
are well preserved. No marrow signal abnormalities are
identified.
MRI of the pituitary: Re demonstrated is the patient's T2
hyperintense, T1 isointense, hypo enhancing pituitary lesion
measuring approximately 1.3 cm TRV by 1.4 cm AP by 1.4 cm cc
overall unchanged compared to the prior exam from ___.
There is no suprasellar or cavernous sinus invasion of the mass.
The infundibulum is displaced towards the left. The cavernous
carotid arteries appear unremarkable without evidence of
encasement or narrowing. There is no mass effect on the optic
chiasm.
IMPRESSION:
1. No acute intracranial abnormalities identified.
2. Stable 1.4 cm pituitary mass compared to the prior exam from
___.
CT Head w/o Contrast:
FINDINGS:
There is no evidence of infarction, hemorrhage, or edema. The
ventricles and sulci are normal in size and configuration.
Compared to ___, there is an unchanged hyperdensity in
the region of the pituitary gland, consistent with patient's
known pituitary ___.
There is no evidence of fracture. There is a small mucous
retention cyst in the left sphenoid sinus. The visualized
portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are otherwise clear. The visualized portion of the
orbits are unremarkable. The patient is edentulous. Visualized
on the scout only, there is C5-C6 ACDF. On the sagittal scout
images, there is an apparent fracture through 1 of the C6 screws
(series 1 a, image 1), this can be seen on prior CT examinations
dating back to ___.
IMPRESSION:
1. No acute intracranial abnormalities. Specifically, no
evidence of subdural hematoma or other sequelae of trauma.
2. No evidence for calvarial fracture.
3. Compared to ___, unchanged hyperdensity in the
region of the
pituitary gland, consistent with patient's known pituitary
lesion.
4. Incidentally noted on scout images, unchanged from prior CT
examinations dating back to ___ is an apparent
fracture through a C6 screw on the C5-C6 ACDF.
Brief Hospital Course:
Mr. ___ is a ___ year-old male with known pituitary
macroadenoma, managed medically by endocrinology as an
outpatient, who was transferred from an OSH after presenting
with progressively worsening headache x 72 hours.
#Pituitary macroadenoma: Patient initially presented to OSH
where CT scan was concerning for possible increase in size of
macroadenoma. However, MRI-pituitary at ___ showed stable size
of lesion without mass effect of the optic chiasm. Patient was
initially placed on neurosurgical service for consideration of
surgery. On exam, he had no focal neurologic deficits but was
poorly compliant with visual field exam and refusing fundoscopy.
Given no indication for surgery, decision was made to continue
with medical management for pain control and he was transferred
to medicine service. His prolactin level this admission was
elevated at 456 (was 451 in ___. Endocrine was consulted
and recommended bromocriptine increased from 2.5mg qHS to 5mg
qHS . Would anticipate Prolactin level will slowly drift down.
Repeat levels will be checked on ___ as an outpatient. Of
note, the patient complained of chronic vision changes, namely
peripheral field deficits. Ophthalmology was consulted and
recommended outpatient peripheral field testing which he will
receive immediately upon discharge (is being discharged to his
outpatient appointment).
#Headaches: The chronic pain service was consulted on admission
as patient is on suboxone at home with pain poorly controlled.
He was given x1 Amitriptyline 25mg and started on Dilaudid PO.
He tolerated this well and was initiated on 25mg Amitriptyline
at bedtime and will continue on 50mg qHS. He will be discharged
with 3 days worth of Dilaudid and has begun a transition to
gabapentin (300 mg QHS for 1 week, 300 mg BID for 1 and then 300
mg TID with option to uptitrate as needed). We avoided NSAIDs
at the recommendation of the pain service given concern for
possibility of bleeding into macroadenoma. His home suboxone
was continued at 8mg-2mg. He will ___ with his PCP and
can follow up with ___ Pain Management ___ after
discharge. Please review transitional issues below.
#Head trauma: on the day of discharge, patient dismantled the TV
in his room and while doing so hit his head. He subsequently had
a CT head which showed no concerning findings for sequelae of
trauma including SDH. Neurologic exam was wnl after injury.
=========================================
Transitional Issues:
-**PMP reviewed given multiple patient requests for dilaudid,
clonazepam, and Adderall. In conjunction with chronic pain
service, it would be reasonable for 3 day course of dilaudid and
will write for 3 days of HOME klonopin and Adderall as well per
patient request. However, review of PMP does show that he has a
30 day supply available of these drugs since ___ and
therefore should have a sufficient amount. Given new dilaudid
this admission, he will receive 3 day course only. We attempted
to contact PCP to alert of this plan. We would NOT recommend
ongoing narcotic use for his chronic pain. Please consider
uptitration of gabapentin if requires more pain control. Patient
was amenable to this plan.** PLEASE LIMIT NARCOTICS given
concern for drug seeking behavior.
- Amitryptiline added per chronic pain recommendation.
- His bromocriptine was increased from 2.5 to 5 mg per
endocrinology recommendation. He should have a repeat prolactin
checked on ___ to assess for reduction in response to
increase in therapy.
- We have discharged him with 3 days of Dilaudid therapy and
have begun a transition to gabapentin. He is currently taking
300 mg QHS, if he tolerates this, it should be transitioned to
BID for 1 week and then TID moving forward. It can be uptitrated
afterwards, as needed. Please consider discontinuing his
Fiorcet.
- He is having peripheral vision field testing on ___ at 11:30
AM as an outpatient at ___ please ___ the results.
- Recent labs suggestive of iron-deficiency (iron 21, ferritin
14); please have GI f/u in outpatient setting for source work-up
and/or colonoscopy.
- He is being continued on home Citalopram and Clonazepam for
anxiety.
-Scout films of CT head on the day of discharge notable for is
an apparent fracture through a C6 screw on the C5-C6 ACDF. Per
read, incidentally noted and consistent with prior CT studies
dating back from ___.
- CODE: Full (confirmed)
- COMMUNICATION: CONTACT/ HCP: ___ ___
Medications on Admission:
Celexa 20mg daily
Adderal 20mg TID
Fioricet 1 tab PO q8h
Suboxone 8mg-2mg 1 tab SL BID
Bromocriptine qHS
clonopin 1mg BID PRN anxiety
Discharge Medications:
1. Amitriptyline 50 mg PO QHS
RX *amitriptyline 50 mg 1 tablet(s) by mouth at bedtime Disp
#*14 Tablet Refills:*0
2. Gabapentin 300 mg PO QHS
RX *gabapentin 300 mg 1 capsule(s) by mouth at bedtime Disp #*14
Capsule Refills:*0
3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Severe
Duration: 3 Days
RX *hydromorphone [Dilaudid] 4 mg 1 tablet(s) by mouth q6h PRN
Disp #*12 Tablet Refills:*0
4. Bromocriptine Mesylate 5 mg PO QHS
RX *bromocriptine 5 mg 1 capsule(s) by mouth at bedtime Disp
#*30 Capsule Refills:*0
5. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN Pain -
Moderate
6. Amphetamine-Dextroamphetamine 20 mg PO TID
7. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID
8. ClonazePAM 1 mg PO BID anxiety
9. Docusate Sodium 100 mg PO BID constipation
10.Outpatient Lab Work
Please check prolactin level and fax to ___ ___
endocrinology)
ICD10 D35.2
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Pituitary macroadenoma with hyperprolactinemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
We have cared for you in the hospital for your pain as well as
your pituitary macroadenoma. The dose of your medication,
bromocriptine, was increased to 5 mg every day in conjunction
with endocrine. Please continue to take this medication and we
have set-up ___ for you with endocrinology in the
outpatient setting. Part of this ___ will involve getting
a prolactin level drawn on ___. In terms of your pain, we
have supplied you with a 3-day course of hydromorphone for your
pain and it is to be replaced with gabapentin; this is
consistent with the chronic pain service's recommendation. Your
PCP ___ your pain medications; please see the
information below regarding follow up with the pain clinic.
Lastly, you are scheduled for peripheral vision testing on ___
at 11:30 AM on the ___ Floor of the ___ in ___
___ of ___. You must be early for your appointment.
We have appreciated taking part in your care.
Best wishes,
___ 7 Care Team
Followup Instructions:
___
|
10644222-DS-15
| 10,644,222 | 24,041,651 |
DS
| 15 |
2134-05-15 00:00:00
|
2134-05-18 16:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
ibuprofen / tramadol
Attending: ___.
Chief Complaint:
Altered mental status, ?seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with pituitary
macroadenoma and ACA aneurysm who presents after a period of
unresponsiveness and headache.
He was in the dentist office earlier today when he became
unresponsive. Per OSH records as pt was unable to remember what
happened, pt became tremulous, lasted 30 seconds. He was more
confused afterwards while he was in the ambulance and was
complaining of severe ___ pain. He is now back to baseline
except for severe headache.
Pt reports no history of seizures but then addends his history
saying that he did have seizures when he was driving a rental
car
and crashed it. Blacked out for 30 seconds, did not feel it
coming on. On chart review from endocrinology note dated
___,
he had multiple concussions and motor vehicle accidents. With
one
accident, he reported to the endocrine team that he had "mini
seizures" behind the wheel. Endorses an odd taste in his mouth
but no odd smells, unable to describe it further. Endorses de ___ ___ times per week, no epigastric rising sensation, no
urinary
incontinence, does endorse tongue biting where his sister
remarked that his tongue has been hanging out of his mouth more
recently. No family history of seizures.
He endorses a headache that is worse than his usual headache.
Described as holocephalic, throbbing/stabbing pain, worse with
light and sound, associated with nausea but no vomiting. Usually
amitriptyline and bromocriptine help. Headache started yesterday
and has been constant.
Typical migraine headaches are throbbing without stabbing
quality, last a few hours, worse with light and sound, better
with lying in the dark and taking his medications.
Past Medical History:
- Anxiety
- Aneurysm
- Pituitary Macroadenoma
- Substance Abuse
- Personality D/O NOS
- Gastric bypass surgery
- Chronic pain
Surgery:
- Cervical fusion ___
- Gastric bypass ___
- Cholecystectomy
- Hernia repairs
Social History:
___
Family History:
Father had migraines
Physical Exam:
=== ADMISSION EXAM ===
Vitals: T: 98.6F HR: 68 BP: 139/96 RR: 19 SaO2: 100% RA
General: curled up in bed, shaking
HEENT: NCAT, no oropharyngeal lesions, neck tight especially on
the R, increased pain with palpation over back of neck, no
meningismus
___: RRR, no M/R/G
Pulmonary: CTAB
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented, some trouble relating
history ___ pain. Speech is fluent with full sentences, no
paraphasias. No dysarthria. Normal prosody. No evidence of
hemineglect. No left-right confusion. Able to follow both
midline
and appendicular commands.
- Cranial Nerves: PERRL 3->2 brisk. VF full to number counting,
no diplopia. EOMI, no nystagmus. Decreased sensation to V1-V3 on
the right to light touch, decreased sensation to pin prick over
V2 and V3 on the right. No facial movement asymmetry. Hearing
intact to finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. Unable to complete formal motor
exam as pt in pain, all muscle groups are at least 4+. Pt was
able to walk to bathroom.
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 3+ 3+ 3+ 3+ 2
R 3+ 3+ 3+ 3+ 2
Plantar response flexor bilaterally
- Sensory: decreased sensation to light touch in RUE 65%
compared
to 100% in LUE. Decreased sensation to light touch in LLE 80%
compared to 100% RLE. Decreased sensation to pin prick in LUE
80%
compared to RUE. Decreased sensation to pin prick in RLE
compared
to LLE. Decreased sensation to light touch 80% R V1-V3 but
decreased sensation to pin prick in R V2 and V3 only.
- Coordination: No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait: Normal initiation. Narrow base. Normal stride length and
arm swing. Stable without sway. Negative Romberg.
=== DISCHARGE EXAM ===
(Unchanged except as noted below)
General: In bed, conversant, in no apparent distress.
HEENT: Minimal tenderness with palpation over back of neck.
Neurologic Examination:
- Mental status: No difficulty relating medical history.
- Cranial nerves: Normal sensation to light touch in bilateral
V1-V3.
- Motor: Full strength throughout.
Pertinent Results:
=== SELECTED LABS ===
# CBC
___ 09:45PM BLOOD WBC-8.3# RBC-4.26*# Hgb-10.0* Hct-32.9*#
MCV-77* MCH-23.5* MCHC-30.4* RDW-16.3* RDWSD-45.3 Plt ___
___ 09:45PM BLOOD Neuts-55.4 ___ Monos-10.6
Eos-0.6* Baso-0.8 Im ___ AbsNeut-4.60 AbsLymp-2.69
AbsMono-0.88* AbsEos-0.05 AbsBaso-0.07
___ 04:45AM BLOOD WBC-7.1 RBC-3.72* Hgb-8.9* Hct-29.2*
MCV-79* MCH-23.9* MCHC-30.5* RDW-16.1* RDWSD-45.9 Plt ___
# METABOLIC
___ 09:45PM BLOOD Glucose-152* UreaN-6 Creat-0.9 Na-139
K-4.2 Cl-100 HCO3-25 AnGap-18
___ 04:45AM BLOOD Glucose-94 UreaN-8 Creat-0.7 Na-136 K-4.0
Cl-100 HCO3-26 AnGap-14
___ 04:45AM BLOOD ALT-10 AST-17 AlkPhos-112 TotBili-0.2
___ 09:45PM BLOOD Calcium-10.3 Phos-4.3 Mg-2.2
___ 04:45AM BLOOD Calcium-8.9 Phos-5.1* Mg-1.9
# ENDOCRINE
___ 04:45AM BLOOD ___
# URINE
___ 05:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
___ 05:30PM URINE Color-Straw Appear-Clear Sp ___
# CSF
___ 03:42AM CEREBROSPINAL FLUID (CSF) WBC-16 RBC-6* Polys-0
___ ___ 03:42AM CEREBROSPINAL FLUID (CSF) WBC-13 RBC-2* Polys-1
___ ___ 03:42AM CEREBROSPINAL FLUID (CSF) TotProt-22 Glucose-73
CSF VZV PCR - Not detected
CSF HSV 1&2 PCR - Negative
CSF Gram stain - No PMN, No microorganisms seen. No growth
(final ___.
=== IMAGING ===
# MR ___ W&WO Contrast (___)
1. No definite intraparenchymal abnormalities to suggest HSV
encephalitis or seizure focus.
2. Minimal pachymeningeal enhancement is nonspecific. This
could represent
sequela of meningitis or potentially secondary to recent lumbar
puncture.
3. Stable pituitary mass, unchanged from the ___.
=== EEG ===
# Routine EEG (___)
This is a normal waking EEG. No focal abnormalities or
epileptiform discharges are present. If clinically indicated,
repeat EEG with sleep recording may provide additional
information.
Brief Hospital Course:
___ year-old man with known macroadenoma, ACA aneurysm, chronic
headaches on TID Fioricet, substance abuse on Suboxone, and
possible poorly defined seizures in the past presents with a
severe headache followed by an episode of loss of consciousness
with tremors and confusion. This episode of loss of
consciousness reportedly occurred while at his dentist's office
and was accompanied by minor shaking and tremors with a short
period of confusion afterward. He only recalls the headache and
then being transported to ___ ED by ambulance. In the ED, his
LP showed ___ WBCs with a lymphocytic predominance and normal
protein and glucose. Given his mild-moderate nuchal rigidity and
photosensitivity, his presentation and findings were most
concerning for aseptic meningitis caused by a viral entity such
as HSV or VZV. However, he has chronic HAs and the inflammatory
LP may be secondary to headache inflammation. This is unlikely
to be bacterial meningitis given lymphocytic LP results and lack
of systemic signs of infection or inflammation. Unlikely to be
subarachnoid hemorrhage given no focal neurologic deficits and
only 6 and 2 RBCs in LP. He was started on acyclovir, and this
was stopped after CSF HSV and VZV returned negative.
With regard to vague seizure history, he has two reported events
that have occurred while driving as well as the report of mild
tremors and shaking during this most recent loss of
consciousness. While seizures cannot be ruled out, his seizure
history is unclear and this most recent event may be syncopal,
as his confusion was only brief after the event subsided, no
true post-ictal period, and tremors are often associated with
syncope. An EEG and contrast brain MRI were obtained in order to
evaluate possible causes of seizure, such as focal lesion or
expanding macroadenoma. Both were normal.
# Headache in the absence of fever with leukocytosis in CSF: As
above. Initially concerning for aseptic meningitis, though HSV
and VZV negative. Likely due to chronic headache secondary to
analgesic overuse. Chronic headache can also explain mild CSF
leukocytosis.
- Discontinue Fioricet due to rebound headaches.
- Discharge with 3 days PO Dilaudid until f/u with PCP on
___. Recommended analgesic/polypharmacy simplification.
- Continue home medications: Amitriptyline 50mg PO QHS,
gabapentin 300mg QHS, clonazepam 1mg PO QD. Consider
tapering-off/discontinuing some of these and simplifying to a
maintenance/prophylactic regime once the analgesic overuse
headache is addressed. Consider steroid pulse to escape
analgesic overuse.
# Loss of consiousness: Concerning for seizures, but may be
syncopal in nature. MRI brain W&WO contrast was negative, as was
routine EEG.
# Susbtance abuse: Continue home Suboxone.
# Pituitary macroadenoma: Continue home bromocriptine. PRL was
reduced from prior, now ___.
# ADHD: Continue home Adderall 20mg TID for now, though consider
alternatives, adjustment, or discontinuation of this medication
given his headache and already complex medication regime. He
insists that Adderall helps his headaches (and was asking for it
even at 11PM on the night of admission), but this is likely a
non-specific effect. It is more likely that Adderall is
contributing to triggering his headaches when its serum
concentrations are declining. It is also not recommended in
those with a history of substance abuse.
# ___:
- PCP ___ on ___.
- Neurology ___ in resident clinic ___ ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amitriptyline 50 mg PO QHS
2. Gabapentin 300 mg PO QHS
3. Bromocriptine Mesylate 5 mg PO QHS
4. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN Headache
5. Amphetamine-Dextroamphetamine 20 mg PO TID
6. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID
7. ClonazePAM 1 mg PO BID Anxiety
8. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN Pain - Moderate
RX *hydromorphone 4 mg 1 tablet(s) by mouth TID PRN Disp #*11
Tablet Refills:*0
3. Amitriptyline 50 mg PO QHS
4. Amphetamine-Dextroamphetamine 20 mg PO TID
5. Bromocriptine Mesylate 5 mg PO QHS
6. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID
7. ClonazePAM 1 mg PO BID Anxiety
8. Gabapentin 300 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Chronic Headache
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr ___,
You were admitted to the hospital for symptoms of shaking and
headache that were concerning for seizure. You had a lumbar
puncture which suggested possible infection of the fluid
surrounding your brain and spinal cord. This, along with your
symptoms were consistent with a viral meningitis. You were
started on an antiviral medication while we awaited lab tests.
The viral tests came back negative and these medications were
stopped. Your brain MRI was normal - your pituitary gland was
not too large. EEG also did not show anything concerning for
seizures. Your spinal fluid inflammation was most likely due to
your chronic headaches, which is likely due to overuse of pain
medication, paradoxically, for headache.
- STOP taking Fioricet for your headaches. This is a common
cause of chronic headaches.
- You may take the Dilaudid for headache until ___ when you
see your PCP ___. You should limit your use of this medication
and use it AS NEEDED ONLY.
- ___ at your previously scheduled PCP appointment on
___.
- ___ at the Neurology Clinic on ___ (see below).
Thank you,
Your ___ Neurology Team
Followup Instructions:
___
|
10644529-DS-12
| 10,644,529 | 28,479,110 |
DS
| 12 |
2182-01-15 00:00:00
|
2182-08-31 12:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
prostate cancer
DVT (LLE)
___ s/p channel TURP
hematuria
compartment syndrome
Cardiac arrest (circulatory arrest)
Major Surgical or Invasive Procedure:
Date: ___
Surgeon: ___, MD
PROCEDURES: Exploratory laparotomy and superior abdominal
closure.
Date: ___ Surgeon: ___, MD
PROCEDURE: Removal of VAC sponge and secondary abdominal
closure.
Date: ___ Surgeon: ___, MD
PROCEDURE: Exploratory laparotomy with complex repair of
bladder laceration, temporary abdominal wound closure.
PRIOR ADMISSION:
Date: ___ Surgeon: ___, MD
PROCEDURE: Bipolar transurethral resection of prostate.
History of Present Illness:
Mr. ___ is an ___ M w/PMHx prostate CA s/p TURP on ___,
LLE DVT on Coumadin at home (bridging with Lovenox s/p TURP),
presented to the ED on POD#4 with decreased UOP, belly pain,
hematuria, and vomiting. The foley was exchanged by urology and
CBI was started. Patient went to the floor and became worse-
hypotensive to SBP 70's, tachypneic, hypothermic to T ___, and
lethargic, with belly looking more distended. He was moved to
the FICU with plans to do a stat CT, but pt continued to
decompensate- increasingly hypotensive and tachypenic. FAST exam
showed free fluid, pt was intubated for stat OR; when resident
went to place arterial line, felt the pulse get lost. CPR
initiated, multiple rounds of epi, chest compressions continued
while bedside ex lap was done. Large amount of blood tinged free
fluid from bladder perforation. Was started on Levophed,
fentanyl gtt, and sent to OR. ACS team called to assist. In
OR, closed bladder injury. Placed suprapubic catheter as well as
a foley, irrigating through the SPC and draining out foley.
Abdomen was left open. Pt was stabilized post-operatively in the
FICU and then transferred to the TICU.
Past Medical History:
PMH:
- Prostate cancer with bone mets
- Hypertension
- DVT, LLE
- urinary retention
- arthritis
- GERD
PSH:
___ Cystoscopy, Bipolar Transurethral Resection of
Prostate
Social History:
___
Family History:
No history of malignancy.
Physical Exam:
Gen: No acute distress, alert & oriented
HEENT: Extraocular movements intact, face symmetric
CHEST: Warm and well-perfused
BACK: Non-labored breathing, no CVA tenderness bilaterally
ABD: Soft, non-tender, mild distention, no guarding or rebound
SPT care; waste elimination
Wound care/monitoring; staples removed ___ prior to discharge
and steristrips applied.
EXT: Bilateral lower extremities are warm, dry, well perfused.
There is no reported calf pain to deep palpation. No edema or
pitting
PSY: Appropriately interactive
Pertinent Results:
___ 10:40AM BLOOD WBC-10.5* RBC-3.38* Hgb-9.4* Hct-29.0*
MCV-86 MCH-27.8 MCHC-32.4 RDW-14.4 RDWSD-44.5 Plt ___
___ 07:40AM BLOOD WBC-9.0 RBC-2.87* Hgb-7.9*# Hct-24.1*
MCV-84 MCH-27.5 MCHC-32.8 RDW-14.4 RDWSD-43.6 Plt ___
___ 07:40AM BLOOD WBC-8.9 RBC-2.30* Hgb-6.3* Hct-19.7*
MCV-86 MCH-27.4 MCHC-32.0 RDW-14.1 RDWSD-43.5 Plt ___
___ 05:32PM BLOOD WBC-11.0* RBC-2.57* Hgb-7.2* Hct-22.6*
MCV-88 MCH-28.0 MCHC-31.9* RDW-15.5 RDWSD-49.7* Plt Ct-93*
___ 01:35PM BLOOD WBC-11.6* RBC-2.44* Hgb-6.5* Hct-20.6*
MCV-84 MCH-26.6 MCHC-31.6* RDW-15.1 RDWSD-46.7* Plt ___
___ 03:28AM BLOOD WBC-15.6*# RBC-2.49*# Hgb-6.7* Hct-20.9*#
MCV-84 MCH-26.9 MCHC-32.1 RDW-15.3 RDWSD-46.3 Plt ___
___ 03:28AM BLOOD Neuts-83.9* Lymphs-9.2* Monos-5.8
Eos-0.0* Baso-0.1 Im ___ AbsNeut-13.14*# AbsLymp-1.44
AbsMono-0.90* AbsEos-0.00* AbsBaso-0.01
___ 03:10PM BLOOD ___
___ 10:40AM BLOOD ___
___ 05:58AM BLOOD ___ PTT-34.2 ___
___ 02:43PM BLOOD ___ PTT-86.2* ___
___ 03:28AM BLOOD ___ PTT-32.8 ___
___ 07:40AM BLOOD Glucose-85 UreaN-16 Creat-1.7* Na-141
K-3.6 Cl-108 HCO3-21* AnGap-16
___ 07:40AM BLOOD Glucose-91 UreaN-17 Creat-1.8* Na-143
K-3.4 Cl-111* HCO3-21* AnGap-14
___ 01:35PM BLOOD Glucose-141* UreaN-52* Creat-6.2* Na-134
K-5.3* Cl-100 HCO3-12* AnGap-27*
___ 03:28AM BLOOD Glucose-162* UreaN-46* Creat-5.5*# Na-136
K-4.8 Cl-98 HCO3-16* AnGap-27*
___ 01:30AM BLOOD ALT-725* AST-462* AlkPhos-49 TotBili-0.3
___ 01:30AM BLOOD ALT-960* AST-967* AlkPhos-45 TotBili-0.4
___ 03:41PM BLOOD ALT-107* AST-130* AlkPhos-45 TotBili-0.7
___ 03:41PM BLOOD Lipase-17
___ 07:40AM BLOOD Calcium-7.5* Mg-1.6
___ 12:55AM BLOOD Calcium-7.7* Phos-4.2 Mg-1.9
___ 06:59PM BLOOD Calcium-8.5 Phos-10.2* Mg-2.0
___ 03:41PM BLOOD Albumin-3.1*
___ 01:35PM BLOOD Mg-2.2
___ 07:12PM ASCITES Creat-3.5
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ URINE URINE CULTURE-FINAL INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
Brief Hospital Course:
___ male hx prostate cancer, DVT (LLE) POD4 from channel TURP,
presented to the on ___ with hematuria. Had perforated bladder
and developed abdominal compartment syndrome. Opened acutely at
bedside after circulatory arrest, then taken to OR for
exploration. Subsequently wound vac removed and abdominal wound
closed by ACS on ___ and returned to ___. Extubated ___
ready for floor ___.
Mr. ___ received ___ intravenous antibiotic
prophylaxis and deep vein
thrombosis prophylaxis with subcutaneous heparin, later
converted to lovenox and restarted on Coumadin. With the
eventual passage of flatus, diet was gradually advanced and the
patient was transitioned from IV pain medication to oral pain
medications. At the time of discharge the wound was healing
well
with no evidence of erythema, swelling, or purulent drainage.
His drain was removed and his SPT care reinforced.
Post-operative follow up appointments were
arranged/discussed and the patient was discharged home with
visiting nurse services to further assist the transition to home
with OT, ___, Coumadin titration and waste elimination/care of
the SPT.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Warfarin 2.5 mg PO DAILY16 alternate with 5 mg QOD
4. Enoxaparin Sodium 70 mg SC Q24H
Start: ___, First Dose: Next Routine Administration Time
5. Famotidine 20 mg PO BID
6. Tamsulosin 0.4 mg PO QHS
7. Cyanocobalamin 1000 mcg PO DAILY
8. Vitamin B Complex 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain or fever
2. Artificial Tear Ointment 1 Appl BOTH EYES PRN eye care
3. Docusate Sodium 100 mg PO BID
4. Senna 8.6 mg PO BID
5. amLODIPine 5 mg PO DAILY
6. Cyanocobalamin 1000 mcg PO DAILY
7. Famotidine 20 mg PO BID
8. Finasteride 5 mg PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. QUEtiapine Fumarate 50 mg PO QHS
11. Tamsulosin 0.4 mg PO QHS
12. Vitamin B Complex 1 CAP PO DAILY
13. Warfarin 2.5 mg PO DAILY16 alternate with 5 mg QOD
14.rolling walker
Diagnosis: bladder perforation
Prognosis: good
___: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1) Bladder perforation
2) abdominal compartment syndrome
3) Cardiac Arrest: cardiovascular collapse with return of
circulation after CODE
4) Acute kidney injury on chronic kidney disease
5) generalized deconditioning
6) thrombosis, deep vein (pre-existing)
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:
-Please also reference the instructions provided by nursing on
SUPRAPUBIC TUBE (SPT) catheter care, hygiene and waste
elimination.
-ALWAYS follow-up with your referring provider ___ your PCP
to discuss and review your post-operative course and
medications. Any NEW medications should also be reviewed with
your pharmacist.
-Resume your pre-admission medications except as noted on the
medication reconciliation
-You may take ibuprofen and the prescribed narcotic together for
pain control. FIRST, use Tylenol and Ibuprofen. Add the
prescribed narcotic (examples: Oxycodone, Dilaudid,
Hydromorphone) for break through pain that is >4 on the pain
scale.
-The maximum dose of Tylenol (ACETAMINOPHEN) is 3- 4 grams (from
ALL sources) PER DAY.
-Ibuprofen should always be taken with food. If you develop
stomach pain or note black stool, stop the Ibuprofen. Ibuprofen
works best when taken around the clock.
-For your safety and the safety of others; PLEASE DO NOT drive,
operate dangerous machinery, or consume alcohol while taking
narcotic pain medications.
-Do NOT drive while Foley catheter is in place.
-AVOID lifting/pushing/pulling items heavier than 10 pounds (or
3 kilos; about a gallon of milk) or participate in high
intensity physical activity (which includes intercourse) until
you are cleared by your Urologist in follow-up. Generally about
FOUR weeks. Light household chores are generally ok. Do not
vacuum.
-No DRIVING until you are cleared by your Urologist
-Do not drive or drink alcohol while taking narcotics and do not
operate dangerous machinery
-You may be given prescriptions for a stool softener ___ a
gentle laxative. These are over-the-counter medications that
may be health care spending account reimbursable.
-Colace (docusate sodium) may have been prescribed to avoid
post-surgical constipation or constipation related to use of
narcotic pain medications. Discontinue if loose stool or
diarrhea develops. Colace is a stool-softener, NOT a laxative.
-Senokot (or any gentle laxative) may have been prescribed to
further minimize your risk of constipation.
-You may shower as usual but do not immerse in bath/pool while
foley in place
-Your Foley should be secured to the catheter secure on your
thigh at ALL times until your follow up with the surgeon.
-DO NOT allow anyone that is outside of the urology team remove
your Foley for any reason.
-Wear Large Foley bag for majority of time; the leg bag is only
for short-term when leaving the house, etc.
-___ medical attention for fevers (temp>101.5), worsening pain,
drainage or excessive bleeding from incision, chest pain or
shortness of breath.
Followup Instructions:
___
|
10644688-DS-15
| 10,644,688 | 25,969,506 |
DS
| 15 |
2174-06-09 00:00:00
|
2174-06-09 14:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
adhesive tape
Attending: ___.
Chief Complaint:
fall from horse
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___, otherwise healthy, presenting after a fall from a horse
during a riding competition. Per the patient, witnesses and a
video taken of the incident, she was riding her horse, when it
made a few jerking movements which caused her to likely hit her
head and hyperextend her neck on the back of the horse and lose
consciousness. After a few seconds, she fell off the horse.
According to witnesses, she lost consciousness for about ___
minutes. She denies any memory loss, nausea, vomiting or
headaches.
Past Medical History:
Past Medical History: HTN, lost sense of smell due to head
injury
many years ago
Past Surgical History: cataracts, corneal transplant
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission Physical exam:
Vitals: 97.9 86 133/77 22 97%RA
GEN: A&Ox3, NAD, c-collar in place
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, no chest wall tenderness
PULM: Clear to auscultation b/l
ABD: Soft, nondistended, nontender, no rebound or guarding
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS:98.0, 129/87, 59, 16, 99 Ra
Gen: A&O x3. dressed and ambulating in room. NAD.
HEENT: hard collar on
CV: HRR
Pulm: LS ctab
Abd: soft NT/ND
Ext: WWP no edema, atraumatic
Neuro: Intact. No deficits.
Pertinent Results:
___ 09:35AM BLOOD WBC-6.0 RBC-4.42 Hgb-14.1 Hct-42.1 MCV-95
MCH-31.9 MCHC-33.5 RDW-13.2 RDWSD-46.6* Plt ___
___ 02:47PM BLOOD WBC-7.2 RBC-4.45 Hgb-14.2 Hct-42.6 MCV-96
MCH-31.9 MCHC-33.3 RDW-13.7 RDWSD-48.4* Plt ___
___ 08:45PM BLOOD WBC-10.2* RBC-4.31 Hgb-13.5 Hct-40.9
MCV-95 MCH-31.3 MCHC-33.0 RDW-13.5 RDWSD-47.6* Plt ___
___ 09:35AM BLOOD Glucose-82 UreaN-15 Creat-0.9 Na-137
K-3.7 Cl-95* HCO3-26 AnGap-16
___ 02:47PM BLOOD Glucose-115* UreaN-18 Creat-0.9 Na-142
K-3.8 Cl-99 HCO3-28 AnGap-15
___ 08:45PM BLOOD Glucose-99 UreaN-19 Creat-0.9 Na-141
K-4.0 Cl-100 HCO3-26 AnGap-15
___ 09:35AM BLOOD Calcium-9.2 Phos-2.3* Mg-1.9
___ 02:47PM BLOOD Calcium-9.6 Phos-2.9 Mg-2.0
Radiology:
MR ___ ___: 1. Focal narrowing and irregularity of the distal
V2 segment of the right vertebral artery and as it passes
through
the right C2 transverse foramen at the site of the known
fracture. Findings are suspicious for dissection.
2. There is no infarct or parenchymal hemorrhage. There is a
small amount of dependent hemorrhage in the occipital horns of
both lateral ventricles.
3. 4.5 cm heterogenous right thyroid mass. Ultrasound is
advised
for further evaluation.
CT c-spine ___: 1. Comminuted mildly impacted fracture of the
right C2 articular pillar and transverse process including
significant impingement on the right vertebral artery foramen.
2. Moderate degenerative changes probably explaining small
multilevel spondylolisthesis.
3. Large nodule in the right thyroid. ___ evaluation
with
ultrasound is recommended when clinically appropriate.
CT Head ___: No evidence of a cute intracranial process or
injury.
Pelvis X-ray ___: No evidence of fracture or dislocation.
Brief Hospital Course:
___ admitted to the Trauma service status post fall from horse
with +LOC, found to have C2 fracture and CTA head and neck
concerning for vertebral artery dissection. The patient was
GCS15 and neurovascularly intact and hemodynamically stable.
Orthopedic Spine was consulted and they recommended nonoperative
management with a hard cervical collar at all times. Neurology
was consulted for the vertebral artery
dissection, and they recommended daily aspirin. The patient was
ambulating independently in the room and in no pain. During this
hospitalization, the patient ambulated early and frequently, was
adherent with respiratory toilet and incentive spirometry, and
actively participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient and her husband received discharge teaching and
___ instructions with understanding verbalized and
agreement with the discharge plan. They elected to find
Orthopedic Spine and Neurology providers to ___ with more
locally where they lived in ___, as they had only been
visiting ___ for a horse competition.
Medications on Admission:
aspirin 81mg daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Aspirin 81 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
[] Right C2 articular pillar and transverse process fracture
[] Right vertebral foraminal stenosis and possible focal
dissection of the right distal V2 segment
Incidental Finding:
A large nodule in the right thyroid lobe measures up to 2.9 cm
and contains coarse calcifications.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ after a fall from a horse. You
sustained a fracture in your cervical spine and an associated
vertebral artery dissection. You were seen by Ortho Spine and
they recommend a hard collar at all times. You should ___
with a Spine surgeon in 2 weeks to establish care and to
determine when it is safe to discontinue the cervical collar.
You were seen by the Neurology team for the vertebral artery
injury. ther recommend continuing a daily aspirin. You should
also establish care with a local Neurologist. Your trauma
work-up was also notable for an incidental finding of a large
thyroid nodule. This warrants an ultrasound, as an outpatient.
Please discuss with your PCP looking into this.
You are now medically cleared for discharge.
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
Followup Instructions:
___
|
10645294-DS-8
| 10,645,294 | 23,267,878 |
DS
| 8 |
2184-09-17 00:00:00
|
2184-09-17 12:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Closed R radius / ulnar shaft fractures
Major Surgical or Invasive Procedure:
___: ORIF Right both bone forearm fracture (___)
History of Present Illness:
___ R handed male presents with the above fracture s/p
football injury. Patient was playing a football game last night
when, during a tackle, his arm was wedged between two players
and
he felt a sharp pain in his forearm.
He was evaluated at an OSH where RUE films demonstrated midshaft
radial/ulnar fractures. He sustained no additional injuries and
has been neurovascularly intact since the time of the injury.
Describes no shoulder, wrist, elbow, or finger pain in RUE. No
head, neck, torso, LUE, or b/l ___ pain.
Denies additional recent medical illness.
Past Medical History:
No medical history
reduction surgery for gynecomastia
Social History:
___
Family History:
NC
Physical Exam:
R upper extremity:
- Skin intact
- in splint, dsg cdi
- Fires EPL/FPL/DIO
- SILT axillary/radial/median/ulnar nerve distributions
- no pain with passive stretch
- 2+ radial pulse, 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 Right both bone forearm fractureand was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF Right both bone forearm
fracture (___), 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 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 R upper extremity, and will be discharged on no meds
for DVT prophylaxis (low risk). The patient will follow up with
Dr. ___ trauma clinic per routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
5. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Right both bone forearm 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:
-nonweight bearing right upper extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- none
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
Followup Instructions:
___
|
10645376-DS-8
| 10,645,376 | 24,347,343 |
DS
| 8 |
2188-08-02 00:00:00
|
2188-08-02 12:23:00
|
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 periprosthetic humerus fracture
Major Surgical or Invasive Procedure:
Open reduction internal fixation, left periprosthetic humerus
fracture
History of Present Illness:
___ male past medical history significant for CAD, CHF,
prior MI, A. fib on Xarelto who presents as a transfer from
outside hospital with a left periprosthetic midshaft humerus
fracture after mechanical fall. Notably he has had multiple
mechanical falls in the past. Patient states that he struck his
head but denied loss of consciousness. He remembers the entire
event. He denied any presyncopal symptoms or palpitations. He
was transferred here for definitive management. He underwent
left reverse total shoulder arthroplasty with Dr. ___
___ in ___ and has been doing well ever since up
until this fall. He currently denies any numbness or tingling
in the hand. He denies any weakness in the hand. He denies any
other injuries including neck pain.
Past Medical History:
Obesity, OSA with CPAP, Low Back pain, dyslipidemia, HTN,
Arthritis, DM 2
Social History:
___
Family History:
N/C
Physical Exam:
Vitals: ___ 0410 Temp: 98.5 PO BP: 171/89 R Lying HR: 77
RR:
18 O2 sat: 96% O2 delivery: Ra
General: Well-appearing, breathing comfortably
MSK:
LUE:
- Dressing c/d/i
- Fires epl/fpl/dio
- SILT m/r/u
- Fingers WWP, brisk cap refill
Pertinent Results:
See OMR
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left periprosthetic humerus fracture and was admitted
to the orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction and internal
fixation, which the patient tolerated well. For full details 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.
#Spiritual Care
The patient became tearful describing that he is currently
separated from his wife, who is undergoing treatment at an
assisted living facility. He was seen be the ___ and
offered support during his illness; follow-up is recommended
regarding the patient's emotional well-being.
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
non weight-bearing in the left upper extremity, and will be
discharged on rivaroxaban (home medication) for DVT prophylaxis.
The patient will follow up with Dr. ___ routine. A
thorough discussion was had with the patient regarding the
diagnosis and expected post-discharge course including reasons
to call the office or return to the hospital, and all questions
were answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Losartan Potassium 50 mg PO DAILY
5. Rivaroxaban 15 mg PO DAILY
6. Pantoprazole 40 mg PO Q12H
7. Furosemide 40 mg PO DAILY
8. MetFORMIN (Glucophage) 1000 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO 5X/DAY
Please take 5X per day while on narcotics
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Docusate Sodium 100 mg PO BID
4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 0.5 - 1 tablet(s) by mouth Every ___ hours as
needed Disp #*30 Tablet Refills:*0
5. Senna 8.6 mg PO BID
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Furosemide 40 mg PO DAILY
9. Losartan Potassium 50 mg PO DAILY
10. MetFORMIN (Glucophage) 1000 mg PO DAILY
11. Metoprolol Succinate XL 50 mg PO DAILY
12. Pantoprazole 40 mg PO Q12H
13. Rivaroxaban 15 mg PO DAILY
RX *rivaroxaban [Xarelto] 15 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left periprosthetic humerus fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Non-weight bearing left upper extremity, range of motion as
tolerated
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 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 and may 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 your home dose of apixaban daily for 4 weeks. You
may transition to rivaroxaban per your cardiologist; please make
sure that you are taking some type of medication for
anticoagulation.
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.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
Physical Therapy:
Non weight-bearing, left upper extremity
ROMAT at shoulder, elbow, wrists
No brace or splint needed
Treatments Frequency:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be
left open to air unless actively draining. If draining, you may
apply a gauze dressing secured with paper tape. You may shower
and allow water to run over the wound, but please refrain from
bathing for at least 4 weeks postoperatively.
Followup Instructions:
___
|
10645926-DS-28
| 10,645,926 | 22,637,281 |
DS
| 28 |
2192-04-02 00:00:00
|
2192-04-02 20:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Methotrexate
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
___ endotracheal intubation
___ femoral central venous catheter placement
History of Present Illness:
___ xfer from OSH (___ after being found down by
___ earlier today. Recent hosp admission for UTI, Klebsiella PNA
completed antibiotics and discharged home. History is unclear,
however medflight reports that she is on the liver transplant
list. History of rheumatoid arthritis and ankylosing spondylitis
on Florinef. Outside hospital, patient was intubated for her
unresponsiveness. Received vancomycin and Zosyn. Also noted to
have a left hip dislocation that was reduced ___ the ER.
Hypotensive, requiring norepinephrine after 2 L of IV fluids.
Transferred for further care. PH 7.1, CO2 50 with a bicarbonate
of 18 on initial ABG. At outside hospital, attempted right and
left IJ resulted ___ subcutaneous fluid extravasation.
.
___ the ED, initial vitals she recieved hydrocortisone 100 mg IV
because chronically on florinef and had a right femoral CVL
placed. Also, she underwent a CT head which was negative for
acute bleed and a CT torso which showed bilateral aspiration
versus effusions. Her hip had to be reduced twice, once with
vecuronium.
.
On arrival to the MICU, she was intubated and sedated with
initial vital signs 88/69, 120, 14, 100% on AC (volume).
.
Review of systems not obtained because patient intubated.
Past Medical History:
h/o Tylenol OD ___ and ___ c/b hepatic failure
VAP
foot necrosis ___ pressors
Bilateral DVT ___
8mm clean ulcer at prepyloric antrum seen on EGD ___
(H.Pylori neg) c/b GIB bleed s/p transfusion 4U pRBCs
Psychiatric disorder (anxiety vs bipolar)
chronic pain
h/o domestic abuse
Crohn's disease
anklyosing spondylitis
Long term alcoholism
h/o Hep A
iron-deficiency anemia
Distal ileum resection ___
CCY ___
R hip replacement ___ c/b osteomyelitis
L hip replacement ___ also c/b osteomyelitis
back/knee surgeries per past notes
Social History:
___
Family History:
Father - colitis? (frequent stomach pain)
Mother - RA, ankylosing spondylitis
Grandmother - ankylosing spondylitis
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98.0, BP: 113/67, P: 119, R: 18 O2: 100% on 100% FiO2
General: intubated, sedated
HEENT: Sclera anicteric, MMM, pupils fixed and non-reactive
Neck: subcutaneous infiltration by saline, unable to assess LAD
or JVP
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, no organomegaly
GU: foley draining yellow urine
Ext: cold, thready pulses, no clubbing, cyanosis or edema. left
lower extremity with chronic ulceration
DISCHARGE PHYSICAL EXAM:
Vitals: 97.8 150/82 72 18 99%RA
General: WDWN female, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: no lymphadenopathy, no JVD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, no organomegaly, right
hip with small subcentimeter wound with minimal serous drainage
Ext: no clubbing, cyanosis or edema. left lower extremity with
chronic ulceration. left hand with erythema and edema from
previous PIV, pink granulation tissue (much improved since
admission), left hip without swelling or erythema, tender on
palpation but pt able to ambulate
Skin: several macules on right leg and lower back with central
clearing c/w tinea corporis
Neuro: A & O x 3, moving all extremities
Pertinent Results:
ADMISSION LABS:
___ 11:20PM BLOOD WBC-17.4* RBC-4.27 Hgb-11.5* Hct-38.5
MCV-90 MCH-27.0 MCHC-29.9* RDW-15.0 Plt ___
___ 11:20PM BLOOD Neuts-95.2* Lymphs-3.3* Monos-1.4* Eos-0
Baso-0
___ 11:20PM BLOOD ___ PTT-36.0 ___
___ 11:20PM BLOOD Glucose-65* UreaN-66* Creat-2.2* Na-141
K-4.2 Cl-107 HCO3-14* AnGap-24*
___ 11:20PM BLOOD ALT-156* AST-430* ___
AlkPhos-132* TotBili-0.3
___ 11:20PM BLOOD Lipase-10
___ 11:20PM BLOOD cTropnT-<0.01
___ 11:20PM BLOOD Calcium-6.7* Phos-7.4* Mg-2.4
___ 11:20PM BLOOD Osmolal-314*
___ 11:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-POS
___ 04:50AM BLOOD Type-ART Rates-18/ Tidal V-450 PEEP-5
FiO2-50 pO2-78* pCO2-38 pH-7.09* calTCO2-12* Base XS--17
Intubat-INTUBATED Vent-CONTROLLED
___ 11:21PM BLOOD Lactate-0.6
___ 04:15PM BLOOD freeCa-1.02*
.
ABG TREND:
___ 04:50AM BLOOD Type-ART Rates-18/ Tidal V-450 PEEP-5
FiO2-50 pO2-78* pCO2-38 pH-7.09* calTCO2-12* Base XS--17
Intubat-INTUBATED Vent-CONTROLLED
___ 07:12AM BLOOD ___ Temp-38.0 ___ Tidal V-450
PEEP-5 FiO2-60 pO2-62* pCO2-42 pH-7.21* calTCO2-18* Base XS--10
Intubat-INTUBATED Vent-CONTROLLED
___ 09:44AM BLOOD Type-ART Temp-38.2 Rates-22/ Tidal V-450
PEEP-10 FiO2-50 pO2-31* pCO2-51* pH-7.20* calTCO2-21 Base XS--9
-ASSIST/CON Intubat-INTUBATED
___ 12:21PM BLOOD Type-CENTRAL VE Temp-37.2 pO2-170*
pCO2-35 pH-7.35 calTCO2-20* Base XS--5 -ASSIST/CON
Intubat-INTUBATED Comment-GREEN TOP
___ 09:44AM BLOOD Type-ART Temp-36.9 Tidal V-500 PEEP-8
FiO2-40 pO2-146* pCO2-40 pH-7.36 calTCO2-24 Base XS--2
Intubat-INTUBATED
.
DISCHARGE LABS:
___ 12:00PM BLOOD WBC-4.8 RBC-3.30* Hgb-9.0* Hct-28.7*
MCV-87 MCH-27.3 MCHC-31.4 RDW-16.8* Plt ___
___ 12:00PM BLOOD ___
___ 12:00PM BLOOD Glucose-88 UreaN-11 Creat-0.6 Na-140
K-4.1 Cl-111* HCO3-23 AnGap-10
___ 03:42AM BLOOD ALT-38 AST-23
___ 12:00PM BLOOD Calcium-8.4 Phos-3.7 Mg-1.5*
.
URINE:
___ 11:25PM URINE Color-LtAmb Appear-Hazy Sp ___
___ 11:25PM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR
___ 11:25PM URINE RBC-5* WBC-30* Bacteri-FEW Yeast-NONE
Epi-2
___ 11:25PM URINE UCG-NEGATIVE
___ 11:25PM URINE bnzodzp-POS barbitr-NEG opiates-POS
cocaine-POS amphetm-NEG mthdone-NEG
.
MICRO:
___, 4, 6, 7 BLOOD CULTURES NGTD
___ 11:00 am SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS, CHAINS, AND
CLUSTERS.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Preliminary):
SPARSE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. HEAVY GROWTH.
BETA STREPTOCOCCI, NOT GROUP A. MODERATE GROWTH.
Blood Culture, Routine (Final ___: NO GROWTH.
Blood Culture, Routine (Final ___: NO GROWTH.
URINE CULTURE (Final ___: YEAST. >100,000
ORGANISMS/ML..
Stool Studies:
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ___:
Feces negative for C.difficile toxin A & B by EIA.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ___:
Feces negative for C.difficile toxin A & B by EIA.
___: C. difficile Toxin PCR Negative
.
IMAGING:
___ CT C/A/P: TECHNIQUE: MDCT axial images were obtained from
the chest, abdomen and pelvis with the administration of IV
contrast. Multiplanar reformats were generated and reviewed.
CT OF THE CHEST: Right pleural effusion with adjacent
compressive
atelectasis. Left base opacification likely represents collapsed
left lower lobe which appears airless and filled with higher
density material, possibly blood. The patient has a nasogastric
tube which passes into the stomach. ETT tube appears
approximately 4.7cm above the carina.
The visualized heart and pericardium are unremarkable.
CT OF THE ABDOMEN AND PELVIS: The intra-abdominal vasculature
and
intra-abdominal solid organs are incompletely evaluated ___ the
absence of IV contrast. Within this limitation, the liver,
pancreas, and bilateral adrenal glands appear unremarkable. Note
is made of splenomegaly. Both kidneys show no evidence of large
masses. A non-obstructive 9-mm stone is noted within the lower
pole of the left kidney (601B, 32). Small stones are noted
within the right kidney. The patient is status post
cholecystectomy.
Surgical sutures are noted ___ the RLQ, otherwise,
intra-abdominal loops of
large and small bowel appear unremarkable. There is no free air
or free fluid within the abdomen. Retroperitoneal and mesenteric
lymph nodes do not meet size criteria for pathologic
enlargement.
The structures within the pelvis are incompletely evaluated due
to the
presence of streak artifact due to bilateral total hip
replacements. Within this limitation, the patient is status post
a Foley catheter. A right femoral vein catheter is identified. A
possible rectal catheter is noted. Bilateral hip prosthesis are
noted; the right femoral component appears well seated within
the acetabular component; however, the left femoral component is
not well seated within the left acetabular component.
Decrease ___ vertebral body height of L1 vertebral body is noted
with possible retropulsion of fragment into the spinal canal and
indentation of the thecal sac. This is of indeterminate
chronicity, but likely represents more chronic process with the
presence of what looks like kyphoplasty material within L1
vertebral body. Intra-abdominal vasculature is not well
evaluated ___ the absence of contrast technique.
IMPRESSION:
1. Right pleural effusion with adjacent compressive atelectasis.
Left base
opacification likely represents collapsed left lower lobe which
appears
airless and filled with higher density material, possibly blood.
2. Left lower pole renal calculus.
3. Incomplete evaluation of the pelvis due to streak artifact.
4. Left total hip arthroplasty prosthesis shows femoral
component is not well seated within the acetabular component.
5. Loss of vertebral body height of L1 vertebral body with
possible
retropulsion of fragments into the spinal canal; this is of
indeterminate
chronicity, however, appears to be chronic due to presence of
what appears to be kyphoplastic material.
.
___ CT HEAD:TECHNIQUE: Contiguous axial images were obtained
through the head without the administration of IV contrast.
Multiplanar reformats were generated and reviewed.
There is no evidence of acute fracture or traumatic dislocation.
Bilateral
mastoid air cells are clear. Minimal mucosal thickening is noted
within
bilateral maxillary sinuses.
There is no evidence of acute intracranial hemorrhage, discrete
masses, mass effect or shift of normally midline structures. The
ventricles and sulci are normal ___ size and configuration.
Gray-white matter differentiation is preserved with no evidence
of large acute major vascular territory infarction.
IMPRESSION: No acute intracranial pathological process.
ADDENDUM AT ATTENDING REVIEW: There is marked anterior rotation
of the
odontoid process relative to a thickened appearance of the body
of C2. The
finding likely represents a fracture/subluxation deformity.
There is resultant prominent central canal narrowing at this
level. There is no prevertebral soft tissue swelling at this
locale. It is possible that the finding represents a prior,
healed fracture, but clearly this question must be resolved,
through either obtaining prior records/imaging studies
immediately, and/or subsequent spinal CT imaging. ___ the
meantime, the patient's neck needs to be stabilized.
.
___ CT CSPINE: COMPARISON: CT head from ___ and
portable C-spine radiograph from ___.
TECHNIQUE: Helical 2.5-mm axial MDCT sections were obtained from
the skull
base through the level of T2. Sagittal and coronal reformations
were obtained and reviewed.
FINDINGS: There is a large mass of new bone formation causing
fusion of the C1 and C2 vertebral bodies anteriorly, with
anterior subluxation of C1 with respect to C2(400b:27). This
results ___ severe encroachment on the spinal canal by the
posterior arch of C1. The degree of subluxation is unchanged
from the prior study. There is no fracture identified.
There is extensive fusion of every facet joint from C2 to T3,
comprising all the levels imaged. There is also interbody fusion
involving every cervical level. There has been surgical anterior
fusion at C6-7. There is extensive fusion of the lamina and
interlaminar ligaments throughout the visualized levels. ___ the
portion of thoracic spine included ___ the study, there is fusion
of costovertebral and costotransverse articulations. Comparison
with a torso CT of ___ reveals similar ankylosis ___ the
lumbar spine and sacroiliac joints. These findings indicate a
spondyloarthropathy with manifestations typical of ankylosing
spondylitis. Correlation with the remainder of her medical
history will be helpful.
IMPRESSION:
1. Anterior subluxation of C1 on C2 without evidence of
fracture. The
anterior arch of C1 is fused to the odontoid process via a thick
layer of bone that contributes to the subluxation. This produces
severe encroachment on the spinal canal by the posterior arch of
C1.
2. There are extensive fusions of multiple spinal joints most
suggestive of ankylosing spondylitis.
3. No evidence of acute fracture.
.
___ PELVIS PLAIN FILM: Comparison is made to selected images
from an abdominal pelvic CT scan dated ___.
SINGLE PORTABLE AP PELVIC FILM WAS OBTAINED ___ AT 0452:
Bilateral total hip replacements are seen. The femoral and
acetabular
components appear to be well approximated on this single AP
view. The distal end of both femoral components is not included
on the image. There is no evidence of loosening of the femoral
components. Hypertrophic bone is seen lateral to the right
femoral component. A right femoral catheter is ___ place. No
displaced fracture of the pelvis is appreciated. Surgical chain
sutures are seen ___ the right lower quadrant, suggesting prior
colonic surgery. A Foley catheter is ___ place. Several
radiopaque densities are seen lateral to the left femoral
component within the soft tissues which may be sutural ___
etiology. Clinical correlation is advised.
IMPRESSION:
Bilateral total hip replacements with both appearing to be
normally positioned on this single portable view. No evidence of
displaced fracture of the pelvis.
Left upper extremity ultrasound ___:
IMPRESSION: Non-occlusive thrombus within one of two paired
brachial veins, which extends to the axillary vein.
Portable chest x-ray ___:
IMPRESSION: Persistent sizable parenchymal infiltrate ___ left
lower lobe
area. No new abnormalities ___ this portable chest examination.
Brief Hospital Course:
Ms. ___ is a ___ year old female with a history of suicide
attempts and subsequent liver disease, multiple infections
including ESBL Klebsiella and osteomyelitis who takes chronic
steroids for ankylosis spondylitis presented from an outside
hospital intubated and requiring pressors.
.
ACTIVE PROBLEMS BY ISSUE:
# Acute metabolic acidosis without respiratory compensation:
Her pH upon admission to ICU was 7.1 with a bicarb of 14, later
worsened to 7.09 with bicarb of 12. The possible etiologies of
her primary metabolic acidosis include intoxication versus
sepsis. The active agent/s seem to have suppressed her
respiratory drive (additional respiratory acidosis) as well as
causing a primary metabolic acidosis. She was treated with IV
fluids with bicarbonate as well as hyperventilation on
mechanical ventilation ___ order to improve the acidosis and
elevated pCO2. Also, the toxicology and psychiatry services
were consulted to assist with identifying the cause of her
ingestion. Finally, she was started empirically on
piperacillin/tazobactam with vancomycin to cover for possible
aspiration pneumonia.
.
# Respiratory failure: She was intubated upon arrival but able
to be ventilated well including a recruitment procedure to open
her atelectatic lung seen on CT. She was extubated easily and
did well on room air afterwards. As discussed above, it was
thought that she aspirated while she was impaired from an
unknown ingestion. Her CT chest was consistent with some small
bilateral pneumonia. Following stabilization and extubation,
induced sputum results returned positive for MRSA. She
completed a 7 day course of vancomycin. She remained afebrile
throughout remainder of course on the medical floor. PICC was
discontinued prior to discharge.
.
# Hypotension: Pt was hypotensive on admission to ICU. Her
hypotension is of unclear etiology. It seems possible that she
had sepsis--likely from pneumonia. Also, she may have been down
long enough to miss her home florinef dose, resulting ___
hypotension. Lastly, the ingestion itself could have caused
hypotension. She was treated with IV fluids, antibiotics as
above, and stress doses of steroids. Blood pressures were
stable during floor course. She was started on captopril when
she became hypertensive with subsequent good control.
.
# Psychologic issues: We suspect that she had a purposeful
ingestion with suicidal attempt. Blood tox was positive for
benzos and tricyclics. Urine tox was positive for benzos,
cocaine, and opiates. However, the patient did not admit
suicide ideation; she intermittently reported that she may have
accidentally ingested more medications than intended. Psychiatry
was consulted and they recommended a 1:1 sitter. She was placed
on ___. She was followed by psychiatry and often refused
full interviewing. She did not admit to suicide ideation but
given her prior suicide attempts and depression with inability
to care for herself, she was transferred to psych facility for
further care. All of her psychiatric medications were held
during hospital stay. She was started on low dose seroquel on
the floor prior to transfer to help with sleep.
.
# Rhabdomyolysis: Her admission Creatinine was 2.2 (baseline is
< 1.0) with phosphate >7 and CK of ___. She was treated with
IV fluids and alkalinization of the urine (with bicarb). Her
creatinine improved to baseline and her CK trended down quickly.
.
# Transaminitis: She has a history of liver disease secondary
to toxic ingestions. Her AST/ALT ratio suggests EtOH damage.
APAP < 2 at OSH. LFTs normalized by time of discharge.
.
# Odontoid fracture and Hip dislocation: Patient originally
arrived ___ the ED with dislocated hip which was reduced.
However, while intubated she awoke and again dislocated her hip
while agitated. It has been put ___ a brace after a second
reduction. Her CT head showed an old odontoid fracture,
confirmed with CT neck. She was kept immobilized until cleared
by ortho spine team. For her hip, ortho recommended that she
continue with posterior hip precautions. She is weight bearing
as tolerated.
.
# Left upper extremity DVT: Patient failed bilateral internal
jugular central lines ___ the outside hospital and then failed a
left subclavian and left ___ PICC here. Imaging looks
like there is some type of central obstruction, L
brachiocephalic vein no flow past it on venogram. She was
eventually able to get a midline at level of axillary.
Ultrasound showed left upper extremity DVT. She was initially
started on heparin gtt with coumadin. She was then transitioned
to lovenox with coumadin. INR was therapeutic for several days
between 2 and 3 by time of discharge on 3mg of warfarin daily.
Pt currently is at risk of falling (due to her ankylosing
spondylitis and hip dislocations) and syncope from substance
abuse. However, given that she will be transferred to an
extended care facility, it was felt that benefits of
anticoagulation would outweigh the risks at this time. When
ready for discharge, there should be another discussion of
anticoagulation. After rehabilitation from both physical and
mental viewpoint, risks/benefits of anticoagulation should be
re-assessed. ___ the meantime, fall precautions should be
continued at psych facility
.
# Diarrhea: Pt had several loose BMs daily. C.diff was negative
x 2. Given amount of diarrhea, she was empirically started on
oral flagyl 500mg TID. C.diff PCR was sent ___ the meantime.
PCR returned negative and flagyl was discontinued. She was
started on immodium with symptomatic relief
.
# Tinea corporis: Pt had several macular patches on lower back
and right leg with central clearing. This was consistent with
tinea corporis. She was treated with clotrimazole cream BID.
.
# Pain control: Pt with longstanding history of narcotic use.
She frequently demanded IV dilaudid for nonspecific complaints,
including abdominal pain. Also has ankylosing spondylitis, left
hip dislocation, and left hand IV infiltration of levophed from
OSH that can contribute to pain. Pain consult obtained who
recommended maintaining current narcotic regimen of oral
dilaudid q6h. She was also given lidoderm patch and ibuprofen
for pain relief. Oral dilaudid was transitioned to oral
oxycodone prior to discharge which patient reported was more
satisfactory.
.
# Communication: ___ (HCP) - ___ ___
___ (son) - ___
Medications on Admission:
clonazepam 1 mg bid, 0.5 mg daily
tizanidine 2 mg qhs
ranitidine 150 mg bid
trazodone 50 mg daily
gabapentin 800 mg tid
fentanyl patch 50 mcg/hr every 72 hours
ketoconazole
tramadol 50 mg qid
macrobid ___ mg bid
Discharge Medications:
1. captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
2. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): On for
12 hours daily.
3. warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
4. clotrimazole 1 % Cream Sig: One (1) Appl Topical BID (2 times
a day): Use twice daily until ___.
5. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
6. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
7. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours).
8. quetiapine 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day) as needed for diarrhea.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Overdose
Depression/ Hx of suicide attempt
Pneumonia
Left upper extremity DVT
Hypertension
Tinea corporis
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 ___ the hospital. You were
admitted after being found ___ your home unconscious. You were
intubated and ___ the ICU. You likely had an ingestion that
caused you to lose consciousness. You will be transferred to a
psychiatric facility where you will continue to receive mental
health care.
During your hospital stay, you were treated for pneumonia with
an IV antibiotic; you finished this course.
You were also started on a blood thinner called coumadin for a
blood clot found ___ your left arm. You will need to have levels
of this medication ___ your blood monitored ___ times weekly.
After psychiatric and physical rehabilitation, the risks and
benefits of blood thinners should be revisited so that we can
determine how long you should stay on this medication.
Please see attached sheet for your new medications.
Followup Instructions:
___
|
10645933-DS-8
| 10,645,933 | 26,882,053 |
DS
| 8 |
2199-09-18 00:00:00
|
2199-09-19 12:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ibuprofen / tramadol / lidocaine
Attending: ___.
Chief Complaint:
abdominal pain, fevers
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ y/o female with a medical history notable for DM,
gastritis/GERD, HTN, chronic constipation, who presents here
with a fever x 24 hours and persistent abdominal bloating,
associated with GERD-like symptoms. Per patient, her fever
began at 2 am yesterday with no associated symptoms, except her
abdominal symptoms that have been long-standing. She denies any
recent travel, unusual food exposures, recent sick contacts, URI
symptoms, cough, diarrhea, or rashes. She does note feeling
weak and developing nausea and vomiting today. No blood or bile
in the emesis.
.
She has been having chronic constipation despite near-daily use
of miralax. Last BM was yesterday, but small in nature, no
blood. She notes she has been having generalized abd bloating,
discomfort, as well as epigastric pain with burning radiation up
her chest and into her mouth for 2 months. She also notes
increased belching and a bad taste in her month along with these
symptoms. These abd symptoms are not new today.
.
She however reports some dysuria and urinary retention while in
the ED today.
.
In the ED, initial VS were notable for T 102.7, HR 154
(triggered), BP 111/86, RR 19, SaO2 98/RA. She received
morphine, zofran, reglan, and dilaudid. Work-up was
unremarkable by labs, CXR, and CT scan. Admitted to medicine
.
Currently, patient is very uncomfortable from nausea and is
vomiting during our interview. 12-pt ROS otherwise negative in
detail except for as noted above.
Past Medical History:
Osteoarthritis
Chronic back pain
Chronic pelvic pain
Diabetes
Gastritis
GERD
Hyperlipidemia
Hypertension
Interstitial cystitis
Obesity
Social History:
___
Family History:
Father with MI/stroke in his ___. No known family history of
autoimmune diseases including hyperthyroidism and lupus.
Physical Exam:
VS: Tc 97.4, BP 145/78, HR 88, RR 18, SaO2 100/RA
General: Uncomfortable-appearing female in some distess ___
vomiting, AO x 3
HEENT: NC/AT, PERRL, EOMI. Anicteric sclerae, MM slightly dry,
OP clear
Neck: supple no LAD
Chest: CTA-B, no w/r/r
CV: RRR s1 s2 normal, no m/g/r
Abd: soft, slightly distended, NABS, NT
Ext: no c/c/e, wwp
Skin: warm, dry
GU: + foley
Pertinent Results:
___ 02:59PM WBC-9.8 RBC-4.77 HGB-14.6 HCT-43.4 MCV-91
MCH-30.7 MCHC-33.8 RDW-12.7
___ 02:59PM NEUTS-81.3* LYMPHS-13.5* MONOS-5.1 EOS-0.1
BASOS-0.1
___ 02:59PM PLT COUNT-233
___ 02:59PM ___ PTT-28.9 ___
___ 02:59PM LACTATE-2.0
___ 02:59PM ALBUMIN-4.6
___ 02:59PM cTropnT-<0.01
___ 02:59PM LIPASE-27
___ 02:59PM ALT(SGPT)-37 AST(SGOT)-26 ALK PHOS-69 TOT
BILI-0.8
___ 02:59PM GLUCOSE-192* UREA N-19 CREAT-0.9 SODIUM-138
POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-22 ANION GAP-20
___ 04:00PM URINE RBC-3* WBC-2 BACTERIA-FEW YEAST-NONE
EPI-7
___ 04:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-TR KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-NEG
___ 04:00PM URINE COLOR-Straw APPEAR-Clear SP ___
.
___ CXR: no acute process
.
___ CT a/p: no acute process
.
___ EKG: sinus tachy, no acute changes
Brief Hospital Course:
Assessment: ___ y/o female with chronic constipation, GERD,
gastritis, HTN, DM, PMR, a/w nausea, vomiting, and fever.
.
# Nausea/Vomiting - No acute intra-abdominal processes on CT
scan and abd benign on exam. Suspect combo of viral
gastroenteritis with a significant component of GERD given her
chronic prednisone. I initially treated supportively with bowel
rest, IVF, anti-emetics. She improved with a PPI on a daily
basis. I counseled her on diet and not eating spicy foods. If
there are any alternatives to prednisone for arthritis, she may
benefit from alternative therapies. She ruled-out for MI with 2
negative troponins 8 hours apart for low initial suspicion.
.
# Epigastric pain - Infectious w/u thus far unremarkable, no
leukocytosis. Pt reports urinary symptoms, but u/a in ED was
contaminated was unremarkable. She did not have any fevers
during the admission, without the addition of antipyretics.
Blood cultures were negative at the time of discharge but should
be followed-up as an outpatient to ensure negativity after 5
days. She did have constipation which I believe contributed to
her abdominal cramps and gave her Colace, with advice to
follow-up with her PCP.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY Start: In am
2. Lorazepam 1 mg PO HS:PRN insomnia
3. Lovastatin *NF* 20 mg Oral daily
4. PredniSONE 7 mg PO DAILY
5. Pioglitazone 30 mg PO DAILY
6. Calcium Carbonate 500 mg PO BID
7. Vitamin D 400 UNIT PO BID
8. Savella *NF* (milnacipran) 50 mg Oral BID
9. Polyethylene Glycol 17 g PO DAILY constipation
hold for loose stools
Discharge Medications:
1. Calcium Carbonate 500 mg PO BID
2. Lisinopril 10 mg PO DAILY
3. Lorazepam 1 mg PO HS:PRN insomnia
4. Lovastatin *NF* 20 mg Oral daily
5. Polyethylene Glycol 17 g PO DAILY constipation
hold for loose stools
6. PredniSONE 7 mg PO DAILY
7. Savella *NF* (milnacipran) 50 mg Oral BID
8. Vitamin D 400 UNIT PO BID
9. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*60
Tablet Refills:*5
10. Pioglitazone 30 mg PO DAILY
11. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*120 Capsule Refills:*5
Discharge Disposition:
Home
Discharge Diagnosis:
Constipation, GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with worsening heartburn (GERD) which can
happen to people on prednisone for a long time. You also had
abdominal pain caused by constipation. You had no further
fevers, and the temperature was likely caused by a viral
syndrome and not a bacterial infection.
Followup Instructions:
___
|
10646008-DS-17
| 10,646,008 | 22,423,127 |
DS
| 17 |
2154-05-23 00:00:00
|
2154-05-28 17:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with hx of pancreatitis presenting with acute
onset of abdominal pain and N/V. Pt reports that he was in his
usual state of health until this morning when he awoke with
mid-epigastric and right sided chest pain similar to previous
episodes of pancreatitis. States that he had nausea and ___mesis, nonbloody. He had BM this morning that
didn't feel "satisfying." Denies black or bloody BMs. Denies
diarrhea/constipation. Reports no unusual dietary intake prior
to today. Has not eaten anything today.
.
He states that he has had pancreatitis for the last ___ years. No
etiology was ever identified; he has no history of alcohol use,
has not been told he had gallstones and has not been told he has
elevated cholesterol. He had his gallbladder removed over one
year ago as possible source of pancreatitis but this did not
relieve symptoms. He states that he has a bout of pancreatitis a
couple of times every year, last episode in ___ that was
treated at ___. He is usually
hospitalized for ___ days. He came to the ___ ED today instead
of other hospitals where he usually receives care because he was
told by his PCP that there was a gastroenterologist who
specializes in pancreatitis here. He came to ___ in hopes of
being treated by Dr. ___.
.
In the emergency room, initial vitals were 97.8 132/81 78 20
98%RA. He received 1L normal saline prior to being transferred
to floor. Labs were significant for lipase 1103, WBC 16.
Electrolytes wnl. No imaging studies were pursued.
.
On the floor pt reports pain decreased from ___ on admission to
___ currently. Continued nausea.
.
Review of systems:/i>
.
(+) Per HPI: also reports weight gain of ___ from lack of
activity
(-) Denies fever, chills, night sweats, recent weight loss.
Denies headache, rhinorrhea or congestion. Denies palpitations.
Denies cough, shortness of breath, or wheezes. Denies nausea,
vomiting, diarrhea, constipation. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Denies rashes or skin breakdown. All other review of systems
negative.
Past Medical History:
Pancreatitis
Social History:
___
Family History:
Mother: breast cancer
No family history of gastrointestinal cancer, cardiovascular
disease, or pancreatic disorders
Physical Exam:
On admission:
Vitals: 98 124/80 79 18 97%RA
GEN: WDWN male, appears fatigued, no acute distress.
HEENT: Dry mucous membranes, no lesions noted. Sclerae
anicteric. No conjunctival pallor noted.
NECK: JVP not elevated. No lympadenopathy.
CV: Regular rate and rhythm, no murmurs, rubs or ___. Tender
on palpation of right nipple
PULM: Clear to auscultation bilaterally, no wheezes, rales or
rhonchi.
ABD: Soft, tender to palpation diffusely, worse at epigastrium
and right nipple, non distended, hypoactive bowel sounds. No
hepatosplenomegaly. No rebound/guarding
EXTR: No edema, 2+ Dorsalis pedis and radial pulses bilaterally.
NEURO: Alert and oriented x3. CN II-XII intact. ___ strength in
UE and ___ b/l.
SKIN: No ulcerations or rashes noted.
On discharge:
Vitals: 98.3 124/84 86 16 93%RA
GEN: WDWN male, appears fatigued, no acute distress.
HEENT: Moist mucous membranes, no lesions noted. Sclerae
anicteric. No conjunctival pallor noted.
NECK: JVP not elevated. No lympadenopathy.
CV: Regular rate and rhythm, no murmurs, rubs or ___.
PULM: Clear to auscultation bilaterally, no wheezes, rales or
rhonchi.
ABD: Soft, nontender, non distended, NABS. No
hepatosplenomegaly. No rebound/guarding
EXTR: No edema, 2+ Dorsalis pedis and radial pulses bilaterally.
NEURO: Alert and oriented x3. CN II-XII intact. ___ strength in
UE and ___ b/l.
SKIN: No ulcerations or rashes noted.
Pertinent Results:
On admission:
___ 12:15PM BLOOD WBC-16.3* RBC-5.65 Hgb-16.4 Hct-45.8
MCV-81* MCH-29.0 MCHC-35.8* RDW-12.9 Plt ___
___ 12:15PM BLOOD Neuts-93.4* Lymphs-4.9* Monos-1.4*
Eos-0.2 Baso-0.1
___ 02:00PM BLOOD ___ PTT-31.0 ___
___ 12:15PM BLOOD Glucose-120* UreaN-13 Creat-0.8 Na-138
K-4.0 Cl-100 HCO3-27 AnGap-15
___ 12:15PM BLOOD ALT-43* AST-24 CK(CPK)-48 AlkPhos-156*
TotBili-0.6
___ 12:15PM BLOOD Lipase-1103*
___ 12:15PM BLOOD CK-MB-1 cTropnT-<0.01
___ 08:15PM BLOOD Albumin-3.6 Calcium-8.8 Phos-3.7 Mg-1.7
___ 12:15PM BLOOD Triglyc-113
___ 06:45AM BLOOD Triglyc-137 HDL-34 CHOL/HD-4.5 LDLcalc-93
On discharge:
___ 06:50AM BLOOD WBC-7.3 RBC-5.02 Hgb-14.4 Hct-43.6 MCV-87
MCH-28.8# MCHC-33.1# RDW-12.9 Plt ___
___ 06:50AM BLOOD Glucose-96 UreaN-8 Creat-0.8 Na-140 K-4.1
Cl-105 HCO3-29 AnGap-10
___ 06:45AM BLOOD Lipase-752*
___ 06:50AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.0
ECG ___:
Sinus rhythm. Non-specific ST-T wave changes with inferolateral
ST-T wave
flattening. No previous tracing available for comparison.
RUQ ultrasound ___:
FINDINGS: Echogenic liver. No lesions are identified within the
liver. The
portal vein is patent showing hepatopetal flow. The patient is
status post
cholecystectomy. There is no intrahepatic biliary duct
dilatation. The CBD
measures 3 mm.
The right kidney measures 10.7 cm and the left kidney measures
12.2 cm. Both kidneys are normal without hydronephrosis or
stones. The pancreas is
unremarkable, of note, the pancreatic tail is not well
visualized due to
overlying bowel gas. The spleen measures 10.9 cm. The aorta is
of normal
caliber throughout. The distal part of the common bile duct is
not well
visualized.
IMPRESSION:
1. Echogenic liver consistent with fatty liver. Other forms of
liver disease and more advanced liver disease including
significant hepatic fibrosis/cirrhosis cannot be excluded on
this study.
2. The common bile duct is of normal caliber. The distal portion
of the
common bile duct was not seen.
CXR (PA & LAT) ___:
IMPRESSION: PA and lateral chest reviewed in the absence of
prior chest
radiographs:
Lung volumes are low. Bulging mediastinum projecting over the
left main
bronchus and aortopulmonic window could be due to fat deposition
exaggerated by low lung volumes. I would recommend a repeat
frontal chest radiograph at full inspiration to see if this is a
real finding. Lower lungs are grossly clear, though there is
vascular crowding. In the upper lobes, there is the suggestion
of emphysema. Lateral view shows tiny right pleural effusion.
Heart size is normal.
CXR (PA & LAT) ___:
FINDINGS: On today's radiograph, the appearance of the
mediastinum is normal. There is a suggestion of pulmonary
emphysema in both upper lobes. In addition, better visible than
on the previous examination, a linear opacity at the bases of
the right upper lobe that is better visible on the frontal than
on the lateral film. This structure could represent a small
pulmonary nodule with adjacent parenchymal reaction or a
localized atelectasis. Given that the lesion was not visible on
the previous examination two days ago, atelectasis is the most
likely possibility. To confirm, a repeat chest radiograph should
be performed within four weeks from now.
Minimal blunting of the costophrenic sinuses on the lateral
image, probably caused by lesser inspiration than on the
previous examination and a small degree of pleural fat.
No evidence of pneumonia or pulmonary edema. Unchanged normal
size of the
cardiac silhouette.
Brief Hospital Course:
___ male with hx of pancreatitis presenting with acute
onset of abdominal pain and N/V.
.
# Abdominal Pain: Pt presented with abdominal pain similar to
prior episodes of pancreatitis and has elevated lipase. Most
likely etiology of pain was pancreatitis. He was treated
conservatively with aggressive IV fluids, pain control, and
bowel rest. Etiology of pt's recurrent episodes of pancreatitis
was unclear. He did not endorse any alcohol intake, his
triglycerides were not elevated, and RUQ ultrasound did not show
evience of stones. He was s/p CCY. OSH records were obtained
with pt's consent. He had undergone previous ERCP that had
shown choledochoduodenal fistula. He was set up with an
outpatient gastroenterology appointment for further management.
.
# Chest pain: Pt reported pain at right nipple and stated that
this was usual site of pain when he has pancreatitis flares. EKG
shows NSR with no ischemic ST changes. ACS unlikely given normal
EKG and pt was tender on palpation of right nipple. Cardiac
enzymes were negative x 2. Chest pain resolved as pancreatitis
flare improved with pain meds and bowel rest. An initial chest
x-ray suggested a bulging mediastinum projecting over the left
main bronchus and aortopulmonic window could be due to fat
deposition exaggerated by low lung volumes. A repeat chest
x-ray prior to discharge showed normal mediastinum but a linear
opacity at bases of right upper lobe that could be small
pulmonary nodule vs atelectasis. Atlectasis was more likely
given that the finding was not visible on the first chest x-ray.
He should have a repeat chest x-ray in 4 weeks to confirm
resolution of findings.
.
# Leukocytosis: Pt with elevated WBC of 16 on admission. Likely
hemoconcentrated on admission as he had not eaten anything and
other counts were also high end of normal. Pt was afebrile
throughout hospital stay. Leukocytosis was likely secondary to
pancreatitis and hemo-concentration. WBC now downtrended to
normal by time of discharge.
.
# Transaminitis: Pt presented with mild transaminitis ALT 43,
AST 24. RUQ ultrasound showed fatty infiltration of liver. He
should follow up with GI for continued monitoring.
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatitis
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 in the hospital. You were
admitted with abdominal pain similar to previous episodes of
pancreatitis. You also had blood tests that were consistent
with pancreatitis. The cause of your pancreatitis was not
discovered. An ultrasound of your abdomen did not show stones
and your cholesterol was not elevated. The ultrasound did show
that you may have a fatty liver. It is important that you
follow-up with a gastroenterologist who will continue to
investigate the cause of your pancreatitis and monitor your
liver. Please stay on a low-fat diet for a few days while you
recover from your pancreatitis.
You also had right sided chest pain. Your EKG and blood tests
did not indicate that you were having a heart attack. Your
first chest x-ray was a limited study but showed a possible
large mediastinum (which is the middle portion of your chest).
The chest x-ray was repeated and the preliminary read was
normal. Your primary care doctor should follow up on the final
interpretation.
There were no changes made to your medications.
Followup Instructions:
___
|
10646009-DS-9
| 10,646,009 | 28,643,584 |
DS
| 9 |
2183-08-19 00:00:00
|
2183-08-19 19:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ofloxacin / amlodipine
Attending: ___
Chief Complaint:
Abdominal pain, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ speaking only patient with PMH of DM2 not on
insulin, HTN, HLD, OA, spinal stenosis, osteoporosis, lymphoma
in ___ s/p chemo, now in remission, CHF w/ LVEF 35%,
Hypothyroidism, Chronic cough and other issues who presents with
3weeks of abdominal pain and diarrhea. The patient is
accompanied by her daughter, who speaks limited ___, and
Grandson, who speaks fair ___. Via interpreter in the ED,
the pt endorsed poor appetite and diarrhea x3 weeks. She went
to see her PCP for diarrhea and abdominal pain, and was thought
to have colitis vs. diverticulitis. She was given a medicine
for diarrhea that she did not know the name of ___ to be
loperamide); however, her symptoms did not improve, and her
diarrhea worsened. Additionally, she has become more weak. She
is normally ambulatory and able to cook and feed herself (lives
with daughter, receives assistance with iADLs but not ADLs).
She does endorse decreased PO intake. Regarding her diarrhea,
she has had ___ watery BMs / day. No blood or black stools, no
fevers, no chills. no chest pains, shortness of breath. Has
only been eating home-cooked meals, no sick contacts.
In the ED, initial vital signs were: 98.6 79 130/63 20 98% RA.
Exam was notable for distant heart sounds, Lungs clear,
diminished breath sounds. Abdomen tender in all lower quadrants,
LLQ > RLQ. No rebound/guarding. No edema. Labs were notable
for: WBC 5.5 w/ normal diff, Hgb 11.2, plts 216, BUN/Cr ___
(baseline Cr 1.5), Ca ___, Mg 1.2, Lactate 1.6. UA was normal.
CT abdomen/pelvis showed stranding in the SMA/SMV, concerning
for thrombus vs. vasculitis (limited by lack of contrast), and
atrophic kidneys. Surgery was consulted and felt ischemic
colitis was unlikely and recommended workup for other causes of
diarrhea. Patient received 2L NS, Magnesium 4g IV, and was
admitted. VS prior to transfer were 98.3 73 157/71 18 97% RA.
Upon arrival to the floor, the patient was not in distress and
had no complaints. Above history was corroborated with
grandson.
Past Medical History:
DM2
HTN
HLD
OA
spinal stenosis
lymphoma in ___ s/p chemo in remission
CHF EF 35-45%
Hypothyroidism
Chronic cough
CKD
Social History:
___
Family History:
Unable to obtain
Physical Exam:
============================
PHYSICAL EXAM ON ADMISSION
============================
VITALS: 98.3 139/76 78 20 95% RA
GENERAL: NAD
HEENT normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, MM dry.
NECK: Supple, no LAD
CARDIAC: RRR, normal S1/S2, III/VI systolic murmur heard best at
apex
PULMONARY: Clear to auscultation bilaterally, without wheezes or
crackles
ABDOMEN: Normal bowel sounds, soft, mild TTP in LLQ and RLQ.
non-distended
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, grossly normal
============================
PHYSICAL EXAM ON DISCHARGE
============================
VITALS: T 97.9 HR 84 BP 150/98 RR 18 99 RA
GENERAL: NAD
HEENT normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, MMM
CARDIAC: RRR, normal S1/S2, III/VI systolic murmur
PULMONARY: Clear to auscultation bilaterally, without wheezes or
crackles
ABDOMEN: Normal bowel sounds, soft, TTP in LLQ and RLQ.
Non-distended
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash appreciated
NEUROLOGIC: Moving all extremities spontaneously
Pertinent Results:
====================
LABS ON ADMISSION
====================
___ 02:45PM BLOOD WBC-5.5 RBC-4.38 Hgb-11.2 Hct-35.4
MCV-81* MCH-25.6* MCHC-31.6* RDW-13.3 RDWSD-39.0 Plt ___
___ 02:45PM BLOOD Neuts-44.9 ___ Monos-9.3 Eos-8.2*
Baso-1.1* Im ___ AbsNeut-2.46 AbsLymp-1.99 AbsMono-0.51
AbsEos-0.45 AbsBaso-0.06
___ 02:45PM BLOOD Glucose-155* UreaN-23* Creat-1.9* Na-139
K-3.4 Cl-101 HCO3-27 AnGap-14
___ 02:45PM BLOOD ALT-10 AST-20 AlkPhos-40 TotBili-0.4
___ 02:45PM BLOOD Lipase-72*
___ 02:45PM BLOOD Albumin-3.9 Calcium-11.7* Phos-4.3
Mg-1.2*
___ 02:59PM BLOOD Lactate-1.6
___ 07:41PM URINE Color-Straw Appear-Clear Sp ___
___ 07:41PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR
___ 07:41PM URINE RBC-<1 WBC-2 Bacteri-NONE Yeast-NONE
Epi-<1
====================
PERTINENT INTERVAL LABS
====================
___ SED RATE
Test Result Reference
Range/Units
SED RATE BY MODIFIED 28 < OR = 30 mm/h
WESTERGREN
___ 07:35AM BLOOD ANCA-NEGATIVE B
___ 07:35AM BLOOD CRP-2.6
___ 11:49PM URINE Color-Straw Appear-Clear Sp ___
___ 11:49PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD
___ 11:49PM URINE RBC-0 WBC-3 Bacteri-NONE Yeast-NONE
Epi-<1
___ 05:30PM URINE Hours-RANDOM Creat-39 TotProt-16
Prot/Cr-0.4*
====================
LABS ON DISCHARGE
====================
___ 05:35AM BLOOD WBC-5.5 RBC-3.45* Hgb-8.8* Hct-28.2*
MCV-82 MCH-25.5* MCHC-31.2* RDW-14.0 RDWSD-41.0 Plt ___
___ 05:35AM BLOOD Ret Aut-1.4 Abs Ret-0.05
___ 05:35AM BLOOD Albumin-3.2* Calcium-7.1* Phos-2.8 Mg-1.6
Iron-49
___ 05:35AM BLOOD calTIBC-213* ___ Ferritn-336*
TRF-164*
___ 05:35AM BLOOD PTH-326*
___ 05:35AM BLOOD 25VitD-PND
___ 05:35AM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Positive*
___ 05:35AM BLOOD HCV Ab-Positive*
====================
MICROBIOLOGY
====================
___ 11:49 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 7:30 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
__________________________________________________________
___ 11:34 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
.
___ 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.
__________________________________________________________
___ 7:41 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 3:30 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 2:45 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
====================
IMAGING/STUDIES
====================
CT ABD & PELVIS W/O CONTRAST ___ 5:28 ___
1. Fat stranding within the mid right abdomen, surrounding
branches of the SMA and SMV. Given the lack of IV contrast,
differential considerations could include vasculitis vs
intraluminal arterial or venous thrombus cannot be excluded.
2. Compression deformity of L5 with grade 1 anterolisthesis of
L5 on S1 and bilateral L5 pars fractures. In the absence of
prior exams, this is of indeterminate chronicity. An MRI may be
helpful for further evaluation.
3. Atrophic kidneys bilaterally.
4. Ectasia of the infrarenal aortal, measuring up to 3.2-cm.
CTA ABD & PELVIS Study Date of ___ 7:19 ___
1. Persistent stranding surrounding mesenteric vessels, though
the SMV and SMA are patent and the vessel wall is unremarkable.
This could represent a site of prior lymphoma post treatment.
Comparison with remote CT images would be helpful.
2. Background moderate to severe atherosclerosis with an ectatic
infrarenal abdominal aorta measuring up to 3.2 cm, as well as
ectatic bilateral common iliac arteries. Focal partially
thrombosed aneurysmal dilatation of a of the left internal iliac
artery measuring up to 1.7 cm. Partially thrombosed splenic
artery aneurysm at the hilum measuring up to 0.9 cm.
3. Moderate to severe stenosis of the SMA and its origin.
4. Bilateral atrophic kidneys, with evidence of urothelial
thickening. This may be sequelae of prior ureteric stent
insertion. Please correlate with appropriate clinical context
and urinalysis as needed.
5. Calcified pleural plaques within the left lung base.
6. Spondylolysis of L5 on S1, unchanged.
Brief Hospital Course:
# Abdominal pain / diarrhea:
The patient presented with two weeks of abdominal pain and
diarrhea, initially concerning for mesenteric ischemia. However
normal lactate and guaiac negative stool reported in the ED were
reassuring. The patient was evaluated by surgery who thought the
patient had a benign abdominal exam without need for surgical
intervention. Though the patient had a minimally elevated
lipase, this was thought unlikely to represent acute
pancreatitis. The patient had a non contrast CT scan in the ED
(given ___ on CKD) with evidence of stranding in the mid right
abdomen surrounding the branches of the SMA and SMV, and given
lack of IV contrast the differential included vasculitis and
thrombus. Given concern for vascular process the patient had pre
and post hydration and underwent a CTA of her abdomen pelvic for
further evaluation. This revealed persistent stranding around
the mesenteric vessels, though there was no thrombus appreciated
in the SMA or SMV and the vessel wall was unremarkable. This
could be seen in a site of prior lymphoma treatment. The patient
was also found to have an ectatic infrarenal abdominal aorta to
3.2 cm and ectatic bilateral iliac arteries, and aneurysmal
dilatation of the left internal artery and splenic artery
aneurysm. The rheumatology team was consulted due to concern
for possible vasculitis, who did not think that the patient's
clinical picture was consistent with a vasculitis, and no
intervention was required. An infectious workup was also
pursued. A C dif was sent and was negative, and stool cultures
and O+P were also negative. The patient's symptoms improved
without intervention during her hospital course. She was
tolerating PO very well by discharge.
___ on CKD:
The patient presented with a Cr of 1.9 on admission from
baseline of 1.5 in ___. This was likely pre renal secondary to
volume depletion from diarrhea. This improved with IV fluids.
The patient received IV fluids pre and post contrast load with
CTA as above. Her creatinine on discharge was 1.3
# Normocytic Anemia:
The patient had a new hgb drop from 9.8-8.8 on the day of
discharge. There was no evidence of acute bleeding, and the
patient remained without any hypotension and with stable vital
signs. Iron studies were consistent with anemia of chronic
disease. There was no evidence of hemolysis. There was possibly
a dilutional component given IV fluids and increased PO intake.
The patient remained hemodynamically stable and will follow up
as an outpatient.
# Hypercalcemia/Hypocalcemia:
Patient presented with hypercalcemia likely secondary to
dehydration given concomitant ___. This normalized with IV
fluids. On the day of discharge the patient was found to have
hypocalcemia to 7.1, with a significant elevation in PTH to
326. The differential included Vitamin D deficiency/resistance,
CKD, PTH resistance, extravascular deposition. The patient
vitamin D levels were pending on discharge, and she will need
endocrinology follow up for further evaluation as an outpatient.
# Hypomagnesemia:
The patient was markedly hypomagnesemic (1.2) in the ED, likely
secondary to GI losses. This responded to magnesium repletion.
CHRONIC MEDICAL ISSUES:
=======================
# DM2:
The patient' s home glipizide was held and the patient was kept
on sliding scale insulin while inpatient. She was discharged on
her home glipizide.
# CHF:
Per report recent LVEF 35-45%; however, TTE not available in our
records. She appeared euvolemic on exam throughout. She received
IV fluid as above for ___ and contrast hydration, and had no
evidence of clinical heart failure throughout the hospital stay.
# HTN:
On admission the patient was normotensive and appeared slightly
volume down. Her home anti hypertensives were subsequently held.
However as the patients symptoms improved and she was tolerating
PO well, her blood pressure increased and the patient was
subsequently started on her home regimen on discharge.
# GERD:
The patient continued home omeprazole.
# Chronic cough:
The patient continued home albuterol, fluticasone-salmeterol.
Home cetirizine was held inpatient and restarted on discharge.
# HLD:
The patient continued home atorvastatin and aspirin.
# Hypothyroidism:
The patient continued home levothyroxine.
# Osteoporosis:
Weekly home alendronate was held inpatient.
TRANSITIONAL ISSUES:
=====================
- Please obtain CBC and Chem 10 at next PCP visit for evaluation
of hemoglobin and creatinine
- Please follow up pending ESR, 25-OH Vitamin D, 1,25-OH Vitamin
D, iron, haptoglobin, ferritin, transferrin.
- Patient found to be HBc-AB and HCV-Ab positive during workup
of possible vasculitis - this should be followed up by PCP for
further workup if not previously aware
- Patient will need endocrinology follow up for further
evaluation of elevated PTH and low calcium
- Patient with compression deformity of L5 with grade 1
anterolisthesis of L5 on S1 and bilateral L5 pars fractures of
unknown chronicity. An MRI may be helpful for further evaluation
- Consider further workup/management of lower extremity
neuropathy
- If patient has iron deficiency by labs consider colonoscopy if
within goals of care
- patient with ectatic infrarenal abdominal aorta of 3.2 cm
# FULL CODE
# CONTACT: Grandson ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. melatonin 3 mg oral QHS
2. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
QID:PRN
3. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
4. Atorvastatin 80 mg PO QPM
5. alendronate 70 mg oral weekly
6. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral BID
7. Aspirin 81 mg PO DAILY
8. Cetirizine 10 mg PO DAILY
9. Cheratussin AC (codeine-guaifenesin) ___ mg/5 mL oral
Q4H:PRN
10. GlipiZIDE 5 mg PO DAILY
11. Losartan Potassium 100 mg PO DAILY
12. Carvedilol 3.125 mg PO BID
13. Amlodipine 5 mg PO DAILY
14. Hydrochlorothiazide 25 mg PO DAILY
15. Levothyroxine Sodium 75 mcg PO DAILY
16. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. alendronate 70 mg oral weekly
7. Amlodipine 5 mg PO DAILY
8. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral BID
9. Carvedilol 3.125 mg PO BID
10. Cetirizine 10 mg PO DAILY
11. Cheratussin AC (codeine-guaifenesin) ___ mg/5 mL oral
Q4H:PRN
12. GlipiZIDE 5 mg PO DAILY
13. Hydrochlorothiazide 25 mg PO DAILY
14. Losartan Potassium 100 mg PO DAILY
15. melatonin 3 mg oral QHS
16. ProAir HFA (albuterol sulfate) 90 mcg/actuation INHALATION
QID:PRN SOB/wheeze
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
==================
gastroenteritis NOS
Acute on Chronic Kidney Injury
Hypocalcemia
secondary hyperparathyroidism
Secondary Diagnoses:
==================
Type 2 Diabetes Mellitus
Hypertension
Hyperlipidemia
Osteoarthritis
spinal stenosis
lymphoma in ___ s/p chemo in remission
systolic Congestive heart failure with an EF 35-45%
Hypothyroidism
Chronic cough
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you during your stay at ___. You
were admitted to the hospital with abdominal pain and diarrhea.
An initial CT scan of your abdomen in the ED showed that you had
some inflammation around the vessels that supply your bowel. You
underwent a specialized scan called a CT angiogram to evaluate
this which did not reveal any blood clots. Your abdominal pain
and diarrhea improved. Your kidney function tests were higher
than your baseline on admission most likely from dehydration but
improved with fluids. You calcium level was low when you left
the hospital and you will need to have close follow up with your
primary care doctor and with endocrinology for evaluation.
Your appointments and medication list are included in your
discharge summary. It is very important to take your
medications as prescribed.
We Wish You the Best!
-Your ___ Care Team
Your medication list and follow up appointments are listed
below.
We Wish You The Best!
-Your ___ Care Team
Followup Instructions:
___
|
10646068-DS-5
| 10,646,068 | 28,091,281 |
DS
| 5 |
2145-11-14 00:00:00
|
2145-11-14 10:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Compazine
Attending: ___
Chief Complaint:
left sided weakness/clumsiness, parasthesias, dysarthria
Major Surgical or Invasive Procedure:
s/p tPA 10:47 on ___
History of Present Illness:
Ms. ___ is a right handed woman with history of ovarian
cancer
in remission on Avastin, HTN, HLD who presents with acute onset
left sided weakness/clumsiness, parasthesias, dysarthria. Code
stroke was called. Patient arrived to work at ~9:20 this
morning
when she noted sudden tingling/numbness in the left upper and
lower extremity as well as face. She also had left sided
weakness and clumsiness, felt that she could not stand up. When
she tried to speak, noted speech was slurred. There was
transient lightheadedness that quickly resolved. Ms. ___
states symptoms were fluctuating. She first called her
cardiolologists office as she thought symptoms may be to
starting
new medication this morning, HCTZ. She was told to call ___.
Denies vision changes, diplopia, dysphagia. On arrival to the
ED, SBP was elevated to the 190s, responded well to labetalol
10mg IV x1. NIHSS was 7. Patient was counseled about
risks/benefits of tPA and tPA was administered at 10:47am.
In regards to oncological history, patient was diagnosed with
ovarian cancer ___. In ___, she had a total hysterectomy
and was treated with chemotherapy. Currently, she is on
remeission. She continues on Avastin every 3 weeks. Does
endorse
some easy brusing. Soemtimes, has headaches on days of avastin
administration. Her oncologist is Dr. ___ at
___. I spoke with him on the phone and he agreed that
there was no contraindication to tPA with Avastin therapy.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysphagia,, vertigo, tinnitus or hearing
difficulty. Denies difficulties comprehending speech. No bowel
or
bladder incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
Ovarian cancer in remission, as per HPI
HTN secondary to avastin
HLD (not yet on treatment)
Social History:
___
Family History:
Father, paternal grandfather-face/neck cancer
Mother-angina
Physical ___:
ADMISSION EXAM
Vitals: afebrile BP 146-192/70-90 HR ___ RR 16 O2 98 RA
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated.
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was mildly dysarthric. Able
to follow both midline and appendicular commands. Pt. was able
to
register 3 objects and recall ___ at 5 minutes. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
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: Mild left nasolabial fold flattening.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5- ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, cold sensation,
proprioception throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2+ 1
R 2 2 2 2+ 1
Plantar response was flexor on right, mute on left.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally. Mild overshoot with
mirroring on left.
-Gait: deferred
DISCHARGE EXAM
On examination, mental status is normal and alert and oriented
to
person, place and time, no anomia, repeats well and follows 3
step and complex commands. No neglect. Mild dysarthria.
CN examination reveals subtle right >left anisocoria (right 3mm
left 2-2.5mm), mild left facial weakness and otherwise normal.
Limb examination reveals decreased tone in the left side and a
left arm>leg hemiparesis worse proximally in the UE and
intrinsic
hand muscles and worse proximally in the ___ and mild distally.
There is decreased sensation to light touch and temperature on
the entire left side.
Reflexes are slightly brisker on the left and left plantar is
extensor.
There is no ataxia but a right action tremor with an associated
postural tremor.
Pertinent Results:
___ 10:10AM WBC-9.0 RBC-5.12 HGB-15.8 HCT-49.9* MCV-97
MCH-30.8 MCHC-31.6 RDW-13.6
___ 10:37AM CREAT-0.7
___ 10:40AM GLUCOSE-91 NA+-144 K+-3.8 CL--106 TCO2-23
___ 10:42AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 04:39PM ALT(SGPT)-15 AST(SGOT)-21 LD(LDH)-227
CK(CPK)-84 ALK PHOS-76 TOT BILI-0.5
___ 04:39PM CK-MB-2 cTropnT-<0.01
___ 10:10AM %HbA1c-5.7 eAG-117
___ 04:19AM BLOOD Triglyc-203* HDL-45 CHOL/HD-6.0
LDLcalc-185*
___ 04:19AM BLOOD Calcium-9.7 Phos-4.8* Mg-2.2 Cholest-271*
INITIAL NCHCT
FINDINGS: There is no hemorrhage, mass effect or midline shift,
edema, or
acute major territorial infarct. The ventricles and sulci are
normal in size
and configuration. The basal cisterns are patent and there is
normal
gray-white matter differentiation.
No bony abnormality is seen. Minimal mucosal thickening and
aerosolized
secretions in the left maxillary sinus, otherwise the paranasal
sinuses,
mastoid air cells, and middle ear cavities are clear.
IMPRESSION: No acute intracranial process.
CTA
1. No high-grade stenosis or occlusion.
2. Prominent left middle cerebral vein with associated
prominent small
adjacent vessels may represent a normal variant. Alternatively,
although
there is no detectable nidus or enlarged caliber of the left
MCA, this may
represent an underlying shunt such as an arteriovenous
malformation or
fistula. Further evaluation could be considered utilizing
dynamic CTA rather than catheter cerebral angiography.
MRI
FINDINGS: Within the lateral aspect of the right thalamus and
extending into the poster limb of the right internal capsule,
there is a focal area of slow diffusion with faint associatd
T2/FLAIR hyperintensity indicative of an evolving acute infarct.
There is no mass effect at this time. There is no evidence for
intracranial blood products. The ventricles, sulci and cisterns
are normal for patient's age. The major intracranial flow voids
are grossly preserved.
There is ethmoid and maxillary sinus mucosal thickening. There
is a mucus
retention cyst within the right maxillary sinus.
IMPRESSION:
Evolving acute infarct involving the lateral aspect of the right
thalamus with extension into the posterior limb of the internal
capsule.
The study and the report were reviewed by the staff radiologist.
ECHO: No ASD or PFO. Normal global and regional biventricular
systolic function.
Brief Hospital Course:
Ms. ___ was admitted to the ICU following tPA administration
for chief complaint of left sided weakness/clumsiness,
parasthesias, and dysarthria, with an initial NIHSS of 7 for
left sided weakness, sensory loss, and dysarthria. Weakness was
predominantly in the left deltoid, triceps, IP, hamstring and
TA. Her initial NCHCT was normal. Her CTA showed a prominant
left middle cerebral vein, which was not thought to be
associated with her symptoms. All major arteries were patent.
She was given tPA at 10:45am and admitted to the neurology ICU
for post-tPA monitoring.
ICU COURSE
She passed her bedside speech and swallow and was started on a
regular diet. A few hours after arriving to the ICU, she
complained of increased weakness, which was evident on exam. She
was laid flat and given IVF for some improvement in symptoms.
She went for a STAT NCHCT which showed no bleed. Subsequent MRI
showed a right thalamocapsular infarct. Her 24-hr post tPA
non-contrast head CT again showed no bleed. Her blood pressures
were stable in the 140s-150s overnight, on only half-dose of her
metoprolol (other home blood pressure medications were held).
Her telemetry showed only occasional PVCs. She was started on
ASA 81mg and sub-Q heparin. She was transferred to the stroke
team, floor with telemetry.
Due to laying flat, she had some positional lower back pain for
which she was given tylenol, and then 5mg oxycodone.
FLOOR COURSE
# Right thalamocapsular stroke:- Ms. ___ arrived to the
neurology team in stable condition and over the course of her
admission demonstrated improving strength in the left arm and
leg as well as decreasing paresthesias. Her stroke was deemed to
be secondary to small vessel disease. She passed her speech and
swallow evaluation and was started on a regular diet. ___
evaluated her and determined she needed rehab for gait, standing
dynamic activities, therapeutic
exercise, functional mobility training. Her fasting LDL was
noted to be 185 and HbA1c=5.7 and therefore, started on
Atorvastatin 80mg qday. She was continued on SQ heparin, aspirin
81 and will be discharged to ___ with these. She will
follow up with Neurology/ Stroke clinic as outpatient.
# ___: Ms. ___ ECG, serial cardiac enzymes, telemetry were
normal. TTE with bubble showed no ASD or PFO as well as normal
global and regional biventricular systolic function. We kept her
off her antihypertensives (HCTZ, losartan) and resumed half her
home dose of her beta-blocker (metoprolol ER 75mg qd --> 37.5mg
qd)in order to allow her blood pressure to autoregulate with
goal SBP < 185 (goal SBP 140-180s). Her SBP remained in the 140s
off her home antihypertensives and therefore we refrained from
resuming home antihypertensives for now. These can be resumed at
rehab if she starts becoming hypertensive or prior to discharge
to home, with goal SBP<150.
# Onc: Given her history of malignancy, we did check D dimer
which was normal.
She is being discharged to ___ rehab for ___ needs. She
will remain on Aspirin, Atorvastatin and continue with her
bevacizumab. She can resume her home hypertensives when
appropriate or prior to discharge. She will follow up with her
primary care doctor as well as stroke neurology as outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 100 mg PO DAILY
2. Metoprolol Tartrate 75 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Bevacizumab (Avastin) 0 mg IV Q3WEEKS
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet,chewable(s) by mouth once a day Disp
#*30 Tablet Refills:*3
3. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*3
4. Bevacizumab (Avastin) 0 mg IV Q3WEEKS
5. Hydrochlorothiazide 25 mg PO DAILY
THIS HAS BEEN HELD WHILE INPATIENT IN THE HOSPITAL BECAUSE BLOOD
PRESSURE HAS NOT BEEN HIGH
6. Losartan Potassium 100 mg PO DAILY
THIS HAS BEEN HELD WHILE INPATIENT IN THE HOSPITAL BECAUSE BLOOD
PRESSURE HAS NOT BEEN HIGH
7. Metoprolol Tartrate 75 mg PO DAILY
THIS HAS BEEN HALVED WHILE INPATIENT IN THE HOSPITAL BECAUSE
BLOOD PRESSURE HAS NOT BEEN HIGH
8. Docusate Sodium 100 mg PO BID
9. Heparin 5000 UNIT SC TID
10. HydrALAzine 10 mg IV Q6H:PRN SBP>180
11. Metoprolol Succinate XL 37.5 mg PO DAILY
12. Senna 8.6 mg PO BID:PRN constipation
13. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
14. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right thalamo-capsular embolic stroke.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance.
PLAN: Progress gait, standing dynamic activities, therapeutic
exercise, functional mobility training
Recommendations for Nursing: OOB to chair with assist for all
meals, ambulate short distances with gait belt and RW TID
ADL retraining, Compensatory strategies, Functional
Mobility Retraining, UE ther-ex, Patient/Caregiver ___,
Joint Protection, D/C planning
Recommendations for Nursing: Elevate L UE on pillows at all
times
to prevent subluxation and edema, encourage use of L UE
Discharge Instructions:
Dear ___ were hospitalized due to symptoms of left sided weakness,
and clumsiness, difficulty with sensation, and difficulty with
speaking resulting from an ACUTE ISCHEMIC STROKE, a condition
where a blood vessel providing oxygen and nutrients to the brain
is blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed ___ for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- History of ovarian cancer
- Hypertension
- Hyperlipidemia
- Past tobacco use
We are changing your medications as follows:
- Adding Atorvastatin 80mg
- Adding Aspirin
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
It was a pleasure providing ___ with care during this
hospitalization.
Followup Instructions:
___
|
10646211-DS-23
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| 23 |
2197-08-24 00:00:00
|
2197-08-27 07:54:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain/ hematemesis
Major Surgical or Invasive Procedure:
Upper endoscopy ___
History of Present Illness:
___ year old female who complains of vomiting. This patient woke
up at about 3am ___ with nausea and abdominal pain. She vomited
on 3 occasions and on the second time, noted some bright red
blood (tea cup full). The third time she vomited, there was
still some blood but less so. She denies any acute shortness of
breath or chest pain except that to some extent, her abdominal
pain radiated upwards towards her chest. She does have some
chronic shortness of breath which is not any different. She says
that this has happened to her before in the setting of another
GI bleed associated with ___ tear in ___. She has
been eating and drinking normally. She is moving her bowels
normally.
In the ED, initial VS were 97.2 62 181/90 18 98%.
Exam significant for a rectal + hemorhoids, brick colored stool,
guaiac +. No abdominal exam documented in OMR. No further
hematemesis since arrival to ED; did report small BRBPR with
last BM, repeat rectal with hemorrhoids, ___ guaiac negative
stool.
Labs significant for H/H 9.9/30.4, chemistries remarkable for a
K of 5.3, CL 112, HCO3 18, BUN 51, Cr 5. Troponin <0.01.
Transaminases unremarkable, lipase 90. In the ED, Hct trended
down from 30.4 to 28.4, to 25.3 and back to 28.2. No blood
transfusions.
Imaging significant for unremarkable EKG and CXR. Abdominal u/s
not suggestive of an acute process.
Received 5L IVF, IV PPI; GI consulted with concern for UGI
bleed, with plan for endoscopy. Renal also consulted, with
recommendation for IVF for volume resuscitation. She was
admitted to medicine for management of GIB and ___ on CKD.
Transfer VS were 98.1 60 167/74 18 100% RA. She was s/p
endoscopy with evidence ___ tear.
On arrival to the floor, patient reports she feels well. Denies
abdominal pain and nausea. States she had one episode of
hematemesis since noon, after lunch when she became nauseous.
Reports one small cup-full of bright red blood.
Past Medical History:
HYPERCHOLESTEROLEMIA
HYPERTENSION
CHRONIC KIDNEY DISEASE
DUODENAL ULCERS/H.PYLORI
HISTORY OF GI BLEED WITH ___ TEAR ___
LOW BACK PAIN
BRBPR, int/ext hemorrhoids noted on exam ___
ASTHMA
Social History:
___
Family History:
brother and sister died of kidney disease (specifics unknown) in
their ___, mother had hx of MI, father died of lung cancer
Physical Exam:
ON ADMISSION:
VS: 98.1 60 167/74 18 100% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclerae, pink conjunctivae,
patent nares, MMM, good dentition, 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: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
AT DISCHARGE:
VS - Tmax 98.7, 167-179/66-86, ___ 100%RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclerae, pink conjunctivae,
patent nares, MMM, good dentition, 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: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
LABS ON ADMISSION:
___ 09:05AM WBC-6.9 RBC-3.42* HGB-9.9* HCT-30.4* MCV-89
MCH-28.9 MCHC-32.4 RDW-14.0
___ 09:05AM NEUTS-53.7 ___ MONOS-4.0 EOS-4.9*
BASOS-0.3
___ 09:05AM GLUCOSE-90 UREA N-51* CREAT-5.0* SODIUM-140
POTASSIUM-5.3* CHLORIDE-112* TOTAL CO2-18* ANION GAP-15
___ 09:05AM ALT(SGPT)-11 AST(SGOT)-13 ALK PHOS-85 TOT
BILI-0.3
___ 09:05AM LIPASE-90*
___ 09:05AM cTropnT-<0.01
___ 09:05AM ALBUMIN-3.9 CALCIUM-8.9 PHOSPHATE-3.7
MAGNESIUM-2.3
___ 12:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 12:00PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-1
LABS ON DISCHARGE:
___ 05:36AM BLOOD WBC-5.8 RBC-3.14* Hgb-9.3* Hct-27.6*
MCV-88 MCH-29.7 MCHC-33.9 RDW-14.1 Plt ___
___ 05:36AM BLOOD Glucose-81 UreaN-24* Creat-3.5* Na-142
K-5.0 Cl-116* HCO3-16* AnGap-15
EGD REPORT ___:
Impression: Erythema, superficial erosion in the distal
esophagus and GE junction compatible with esophagitis
___ tear
Normal mucosa in the stomach
Erythema in the duodenal bulb compatible with mild duodenitis
Otherwise normal EGD to third part of the duodenum
Recommendations: Continue PPI BID for ___ weeks, then daily
Further recommendations per GI team.
Brief Hospital Course:
___ year old female who presents with abdominal pain in the
setting of hematemesis as well as acute kidney injury on chronic
kidney disease.
ACUTE ISSUES:
# Gastrointestinal Bleed: patient hemodynamically stable
throughout, now s/p endoscopy with ___ tear, which was
determined to be the etiology of her bleed. Wretching likely in
setting of viral gastroenteritis vs mild pancreatitis given
elevated lipase. H/H remained stable throughtout admission;
patient started on PPI and should continue PPI BID for ___
weeks, then daily. Absolutely NO NSAIDs given CKD and GI bleed.
Patient started on clears and advanced to regular diet without
problems. ZOfran IV provided good relief for nausea. Patient did
not require blood transfusions for blood loss. Symptoms resolved
with anti-emetics and slow, gentle meals.
CHRONIC ISSUES:
# Hypertension: restarted home lasix once ___ and K back to
baseline (held in setting ___ and ___. Also added
labetalol for tighter BP control. Losartan was discontinued
given borderline potassium, and should be restarted by PCP or
nephrologist in the outpatient setting when deemed appropriate.
RESOLVED ISSUES:
# Hyperkalemia: resolved, likely in setting ___ superimposed
on baseline CKD.
Initially held home losartan and lasix as above; these were
restarted at time of discharge.
# Acute kidney injury on CKD: Resolved. Cr now back to baseline
of 4.2 (from ___. known stage IV-V CKD ___ NSAIDs/HTN);
baseline Cr recently has been variable, mostly 3.6-5.0. K was
mildly elevated to 5.3 on an ___. Acute insult likely due to
poor PO intake since onset of N/V. No current signs of uremia.
No acute indications for RRT at this time. IVF used PRN for
volume resuscitation. Held Losartan and lasix pending
improvement of kidney function, restarted at time of discharge.
Of note, strict vein preservation of is required of the right
arm - NO PIVs or phlebotomy should be performed.
****TRANSITIONAL ISSUES****
- WILL NEED BID PPI FOR ___ WEEKS, THEN DAILY PPI.
- NO FURTHER FOLLOWUP WITH GI NEEDED PER GI TEAM
- PATIENT WILL LIKELY NEED TITRATION OF BLOOD PRESSURE REGIMEN
AFTER DISCHARGE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
2. Calcitriol 0.25 mcg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Furosemide 40 mg PO DAILY
5. Losartan Potassium 50 mg PO DAILY
6. Lovastatin 40 mg ORAL DAILY
7. Senna 8.6 mg PO BID:PRN constipation
8. TraMADOL (Ultram) 50 mg PO DAILY
9. Calcium Carbonate 500 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
2. Calcitriol 0.25 mcg PO DAILY
3. Calcium Carbonate 500 mg PO DAILY
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Lovastatin 40 mg ORAL DAILY
6. Senna 8.6 mg PO BID:PRN constipation
7. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
8. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*2
9. Ondansetron 4 mg PO Q8H:PRN nausea Duration: 1 Week
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every eight hours
as needed Disp #*24 Tablet Refills:*0
10. Labetalol 100 mg PO BID
RX *labetalol 100 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*1
11. Sodium Bicarbonate 650 mg PO BID
RX *sodium bicarbonate 650 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
PARIMARY DIAGNOSIS:
GI Bleed ___ to ___ Tear
Acute on Chronic CKD with Hyperkalemia
SECONDARY DIAGNOSES:
Hypertension
Chronic Kidney Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your hospital stay
at ___. When you came in, you
were vomiting small cup-fulls of blood and had abdominal pain.
Our gastroenterologists saw you, and performed an endoscopy, a
speical procedure to look inside the digestive organs. They
found a tear in your esophagus, known as a ___ tear.
It was not bleeding at the time of evaluation, but was likely
causing your symptoms. Every time you wretch or vomit, you run
the risk of causing the tear to enlarge. You stopped bleeding
and your symptoms improved. Your blood counts are stable. Your
kidney functioned worsened while you were here, but it improved
back to your baseline with supportive therapy. It is now safe
for discharge, please be sure to go easy with your meals and
take all of your medications as prescribed. We wish you the very
best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10646211-DS-27
| 10,646,211 | 22,512,193 |
DS
| 27 |
2201-11-29 00:00:00
|
2201-11-30 06:08:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin
Attending: ___.
Chief Complaint:
dyspnea, chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ with ESRD on dialysis (MWF) and HTN who
presents with chest pain and dyspnea. Last full dialysis session
was on ___, three days prior to presentation). The
evening prior to presentation, she developed shortness of
breath.
The morning of presentation, she developed substernal chest pain
that was worse with minimal exertion (exertion was limited by
shortness of breath). She also endorses diaphoresis.
She denies any neck, arm, back or abdominal pain. She denies
nausea/vomiting, changes in bowel movements or any urinary
symptoms. She reports that she has never experienced this
shortness of breath or chest pain in the past, despite missing
dialysis sessions previously.
In the ED, her initial vitals were: T 97.2F, HR 72, BP 143/59,
RR
22, SpO2 99% initially on RA. Exam was unremarkable. Labs were
notable for K 8.0 and EKG showed peaked T waves (normal PR
interval). She received fluids, calcium gluconate, insulin and
dextrose, and Lasix after which potassium came down to 5.1.
After
receiving insulin, repeat blood glucose level was 25 requiring
multiple administrations of dextrose to normalize. While in ED
she endorsed worsening dyspnea and had desats leading initially
to placement on 2L NC with escalation ultimately to BiPAP.
ED Exam: unremarkable
ED Labs:
- WBC 6.9, Hgb 9.8, Plt 242
- Na 141, K 8.0, Cl 99, HCO3 22, BUN 91, Cr 10.6, Gluc 85, AG 20
- ___ 11.8, INR 1.1, PTT 32.7
- Trop <0.01, CK-MB 1, CK 127
ED Imaging:
- CXR ___, 10a):
Pulmonary vascular congestion with moderate pulmonary edema.
Difficult to exclude a superimposed subtle pneumonia.
- CXR ___, 2:30p):
In comparison with the study of 4 hours previously, there again
is enlargement of the cardiac silhouette with moderate pulmonary
edema.
ED Consults:
- Dialysis consult:
Urgent UF with HD today (___)
Continue HTN meds
Epo 3000 units with HD
Hectoral 7 mcg with HD
Nephrocaps daily, low phos and low K diet
On arrival in the ICU, her vitals were: T 96.7, HR 75, BP
174/84,
SpO2 on BiPAP ___ w/ FiO2 60%. She reports that her chest pain
has resolved and her breathing is more comfortable on BiPAP. She
is hungry and wants to eat. She reports she thinks her dietary
indiscretion of eating ham on ___ may have contributed
to her increased fluid.
Past Medical History:
- CKD on dialysis
- Hypertension
- Hyperlipidemia
- Low back pain
- Duodenal ulcers
- History of GI bleed with ___ tear
- Asthma
Social History:
___
Family History:
Brother and sister both died from kidney disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VSS
GEN: NAD, alert and interactive, appears comfortable on BiPAP
HEENT: normocephalic, atraumatic
NECK: no LAD, JVP not visualized
CV: RRR, no murmurs/rubs/gallops, nl s1/s2
RESP: diffuse crackles bilaterally, breathing comfortably on
BiPAP
GI: non-tender, non-distended, normoactive bowel sounds
EXT: WWP, no ___ edema, fistula present on LUE
NEURO: AOx3, moving all four extremities with purpose
DISCHARGE EXAM
===============
VSS
GEN: NAD, alert and interactive, appears comfortable
HEENT: normocephalic, atraumatic
NECK: no LAD, JVP not visualized
CV: RRR, no murmurs/rubs/gallops, nl s1/s2
RESP: diffuse crackles bilaterally, breathing comfortably on
NC
GI: non-tender, non-distended, normoactive bowel sounds
EXT: WWP, no ___ edema, fistula present on LUE
NEURO: AOx3, moving all four extremities with purpose
Pertinent Results:
ADMISSION LABS
==============
___ 10:04AM BLOOD WBC-6.9 RBC-3.22* Hgb-9.8* Hct-29.8*
MCV-93 MCH-30.4 MCHC-32.9 RDW-13.9 RDWSD-46.7* Plt ___
___ 10:04AM BLOOD Neuts-58.9 ___ Monos-9.3 Eos-4.5
Baso-0.6 Im ___ AbsNeut-4.03 AbsLymp-1.80 AbsMono-0.64
AbsEos-0.31 AbsBaso-0.04
___ 10:04AM BLOOD ___ PTT-32.7 ___
___ 10:04AM BLOOD Glucose-85 UreaN-91* Creat-10.6*# Na-141
K-8.0* Cl-99 HCO3-22 AnGap-20*
___ 10:04AM BLOOD CK(CPK)-127
___ 10:04AM BLOOD Calcium-7.4* Phos-9.3* Mg-2.2
___ 05:12PM BLOOD ___ Temp-35.8 pO2-193* pCO2-37
pH-7.34* calTCO2-21 Base XS--5
___ 10:32AM BLOOD K-7.6*
DISCHARGE LABS
==============
___ 03:34AM BLOOD WBC-7.8 RBC-3.10* Hgb-9.4* Hct-28.5*
MCV-92 MCH-30.3 MCHC-33.0 RDW-13.8 RDWSD-45.9 Plt ___
___ 03:34AM BLOOD Glucose-110* UreaN-46* Creat-6.6*# Na-139
K-5.2 Cl-100 HCO3-24 AnGap-15
___ 11:24AM BLOOD K-4.8
___ 03:34AM BLOOD Calcium-8.1* Phos-7.1* Mg-2.0
TTE ___: LVEF 60%. Moderate to severe degenerative mitral
regurgitation. Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global biventricular systolic
function. Mild pulmonary hypertension. Compared with the prior
TTE (images not available for review) of ___, severity of
mitral regurgitation has increased and mild pulmonary
hypertension is now appreciated.
Brief Hospital Course:
SUMMARY
========
Ms. ___ is a ___ woman with ESRD on HD and hypertension
admitted with acute hypoxic respiratory failure. She initially
presented to the ED for evaluation of substernal chest pressure
and dyspnea. In the ED, she was afebrile, normocardic (70s),
normotensive (140s systolic), tachypneic (22), and normoxic (99%
on ambient air). She was placed on 2L NC, but then elevated to
BiPAP for assistance with work of breathing. Laboratory studies
were notable for a potassium of 8.0mEq/L with peaked T waves on
EKG. Her white count was 6.9, hemoglobin 9.8, and platelets 242.
Chest x-ray demonstrated moderate pulmonary edema and
cardiomegaly. Renal was consulted and recommended urgent
dialysis / ultrafiltration. She received IV fluids, insulin /
dextrose, and furosemide. Her subsequent potassium level was
5.1, and she
was admitted to the MICU for further care. She underwent HD/UF
on ___ and ___, and her acute respiratory failure and
electrolyte issues resolved. She was then discharged to home.
#Acute hypoxemic respiratory failure
Ms. ___ presented with dyspnea and developed worsening
respiratory status requiring BiPAP. CXR showed moderate
pulmonary edema. Respiratory failure likely secondary to volume
overload in the setting of delayed dialysis and receiving IV
fluids in
setting of hyperkalemia. Also dietary indiscretion with ham
consumption over the weekend. Negative trop and no evidence of
ischemia on ECG to suggest ACS. Respiratory status improved
after dialysis, requiring on nasal cannula after.
#Chest pain
Ms. ___ endorsed non-exertional substernal chest pain. EKG
showed peaked T waves but no signs of ischemic changes. Troponin
and CK-MB non-elevated. ACS was deemed less likely given normal
troponin/CK-MB and no ischemic changes on EKG. Pericarditis
possible in setting of uremia, however unlikely given no
pericardial rub on exam and no diffuse ST segment changes on
EKG, and only missed one day's session of dialysis. Chest pain
resolved. Likely related to her edema. TTE showed LVEF 60%.
Moderate to severe degenerative mitral regurgitation. Mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global biventricular systolic function. Mild
pulmonary hypertension. Compared with the prior TTE (images not
available for review) of ___, severity of mitral
regurgitation has increased and mild pulmonary hypertension is
now appreciated.
#Hyperkalemia
Her potassium was ~8mmol/L on presentation, and it decreased in
response to fluids, diuretics, and insulin/dextrose. EKG with
peaked T waves. Hyperkalemia likely developed in setting of
delayed HD. K 8.0->5.2 after HD.
#Hypoglycemia
Her low blood sugars during her hospitalization were due to
insulin administration in ESRD. Glucose levels normalized
overnight ___.
#End-stage renal disease
Ms. ___ has ESRD, and as noted above she presented with
hyperkalemia and volume overload after delayed dialysis.
Received HD ___, removed 3.5L, but received 1L NS back for
severe cramping.
CHRONIC ISSUES
===============
#Anemia
Likely secondary to chronic kidney disease. She should receive
Epo during HD per the Dialysis Team recommendations.
#Hypertension
This is a chronic issue for her, and she is longitudinally on
amlodipine, carvedilol, and lisinopril at home. We continued
these medications during her hospitalization and on discharge,
with the exception of lisinopril which was held on ___ for
hyperkalemia, and was restarted on ___.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. amLODIPine 10 mg PO DAILY
2. Carvedilol 25 mg PO BID
3. Lovastatin 40 mg oral DAILY
4. Omeprazole 40 mg PO DAILY
5. Sertraline 50 mg PO DAILY
6. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild/Fever
7. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze
8. Docusate Sodium 100 mg PO BID
9. ___ (B complex-vitamin C-folic acid) 0.8 mg oral DAILY
10. Senna 8.6 mg PO BID:PRN constipation
11. sevelamer CARBONATE 800 mg PO TID W/MEALS
12. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TWICE A DAY 2
WEEKS ON/2 WEEKS OFF
13. Lisinopril 5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild/Fever
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze
3. amLODIPine 10 mg PO DAILY
4. CARVedilol 25 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Lisinopril 5 mg PO DAILY
7. Lovastatin 40 mg oral DAILY
8. Omeprazole 40 mg PO DAILY
9. ___ (B complex-vitamin C-folic acid) 0.8 mg oral DAILY
10. Senna 8.6 mg PO BID:PRN constipation
11. Sertraline 50 mg PO DAILY
12. sevelamer CARBONATE 800 mg PO TID W/MEALS
13. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TWICE A DAY 2
WEEKS ON/2 WEEKS OFF
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
=====
-Hyperkalemia
-Acute hypoxemic respiratory failure
-ESRD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure to care for you at the ___
___.
Why did I come to the hospital?
- You came to the hospital because you were short of breath and
were found to have a high potassium
What happened while I was in the hospital?
- We started hemodialysis to help remove some fluid and
normalize your potassium.
What should I do once I leave the hospital?
- Please continue to be very careful about eating salty foods.
- Stick to a low sodium diet.
- Please continue taking all of your medications
- Please keep all of your appointments.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10646287-DS-22
| 10,646,287 | 20,521,001 |
DS
| 22 |
2167-03-23 00:00:00
|
2167-04-03 09:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
bradycardia
Major Surgical or Invasive Procedure:
___. ___ ___ 2240 pacemaker (___)
History of Present Illness:
___ is a ___ yrs female w/ no cardiac history who
complains of intermittent dizziness and found to have
bradycardia. Her daughter had prepared a strong herbal soup for
her mother last evening which she consumed a large amount x2
days. Per her daughter she is unclear what the ___ names for
the medicines are, but that there are "8 different kinds of
medicine good for the heart" She reportedly then exercised 15
minutes on the treadmill without difficulty.
The patient has no cardiac history or alternative medications
that would account for her presentation.
In the ED, initial vitals: 97.2 HR 38 BP 178/30 RR 16 O2Sat 100%
RA
Labs were significant for: labs within normal limits, Dig level
<0.2 In the ED, she was given: IVF 1000 mL NS. Vitals prior to
transfer: 35 172/39 14 100% RA
The patient denies associated fever, chills, headache,
diaphroesis, blurred vision, chest pain or shortness of breath.
Past Medical History:
-hip arthroplasty (___)
-knee replacements (bilaterally)
-cholecystitis complicated by bowel perforation
Social History:
___
Family History:
Unknown.
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
GEN: Alert, lying in bed, no acute distress
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, no edema
NEURO: CN II-XII grossly intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
==========================
VS: T= 7.8-98.9 BP= 142/43 HR= ___ RR= 16 O2 sat 95-97% RA
I/O: 8 hr: Ins 100, Outs 200 24 hrs: 1400/1575
Wt: not noted
GENERAL: ___ woman, NAD, lying in bed, responsive
with simple words, gestures. Affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL
NECK: Supple with JVP at clavicle
CARDIAC: HRRR, ___ systolic murmur at right upper sternal
border. No thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND.
EXTREMITIES: No c/c/e, no edema
SKIN: No stasis dermatitis.
PULSES:
Right: radial 2+ DP 1+ ___ 1+
Left: radial 2+ DP 1+ ___ 1+
Pertinent Results:
Admission Labs
=============
___ 11:13PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 10:28PM ALT(SGPT)-20 AST(SGOT)-22 ALK PHOS-60 TOT
BILI-0.4
___ 04:49PM ___ PO2-38* PCO2-45 PH-7.37 TOTAL CO2-27
BASE XS-0
___ 04:49PM LACTATE-1.3 K+-4.6
___ 04:45PM WBC-5.3 RBC-3.69* HGB-11.6 HCT-36.6 MCV-99*
MCH-31.4 MCHC-31.7* RDW-12.8 RDWSD-46.4*
Discharge Labs
==============
___ 12:52AM BLOOD WBC-6.4# RBC-3.51* Hgb-11.1* Hct-34.2
MCV-97 MCH-31.6 MCHC-32.5 RDW-12.9 RDWSD-45.3 Plt ___
___ 12:52AM BLOOD Plt ___
___ 12:52AM BLOOD Glucose-96 UreaN-32* Creat-1.0 Na-138
K-4.3 Cl-102 HCO3-25 AnGap-15
___ 12:52AM BLOOD Phos-4.3 Mg-2.4
Imaging
==============
TTE ___
Mild aortic regurgitation with mildly thickened leaflets.Mild
aortic valve stenosis. Mild mitral regurgitation. Normal
biventricular cavity sizes with preserved regional and global
biventricular systolic function. Mild pulmonary artery systolic
hypertension. Increased PCWP
CXR ___: The lungs remain hyperinflated. No focal
consolidation is seen. No pleural effusion or pneumothorax is
seen. The cardiac silhouette is moderately enlarged. The aorta
is calcified and tortuous. There may be very minimal
interstitial edema.
CXR ___: Comparison to ___. Status post
insertion of a left pectoral
pacemaker. 1 lead projects over the right atrium and 1 over the
right
ventricle. There is no evidence for the presence of a
pneumothorax.
Borderline size of the heart. No pleural effusions. No
pulmonary edema.
Brief Hospital Course:
___ w/ no cardiac history who complains of intermittent
dizziness and found to have bradycardia.
#high-grade AV-block: Mobitz ___ heart block. Had faster
sinus rate with the 3:1 and complete block, implying worse
disease and likely worsening block with faster heart rate. UTI,
toxin ingestion, were assessed and ruled out. On ___,
pacemaker implanted (St. ___ ___ 2240, Model Number:
___ ___)
(Mode,base and upper track rate: DDD, Base rate: 50bpm, Upper
Track Rate: 130). The procedure was uncomplicated.
Transitional Issues:
-will need ___ interpreter at all visits
-will need follow-up with Dr. ___ on ___ for device check
-will need to avoid lifting arm above head for the next ___
weeks to keep pacemaker leads in place
-contact: Daughter and son-in-law: ___
-code: full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Centrum Silver Women (multivit-min-iron-FA-lutein) 8 mg
iron-400 mcg-300 mcg oral daily
2. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Fish Oil (Omega 3) 1000 mg PO DAILY
2. Centrum Silver Women (multivit-min-iron-FA-lutein) 8 mg
iron-400 mcg-300 mcg oral daily
3. Cephalexin 500 mg PO Q8H Duration: 1 Day
RX *cephalexin 500 mg 1 capsule(s) by mouth three times a day
Disp #*4 Capsule Refills:*0
4. Outpatient Physical Therapy
Please evaluate and treat for physical therapy.
ICD10: I44.0
5. Outpatient Occupational Therapy
Please evaluate and treat.
ICD10: I44.0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
-high-grade atrio-ventricular block
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you at the ___
___. You came to the hospital with
dizziness. This was caused by your heart beating slowly
(bradycardia) due to a problem in the electrical system of your
heart. You then had a pacemaker placed to help fix the problem.
You will need to avoiding raising your arm above your head for
the next ___ weeks to make sure the pacemaker stays in place.
You will need to continue taking an antibiotic until ___ to
keep your pacemaker site clean.
Please follow-up with the appointments listed below and continue
taking your medications as prescribed below.
Wising you the best,
Your ___ team
Followup Instructions:
___
|
10646287-DS-23
| 10,646,287 | 23,684,941 |
DS
| 23 |
2171-01-27 00:00:00
|
2171-01-27 15:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___
Major Surgical or Invasive Procedure:
PCN placement ___
attach
Pertinent Results:
ADMISSION LABS:
===============
___ 03:04PM BLOOD ___
___ Plt ___
___ 03:04PM BLOOD ___
___ Im ___
___
___ 03:04PM BLOOD ___
___
___ 03:04PM BLOOD ___
___ 03:04PM BLOOD ___
___ 04:13AM BLOOD ___ Folate->20
___
___ 03:04PM BLOOD ___
___ 03:09PM BLOOD ___
___ 06:23PM BLOOD ___
___ 3:04 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI. FINAL SENSITIVITIES.
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Anaerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
MICRO:
======
___ blood cultures x2 - growing E. coli
___ urine culture - growing E. coli
___ 8:50 pm URINE,KIDNEY
SOURCE: RIGHT KIDNEY.
**FINAL REPORT ___
FLUID CULTURE (Final ___:
ESCHERICHIA COLI. >10,000 CFU/ML.
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING:
========
EKG with paced rhythm
___ CXR
No acute cardiopulmonary abnormality.
___ CT AP w contrast
1. Severe right hydroureteronephrosis secondary to an 11 mm
obstructing stone
at the right ureteropelvic junction. ___ perinephric
fluid and
stranding is concerning for infection and should be correlated
clinically with urinalysis.
2. ___, somewhat ___ 12 mm hypodensity within
the upper pole of the left kidney could reflect pyelonephritis.
3. Additional, nonobstructing stone within the lower pole of the
right kidney, measuring 4 mm.
4. Chronic collapse of the L1 vertebral body related to prior
osteomyelitis.
No acute fractures identified.
5. Trace left pleural effusion.
___ Perc nephrostomy tube placement
FINDINGS:
1. Ultrasound scan showed severe right hydronephrosis.
2. Successful placement of right 8 ___ PCN with aspiration
of 170 cc of purulent urine. Urine sample was sent for
analysis.
IMPRESSION:
Successful placement of right 8 ___ nephrostomy tube.
RECOMMENDATION(S): The drain is connected to bag drainage.
DISCHARGE LABS:
===============
___
___
___ Plt ___
___
___
___
___
___
___
___
___
___ 07:40PM URINE ___
___
___ 04:00PM OTHER BODY FLUID ___
Brief Hospital Course:
ASSESSMENT/PLAN
=================
Ms. ___ is an ___ ___ speaking woman with history
including high grade AV block s/p PPM in ___, L1/L2 vertebral
body osteomyelitis/discitis (___) who presented with two days
of weakness, fevers/chills, vomiting, and severe right flank
pain, found to have urosepsis from obstructing R
nephrolithiasis, now s/p ___ tube placement ___, admitted
to the ___ for ___ monitoring.
ACUTE ISSUES:
=============
ACUTE/ACTIVE PROBLEMS:
# Sepsis
# E. coli bacteremia, pyelonephritis
# right proximal ureteral 11 mm stone
Patient presenting with fever, leukocytosis, and tachycardia,
elevated lactate, decreased renal function. Found to have an
11mm ___ obstructing stone with E. coli growing from
urine and original blood cultures. She is s/p perc nephrostomy
placement. Had been on cefepime/flagyl in the ICU. Surveillance
cultures negative.
She was discharged with right PCN with ___ setup.
She will continue cipro to complete a 2 week total from
___.
# Transaminitis
AST/ALT mildly elevated to ___ on admission. Hepatocellular
pattern of transaminitis is most likely due to urosepsis. Was
also received cephalosporins which may have worsened LFTs.
# Normocytic anemia
At her baseline, no signs of bleeding. B12 and folate were
normal. Transferrin saturation was 5.56% consistent with iron
deficiency anemia. Held off on iron supplementation in the
setting of acute infection.
#) Left arm swelling
Noted to have left hand swelling on day of discharge. Patient
and family say it was there for several days after an IV
infiltrated. They say swelling is better and that she never had
pain.
Continue to follow up. Can obtain duplex as outpatient if
persists.
#) Dysphagia.
Patient was evaluated by SLP and recommended diet as soft/thin.
She should continue to follow up with SLP as outpatient.
On ___, patient and family adamant about leaving. They did not
want to wait for any more workup or setting up of outpatient
services and requested to be discharged home. ___ initially
recommended rehab but patient and family declined.
Scripts were written for ___ and ___ lift. This
will be delivered in several days and patient and family did not
want to wait in the hospital for this.
They were set up with ___ and discharged.
TRANSITIONAL ISSUES:
====================
[] f/u urology for stone removal - they will call her
[ ] f/u ___ for PCN exchange - they will call her
[ ] left arm swelling - if not improving, obtain duplex
[ ] for PCP - please order for home SLP
[] Consider repeating iron panel as outpatient and Starting iron
supplementation/repletion when no longer acutely infected.
#CODE STATUS: full, confirmed
#CONTACT: ___ (daughter/HCP): ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Fish Oil (Omega 3) 1000 mg PO DAILY
3. Glucosamine Chondroitin (glucos sul ___
___ mg oral DAILY
4. B Complex ___ (vit ___ B ___
acid) 0.4 mg oral DAILY
5. Calcium 500 (calcium carbonate) 500 mg calcium (1,250 mg)
oral DAILY
6. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day
Disp #*180 Tablet Refills:*0
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*18 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
RX *polyethylene glycol 3350 17 gram 1 dose by mouth once a day
Disp #*30 Packet Refills:*0
5. B Complex ___ (vit ___ B
___ acid) 0.4 mg oral DAILY
6. Calcium 500 (calcium carbonate) 500 mg calcium (1,250 mg)
oral DAILY
7. Fish Oil (Omega 3) 1000 mg PO DAILY
8. Glucosamine Chondroitin (glucos sul ___
___ mg oral DAILY
9. Multivitamins 1 TAB PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11.Hospital bed
A41.9 - sepsis. height: 57, weight 139
___: ___
12.Lift
A41.9 - sepsis. Height 57 Weight 139
___: ___
Discharge Disposition:
Home With Service
Facility:
___
___:
Primary diagnoses:
Urosepsis
GNR bacteremia
Right obstructive nephrolithiasis
Severe right hydroureteronephrosis
Complicated UTI
Secondary diagnoses:
Iron deficiency anemia
Transaminitis
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:
Ms. ___,
You were seen at ___ for a kidney stone that developed an
infection behind it. This infected your kidney and then the
bacteria got into your bloodstream. We placed a tube to drain
your kidney and are treating you with antibiotics.
Urology will call you about an appointment to remove the stone.
Interventional radiology will call you about an appointment to
remove the tube once the stone is removed.
Please continue to take antibiotics until ___.
Please call to schedule a follow up with your primary care
doctor ___ weeks from discharge.
Followup Instructions:
___
|
10646419-DS-10
| 10,646,419 | 27,056,050 |
DS
| 10 |
2150-06-22 00:00:00
|
2150-06-22 13:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Dilantin / iodine / fish derived
Attending: ___.
Chief Complaint:
Pt is a ___ w/ Meniere's disease, DM, who sustained a fall
down the stairs on ___ and suffered a L trimalleolar ankle
fracture. At baseline, she is wheelchair bound ___ Meniere's
disease and has been for ___ years. She initially presented to
___, where she was seen there by Ortho, splinted and reduced.
She
reports that she was discharged from the ED with one week follow
up. She presents today as someone from ___ told her that she
would have to go to ___ for further care given her insurance.
Upon further review of the ___ records, she, indeed, was seen on
___ by Ortho and subsequently discharged. She was told to
follow
up in one week for wound evaluation. Today, she has no other
complaints.
Major Surgical or Invasive Procedure:
External fixation of left ankle
History of Present Illness:
Pt is a ___ w/ Meniere's disease, DM, who sustained a fall
down the stairs on ___ and suffered a L trimalleolar ankle
fracture. At baseline, she is wheelchair bound ___ Meniere's
disease and has been for ___ years. She initially presented to
___, where she was seen there by Ortho, splinted and reduced.
She
reports that she was discharged from the ED with one week follow
up. She presents today as someone from ___ told her that she
would have to go to ___ for further care given her insurance.
Upon further review of the ___ records, she, indeed, was seen on
___ by Ortho and subsequently discharged. She was told to
follow
up in one week for wound evaluation. Today, she has no other
complaints.
Past Medical History:
- Meniere's Disease
- DM
- Epilepsy
Social History:
___
Family History:
NC
Physical Exam:
No acute distress
Unlabored breathing
Abdomen soft, non-tender, non-distended
Left lower extremity external fixator in place
_
Left lower extremity fires ___. Difficulty firing ___
Left lower extremity SILT sural, saphenous, superficial
peroneal, deep peroneal and tibial distributions
Left lower extremity dorsalis pedis pulse 2+ with distal digits
warm and well perfused
Pertinent Results:
See OMR for pertinent results.
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 trimalleolar ankle fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for external fixation of the left ankle,
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 was at her baseline physical
function at discharge. 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
non weight-bearing in the left lower extremity, and will be
discharged on Lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
Medications on Admission:
- mirtazapine
- ranitidine
- meclizine
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
5. Loratadine 10 mg PO DAILY
6. Meclizine 25 mg PO TID
7. Mirtazapine 15 mg PO QHS
8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
9. Polyethylene Glycol 17 g PO DAILY
10. Ranitidine 300 mg PO BID
11. Silver Sulfadiazine 1% Cream 1 Appl TP QID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left trimalleolar ankle fracture
Discharge Condition:
Vitals: AVSS
General: Well-appearing, breathing comfortably on RA.
MSK:
LLE:
-Ex-fix in place, Kerlix covering pin sites
-Wiggles toes (cannot extend big toe)
-SILT s/s/sp/dp/t nerve distributions distally
-Foot WWP
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 left lower extremity
- Wheelchair bound at baseline
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Please cover left lower extremity prior to shower
- Place dry krelex at pin sites, change as needed
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
Physical Therapy:
Wheelchair bound at baseline.
Activity: Left lower extremity: Non weight bearing
Treatments Frequency:
Please wrap clean dry gauze around the pin sites for drainage.
Remove and change as needed.
Silver sulfadiazine cream spread over blistered area
Followup Instructions:
___
|
10646419-DS-11
| 10,646,419 | 21,153,234 |
DS
| 11 |
2150-06-27 00:00:00
|
2150-06-27 11:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Dilantin / iodine / fish derived
Attending: ___.
Chief Complaint:
Worsening pain and swelling following external fixation of left
ankle trimalleolar fracture
Major Surgical or Invasive Procedure:
Closed manipulation with external fixator adjustment
History of Present Illness:
___ w/ Meniere's disease, DM, who sustained a fall down the
stairs on ___ and suffered a L trimalleolar ankle fracture.
This was initially evaluated at ___, where she was splinted and
reduced and referred for further follow up at ___ ___ to
insurance reasons and had an external fixator placed ___ with
discharge to home with service on ___.
She presents to the ED for worsening pain and swelling in her
left ankle. Over the past several days she has had blistering
and drainage from her skin and yesterday fell hitting her medial
pin while trying to ambulate on crutches. She has Meniere's
disease and is generally wheelchair bound at baseline. She
complains of increased swelling and "internal" leg pain. She
denies drainage from her pin sites.
Past Medical History:
- Meniere's Disease
- DM
- Epilepsy
Social History:
___
Family History:
NC
Physical Exam:
Exam on discharge:
OBJECTIVE:
Exam:
Vitals: AVSS
General: Well-appearing. Breathing comfortably on room air.
MSK:
Left lower extremity:
- External fixator in place
- Multiple healing blisters, ecchymosis over ant and lat ankle
w/
one roughly quarter sized full blister over med ankle
- Wiggles toes, extends great toe
- SILT s/s/sp/dp/t nerve distributions distally
- Foot warm, well perfused
Pertinent Results:
See OMR for pertinent results.
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to be malreduced in the left lower extremity external fixator
device and was admitted to the orthopedic surgery service. The
patient was taken to the operating room on ___ for closed
manipulation with external fixator adjustment, 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 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
non weight-bearing in the left lower extremity, and will be
discharged on Lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
Medications on Admission:
- mirtazapine
- oxycodone
- PEG
- ranitidine
- silver sulfadiazine
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Enoxaparin Sodium 40 mg SC DAILY
Continue taking Enoxaparin one time daily for 4 weeks (start
date ___.
3. Mirtazapine 15 mg PO QHS
4. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*20 Tablet Refills:*0
5. Ranitidine 300 mg PO BID
6. Silver Sulfadiazine 1% Cream 1 Appl TP QID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Recurrent talar subluxation following external fixation of left
ankle trimalleolar 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:
- non weight-bearing, left lower extremity
- wheelchair bound at baseline
- Please see attached picture for how to properly prop up your
leg. Do not prop your leg up by putting pillows, towels, etc.
under your calf. It is important to keep your leg in the
position shown in the picture to maintain proper alignment.
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Please cover left lower extremity prior to shower
- Place dry Kerlix at pin sites, change as needed
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
Physical Therapy:
- non weight-bearing left lower extremity
Treatments Frequency:
- apply dry Kerlix to external fixator pin sites as needed
Followup Instructions:
___
|
10646419-DS-12
| 10,646,419 | 28,822,416 |
DS
| 12 |
2150-07-11 00:00:00
|
2150-07-11 19:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Dilantin / iodine / fish derived
Attending: ___.
Chief Complaint:
left ankle pain
Major Surgical or Invasive Procedure:
___: open reduction internal fixation left ankle
History of Present Illness:
___ with an unstable L trimalleolar fracture with history
of subluxation despite external fixation. Now s/p removal of ex
fix, ankle ORIF (___).
Past Medical History:
- Meniere's Disease
- DM
- Epilepsy
Social History:
___
Family History:
NC
Physical Exam:
Discharge Condiiton:
AVSS
NAD, A&Ox3
LLE: Splint applied. Compartments soft, nontender. Dressing
clean and dry. Fires FHL, ___, TA, GCS. SILT ___ n
distributions. 1+ DP pulse, wwp distally.
Pertinent Results:
see OMR for pertinent results
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to be malreduced in the left lower extremity external fixator
device and was admitted to the orthopedic surgery service. Due
to extensive soft tissue swelling and fracture blisters, the
patient was observed on service for improvement before taking
her for definitive fixation. The patient was taken to the
operating room on ___ for ORIF left ankle 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 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
non weight-bearing on the left lower extremity, and will be
discharged on Lovenox for DVT prophylaxis. The patient was put
on Keflex for 5 days to prevent wound infection. The patient
will follow up with Dr. ___ on ___ for wound check. 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 instructed that due to persistent
swelling and poor skin overlying the medial malleolus that this
aspect of her fracture may require definitive fixation in the
future. 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:
mirtazapine
oxycodone
PEG
Ranitidine
silver sulfadiazine
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*2
2. Cephalexin 500 mg PO Q12H Duration: 5 Days
RX *cephalexin 500 mg 1 tablet(s) by mouth every 12 hours Disp
#*8 Tablet Refills:*0
3. Enoxaparin Sodium 40 mg SC QPM
RX *enoxaparin 40 mg/0.4 mL ___aily Disp #*30 Syringe
Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hous Disp
#*60 Tablet Refills:*0
5. Mirtazapine 15 mg PO QHS
6. Ranitidine 300 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
left distal tibia fibular fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
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 left lower extremity
- Wear splint at all times, use crutches to keep weight off left
leg
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox daily for 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.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
Followup Instructions:
___
|
10646419-DS-13
| 10,646,419 | 29,142,627 |
DS
| 13 |
2150-08-17 00:00:00
|
2150-08-19 15:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Dilantin / iodine / fish derived
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old M with a PMH of Meniere's disease, DMII,
epilepsy who presents with ___ days of a fever, cough, poor PO
intake.
Patient reports her symptoms started 3 days ago when she was
having difficulty urinating experiencing pain and hesitancy with
dark urine. Starting yesterday she had fevers up to 102, R back
pain, poor PO intake, nausea, and vomiting. No hematuria, no
migrating pain, no passing renal stones, no history of renal
stones. No chest pain or shortness of breath. No abdominal pain,
diarrhea, or constipation. Reports a new cough day before
admission, no sick contacts.
Has been recently at ___ in ___ and ___own
the stairs on ___ during which she suffered a L trimalleolar
ankle fracture s/p placement of metal plates and screws.
In the ED, patient febrile to 102.5, and tachycardic to the
110s.
She was started on IV fluids, ceftriaxone, and oseltamivir.
Influenza negative.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- Meniere's Disease
- DM
- Epilepsy
Social History:
___
Family History:
FAMILY HISTORY: Reviewed and found to be not relevant to this
illness/reason for hospitalization.
Physical Exam:
Discharge Exam
VITALS: T 98.2 BP 108/58 HR 84 RR 18 O2: 96% on RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, ttp in suprapubic area Bowel
sounds present. No HSM
BACK: no spinal tenderness, pain with palpation of the L>R flank
MSK: Neck supple, moves all extremities
EXT: L ankle with steri-strips in place, venous stasis changes -
___ strength but difficulty lifting L leg against gravity
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:
___ 06:10AM BLOOD WBC-16.4* RBC-3.38* Hgb-8.7* Hct-26.2*
MCV-78* MCH-25.7* MCHC-33.2 RDW-16.6* RDWSD-47.1* Plt ___
___ 06:10AM BLOOD WBC-21.9* RBC-3.79* Hgb-9.7* Hct-30.2*
MCV-80* MCH-25.6* MCHC-32.1 RDW-16.6* RDWSD-48.1* Plt ___
___ 08:50PM BLOOD WBC-19.3*# RBC-4.22# Hgb-10.9*# Hct-33.1*
MCV-78* MCH-25.8* MCHC-32.9 RDW-16.5* RDWSD-46.8* Plt ___
___ 06:10AM BLOOD Neuts-83.5* Lymphs-6.1* Monos-9.1
Eos-0.3* Baso-0.4 Im ___ AbsNeut-18.16* AbsLymp-1.33
AbsMono-1.98* AbsEos-0.06 AbsBaso-0.09*
___ 06:10AM BLOOD Glucose-107* UreaN-19 Creat-1.8* Na-142
K-4.0 Cl-106 HCO3-20* AnGap-16
___ 01:15AM BLOOD Glucose-122* UreaN-20 Creat-1.7* Na-138
K-3.6 Cl-105 HCO3-20* AnGap-13
___ 06:10AM BLOOD Glucose-106* UreaN-22* Creat-2.1* Na-141
K-4.3 Cl-104 HCO3-22 AnGap-15
___ 08:50PM BLOOD Glucose-129* UreaN-19 Creat-1.8* Na-137
K-3.8 Cl-99 HCO3-22 AnGap-16
___ 06:10AM BLOOD ALT-17 AST-27 AlkPhos-127* TotBili-0.4
___ 06:10AM BLOOD Phos-2.1* Mg-1.8
renal us:
IMPRESSION:
Normal renal ultrasound.
CXR
IMPRESSION:
CT abd/pelvis:
IMPRESSION:
1. Minimal stranding and fascial thickening seen adjacent to the
left kidney
given the appearance is felt to be most likely chronic, though
pyelonephritis
cannot definitively be excluded on this noncontrast examination
and should be
correlated with clinical factors.
2. Otherwise no acute findings in the abdomen or pelvis. No
alternate source
of infection. No hydroureteronephrosis or
nephroureterolithiasis. No fluid
collection.
No acute cardiopulmonary abnormality.
Blood culture:
___ 8:56 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
___ year old M with a PMH of Meniere's
disease, DMII, epilepsy who presents with ___ days of a fever,
nausea, vomiting, diarrhea, and dysuria, found to have sepsis
due
to bacteremia and UTI.
ACUTE/ACTIVE PROBLEMS:
#Severe sepsis
#E. Coli bacteremia
#urinary tract infection/pyelonephritis- Clinically improved on
Ceftriaxone. CT of abdomen/pelvis did not reveal any abscess.
Continue to have intermittent fevers and poor PO initially,
however, with improvement in the subsequent days. Tolerating PO
on ___ and was transitioned to oral Ciprofloxacin. She was
prescribed an additional 10 days of cipro to complete a 14 day
course on ___.
#acute kidney injury: Likely prerenal etiology due to infection
and fever. FENA 0.2%. Renal u/s without complication. IMproved
with IVF. Discharge Cre was 1.2.
#L ankle surgery - trimalleolar ankle fracture. Ortho consulted
due to concerning area near her suture line. Ortho did not
think that the wound appeared infected or is the cause of pts
presentation. She was continued on ppx lovenox. Wound care
provided and offered oxycodone prn pain.
-continue lovenox 40 mg daily
-F/u in ___ clinic as planned
#Vertigo- home meclizine 25 mg PO q6h PRN dizziness
#Anxiety/Depression- home mirtazapine 15 mg qhs
#DMII- diet controlled. Normal BG in house.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Mirtazapine 15 mg PO QHS
2. Meclizine 25 mg PO Q6H:PRN dizziness
3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
5. Enoxaparin Sodium 40 mg SC Q24H
Start: ___, First Dose: Next Routine Administration Time
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 10 Days
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*20 Tablet Refills:*0
2. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth q8 Disp #*30 Tablet
Refills:*0
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. Enoxaparin Sodium 40 mg SC Q24H
5. Meclizine 25 mg PO Q6H:PRN dizziness
6. Mirtazapine 15 mg PO QHS
7. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
bacteremia
UTI/pyelonephritis
s/p recent ORIF L.ankle
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 found to have
blood stream and urinary tract infections. Your symptoms
improved with antibiotics which you will need to continue to
take for a 2 week total course.
Followup Instructions:
___
|
10647288-DS-21
| 10,647,288 | 21,004,086 |
DS
| 21 |
2151-02-01 00:00:00
|
2151-02-08 15:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
morphine
Attending: ___
Chief Complaint:
headache, vertigo, dysarthria, and unsteady gait.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
He states this morning he was making breakfast, getting coffee
ready, when he heard a loud sound, he thought was just inside
his
head. It was similar to stereo feedback. Immediately following
that, he lost control of his R arm. His speech became slurred.
He
was worried he was having a stroke, so he called his friend.
Then
called an ambulance and was brought to ___. His
friend was called around 918 am. He felt dizzy, had difficulty
walking. When he went to bathroom he felt vertigo (spinning) the
whole time, so he laid down on couch. His body felt like it was
falling. He continued to have this feeling for several hours. He
was at ___ around 1000am or so. He had
headache,
it started mild and got worse. It was bitemporal and vice like
feeling. The headache persisted then became more general, it was
in base of skull later. After he got ativan headache resolved,
here. THe headache reached maximal intensity in hours, 1.5-2
hours. The headache seemed the worst around ___. He confirms it
did not reach maximal intensity in seconds or minutes. The
headache started after the vertigo. was lying on couch for about
3 minutes before starting to talk about headaches per his
friend.
The slurred speech lasted until shortly before this interview.
Per his friend, speech was very slurred, like they could not
understand him when he said the word banana. Later on it sounded
more groggy. It was difficult to tell later since he had
received
some sedating medications. He feels speech is almost back to
normal currently. The right hand issues he feels lasted for a
few
hours perhaps. He states arm felt funny, so he tried to make a
small movement to test it, and he was only able to make a large
movement instead. No headaches normally. no similar symptoms
prior.
States he sometimes gets optical migraines, he had one the other
day, they are q8months. no headaches, just visual symptoms.
started when he was ___, it looks like a blob, amorphous, that is
static looking like, it lasts for ___ minutes. it starts in
the
R or L eye then migrates around.
He presented to OSH, ___. CTA h/n and LP were done there.
It was stated that the LP results were significant for "RBC's
30->1000." He was transferred here for neurosurgical evaluation
of possible SAH. He was evaluated by neurosurgery. Neurosurgery
did not feel that presentation was consistent with aSAH and
recommended neurology consult.
Reviewing the notes from ___, regarding the LP it states
that "there was a traumatic tap, so there was a drop of bleed
inside the LP needle which I allowed to clear after about ___
drops. Tube 1 was collected, and then when I was about to
collect
tube 2, I noticed a small amount of blood on the most dependent
area of the LP needle, so I cleared it out with the stylette. I
also allowed about another 10 drops of CSF to drip out and then
obtained tubes 2, 3, and 4. While tube 4 was being collected,
the
patient began to have violent vomiting. Tube 4 was not obviously
bloody."
Labwork from ___ reviewed
Chem7 unremarkable. CBC with Hgb 14.5 WBC 8.4, Plt 249. lactate
was 4.2
There were 1040 RBCs in tube 4. 63 glucose, 33 protein. There
was
no xanthochromia prsent. There was <5 wbcs. I did not
specifically find tube 1 reported in the records, but per ED
notes it had 30 RBCs.
Past Medical History:
Depression
Social History:
___
Family History:
reviewed, noncontributory
denies history of IPH in family, no aneurysms.
no sudden unexpected death
Physical Exam:
Vitals: T97.8 HR86 BP132/71 RR18 Spo2 96% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation. Visual acuity
___ bilaterally. Fundoscopic exam revealed no papilledema,
exudates, or hemorrhages.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty.
DISCHARGE
Vitals: Afebrile, HR ___, BP 100s-120s/60s-70s, RR 15, 97%
No acute distress, breathing comfortably on room air,
extremities
warm and well-perfused, non-edematous.
Awake, alert. Attentive throughout exam. Language fluent
without
errors. VFF to confrontation. No dysarthria. EOM full range and
conjugate. No Nystagmus. Face symmetric. Saccades are brisk and
accurate. Full strength throughout.
No dysmetria or intention tremor on FNF. Subjective
dyscoordination of the right hand that is not appreciable to the
examiner.
Pertinent Results:
___ 05:30PM BLOOD WBC-10.2* RBC-4.28* Hgb-12.9* Hct-39.1*
MCV-91 MCH-30.1 MCHC-33.0 RDW-13.2 RDWSD-44.0 Plt ___
___ 05:30PM BLOOD Neuts-84.3* Lymphs-11.9* Monos-3.0*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-8.56* AbsLymp-1.21
AbsMono-0.30 AbsEos-0.01* AbsBaso-0.02
___ 08:55AM BLOOD ___ PTT-33.9 ___
___ 05:30PM BLOOD Glucose-117* UreaN-10 Creat-0.9 Na-142
K-4.1 Cl-106 HCO3-18* AnGap-18
___ 08:55AM BLOOD Calcium-10.0 Phos-2.5* Mg-2.0
Cholest-226*
___ 08:55AM BLOOD Triglyc-94 HDL-66 CHOL/HD-3.4
LDLcalc-141*
___ 08:55AM BLOOD %HbA1c-5.4 eAG-108
___ 08:55AM BLOOD TSH-1.8
___ 08:55AM BLOOD CRP-1.3
___ Cardiovascular Transthoracic Echo Report
IMPRESSION: Premature appearance of a large amount of agitated
saline contrast in the left heartat rest c/w a patent foramen
ovale/atrial septal defect. Normal biventricular cavity sizes
andregional/global biventricular systolic function. No valvular
pathology or pathologic valvular flowidentified.CLINICAL
IMPLICATIONS:Based on the echocardiographic findings and ___
ACC/AHA recommendations,antibiotic prophylaxis is NOT
recommended
___ Imaging MRV PELVIS W&W/O CONTRA
Wet Read Audit # 2 by ___ on ___ 11:23 ___
There is focal high-grade narrowing of the left common iliac
vein, at its
origin, related to compression from the right common iliac
artery. This
appearance is seen in the context of ___ syndrome
(series 6, image 39 and series 11, image 62). However, there is
no evidence of acute or chronic thrombus in the left common
iliac vein. Furthermore, no thrombus in the IVC, right common
iliac vein, bilateral internal or external iliac veins, and
bilateral common femoral veins.
A phlebolith is suspected within a deep pelvic vein on the right
(series 5
image 32 and series 7 image 72).
___ Imaging MR HEAD W & W/O CONTRAS
FINDINGS:
There are bilateral cerebellar hemispheric acute infarctions
without evidence
of hemorrhage.. There is a associated T2/FLAIR hyperintensity.
There is no evidence of hemorrhage, masses, mass effect or
midline shift. The
ventricles and sulci are normal in caliber and configuration.
There is no
abnormal enhancement after contrast administration.
Intracranial flow voids
are maintained.
IMPRESSION:
Acute infarcts in the cerebellar hemispheres bilaterally. No
evidence of
hemorrhagic transformation.
Brief Hospital Course:
___ year old previously healthy presented with an episode of
headache, vertigo, dysarthria, and unsteady gait. He was found
to have bilateral SCA distribution infarcts. He was admitted for
observation and workup for the etiology of these infarcts. LDL
141, A1c 5.4%. Initially, the patient was started on aspirin 81
mg daily. TTE was performed and revealed a PFO. Bilateral LENIs
did not show DVTs; however, MRV of the pelvis was consistent
with ___ Syndrome. Subsequently, the patient was
transitioned from ASA to apixaban 5 mg daily. He was started on
atorvastatin 40 mg daily. He was referred to vascular surgery
for evaluation of ___ and interventional cardiology of
consideration of PFO closure.
TRANSITIONAL ISSUES
- Please ensure follow up with vascular surgery for evaluation
of ___ syndrome and consideration of stenting.
- Please ensure follow up with interventional cardiology for
evalation of PFO and consideration of closure.
-Hypercoagulable labs pending at discharge: Beta-2-Glycoprotein
1 Antibodies and Cardiolipin Antibodies
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No. If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
() Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL = 141) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
() Yes - (x) No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - If no, why not (I.e.
bleeding risk, etc.) (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Escitalopram Oxalate 5 mg PO DAILY
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*30 Tablet Refills:*0
2. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Escitalopram Oxalate 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
- Bilateral ischemic cerebellar infarcts
- Patent foramen ovale
- ___ Syndrome
- Hypercholesterolemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of dizziness, headache,
slured speech, and difficulty walking. These symptoms resulted
from an ACUTE ISCHEMIC STROKE, a condition where a blood vessel
providing oxygen and nutrients to the brain is blocked by a
clot. The brain is the part of your body that controls and
directs all the other parts of your body, so damage to the brain
from being deprived of its blood supply can result in a variety
of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- Patent foramen ovale (PFO)
- High cholesterol
- ___ Syndrome
We are changing your medications as follows:
- Start apixaban 5 mg twice per day
- Start atorvastatin 40 mg daily
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
Please follow up with vascular surgery and interventional
cardiology.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10647315-DS-20
| 10,647,315 | 29,185,953 |
DS
| 20 |
2147-05-10 00:00:00
|
2147-05-10 15:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin / phenobarbital / erythromycin base
Attending: ___.
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of breast cancer followed at ___ s/p
lumpectomy and chemotherapy presenting with new seizure, found
to have metastatic CNS disease in ___.
Pt is unable to recall details of the event. She recalls sitting
in her home in the morning of her admission with her ___ year old
son, ___, and her neighbor, ___. The next thing she recalls
is waking up at the hospital. Per EMS records, neighbor
described tonic-clonic movements with LOC. Pt is unsure if she
had head trauma, but denies tongue biting and incontinence. She
has never had seizures before. She cannot recall antecedent
symptoms such as chest pain, shortness of breath,
lightheadedness.
Followed by Dr. ___ oncology at ___ but he
apparently recently moved to ___, ___. She is unsure who now
follows her for her oncologic care. Her last and final cycle of
chemotherapy was ___ - she unsure what she received, but
believes it was 16 cycles. She describes it as "toxic."
In the ___ ED:
VSS
Labs unrevealing
CT head from ___ reviewed, found to have innumerable
metastatic lesions, the largest within the L frontoparietal
region with surrounding vasogenic edema.
Received dexamethasone, keppra, and morphine
Neurology consulted, but decision made to defer to neurooncology
in the am (not yet consulted)
Admitted to medicine
ROS: All else negative
Past Medical History:
Breast cancer as above
Social History:
___
Family History:
Maternal aunt had breast cancer in her ___, now in remission for
___ years. She has 1 brother and 3 sisters, all in good health
to her knowledge.
Physical Exam:
Admission PE
VS: 97.9, 117/70, 76, 16, 96% RA
GEN: Very pleasant, sleeping comfortably, awakens to voice, NAD,
+alopecia
HEENT: PERRL, EOMI, clear oropharynx, anicteric sclera
Neck: Supple, no cervical or supraclavicular adenopathy
CV: RRR, no m/r/g
Lungs: CTAB, no wheeze or rhonchi
Abd: soft, nontender, nondistended, no rebound or guarding, +BS,
no hepatomegaly
GU: No foley
Ext: WWP, no c/c/e
Neuro: CN II-XII intact, strength ___ in UE and ___ bilaterally,
gait deferred
Skin: No rash
Discharge PE:
VS: T: 97.8 HR: 58 BP: 126/51 RR: 17 100% RA
Gen: NAD, resting comfortably in bed
HEENT: EOMI, PERRLA, MMM
CV: RRR nl s1s2 no m/r/g
Resp: CTAB no w/r/r
Abd: Soft, NT, ND +BS
Ext: no c/c/e
Neuro: AAOx3, CN II-XII intact, ___ strength throughout
Psych: normal affect
Skin: warm, dry no rashes
Pertinent Results:
___ 02:00PM URINE HOURS-RANDOM
___ 02:00PM URINE UHOLD-HOLD
___ 02:00PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 02:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 01:38PM GLUCOSE-99 UREA N-10 CREAT-0.7 SODIUM-136
POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-24 ANION GAP-15
___ 01:38PM estGFR-Using this
___ 01:38PM CALCIUM-9.4 PHOSPHATE-3.8 MAGNESIUM-1.7
___ 01:38PM WBC-8.8 RBC-4.49 HGB-14.4 HCT-41.5 MCV-92
MCH-32.1* MCHC-34.7 RDW-12.7 RDWSD-42.8
___ 01:38PM NEUTS-74.8* LYMPHS-18.4* MONOS-4.8* EOS-0.8*
BASOS-1.0 IM ___ AbsNeut-6.60* AbsLymp-1.62 AbsMono-0.42
AbsEos-0.07 AbsBaso-0.09*
___ 01:38PM PLT COUNT-298
___ 01:38PM ___ PTT-26.5 ___
CT head from ___:
Final Report
INDICATION: ___ female with metastatic disease with new
onset
seizure. Outside hospital examination very request for second
read.
TECHNIQUE: Study was performed at an outside facility and a
second opinion
read was requested. Multi detector CT images through the brain
were performed
in soft tissue and bone algorithm windows. Coronal and sagittal
reformations
were generated and reviewed.
DOSE: 714 mGy cm.
COMPARISON: None available.
FINDINGS:
Diffuse metastatic lesions are identified throughout the brain
parenchyma,
some of which are located at the gray-white matter junction and
others of
which are periventricular in location. Lesions are iso to
slightly hyperdense
to gray matter. The largest lesion within the left
frontoparietal region
measures approximately 1.2 x 1.6 cm with surrounding vasogenic
edema. Another
lesion adjacent to the frontal horn of the right lateral
ventricle measures
approximately 1.0 x 1.1 cm. A 1.3 x 0.8 cm lesion abuts the
posterior horn of
the left lateral ventricle (02:14). A lesion within the right
cerebellar
hemisphere measures 0.8 x 0.4 cm (2:7).
There is no shift of normally midline structures. Ventricles
and sulci are
age appropriate. No evidence of hydrocephalus. Basal cisterns
are patent.
There is no acute hemorrhage or extra-axial fluid collection.
Orbits are unremarkable. Mild mucosal thickening involves the
right ethmoidal
air cells. Remaining visualized paranasal sinuses, mastoid air
cells and
middle ear cavities are clear.
IMPRESSION:
Innumerable metastatic lesions which are iso to slightly
hyperdense throughout
the brain parenchyma, the largest within the left frontoparietal
region with
surrounding vasogenic edema. There is no evidence of acute
hemorrhage or
shift of normally midline structures. There is no
hydrocephalus.
RECOMMENDATION(S): MR for further assessment and
characterization can be
performed as clinically indicated.
MRI head with and without contrast ___:
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old female with metastatic breast cancer
presenting with
new seizure and newly found multiple brain metastatic lesions.
Further
evaluation of lesions.
TECHNIQUE: Sagittal and axial T1 weighted imaging were
performed. After
administration of the 8 mL of Gadavist intravenous contrast,
axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1
technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and
coronal
orientations.
COMPARISON: CT head from ___.
FINDINGS:
There are numerous supra and infratentorial FLAIR hyperintense,
contrast
enhancing lesions, including within the deep gray matter, corpus
callosum,
brain stem and cerebellum. A 1.7 cm x 1.6 cm contrast enhancing
lesion is
seen in the right cerebellar vermis with associated mild
surrounding edema but
no significant mass effect or occlusion of the fourth ventricle.
A 1.6 cm x
1.6 cm right occipital lesion is seen with mild to moderate
degree of
surrounding FLAIR hyperintense signal but no significant mass
effect. There
is mild effacement of the right frontal horn secondary to an
enhancing lesion
in the right caudate measuring 1.2 cm x 1.4 cm. Multiple
additional lesions
are seen, none of which are producing mass effect or midline
shift.
There is no evidence of hemorrhage, midline shift or infarction.
There is a 0.8 cm T2/FLAIR hyperintense, noncontrast enhancing
lesion in the
posterior nasopharyngeal soft tissues, series 900, image 117 and
series 7,
image 4, likely representing a retention cyst.
The orbits and mastoid air cells are normal. Minimal
fluid-filled
opacification of the right ethmoid air cells is seen. The major
vascular flow
voids are preserved.
IMPRESSION:
1. Numerous supra and infratentorial enhancing lesions, as
described above,
with surrounding mild edema and no evidence of midline shift,
consistent with
diffuse intracranial metastatic disease.
Brief Hospital Course:
___ with hx of stage II triple negative invasive ductal
carcinoma of right breast s/p wide resection with sentinel node
biopsy on ___, s/p 4 cycles of dose dense Adriamycin and
Cytoxan and 12 weeks of Taxol presenting with new seizure, found
to have metastatic CNS disease in ___.
# New seizure: In setting of newly identified metastatic
disease, presumably ___ known breast ca, with associated
vasogenic edema. No hx of seizures. Received dexamethasone and
keppra in ED. She had no further seizure activity and
neurologic exam was unremarkable. She underwent MRI head which
showed inummerable metastatic lesions without midline shift or
hemorrhage. Neuro-oncology and radiation oncology were
consulted. She was continued on decadron and keppra. She
wished to have her radiation therapy at ___, she was
arranged for very close follow-up with ___ radiation
oncologist at ___, to start whole brain radiation on ___.
- Continue keppra 1000 mg BID and decadron 4 mg BID to be
tapered to 4 mg daily after 4 days.
- F/u with ___ radiation oncology and Dr. ___
medical oncology at ___
-F/u with Dr. ___ after finishing radiation therapy
with plan for repeat MRI head
# Hx of breast cancer: Previously followed by Dr. ___ at
___ now followed by Dr. ___. Had finished her planned
chemotherapy and was going to start local radiation prior to
this episode.
-Follow-up with Dr. ___ ___ likely need restaging scan given new metastatic disease
# Psychosocial: Pt states several times during H+P that "People
don't die from this.... Do they?" She also states that she is
eager to be discharged home to take care of her ___ year old
autistic son. Discussed with her that her cancer is now stage IV
and metastatic and thus not curable but can be treated.
- Follow-up with oncology providers, continued discussion
regarding prognosis and goals of care.
# FEN: Regular diet, replete lytes prn
# PPx: Heparin sc
# Code status: FULL
# Contact: friend, ___. Will need to have formal HCP
designated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Dexamethasone 4 mg PO Q12H
RX *dexamethasone 4 mg 1 tablet(s) by mouth twice a day Disp #*8
Tablet Refills:*0
RX *dexamethasone 4 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
2. LeVETiracetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic breast cancer to brain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were transferred from ___ after having a
seizure. Your MRI showed that your cancer has spread to your
brain (metastatic cancer). You were started on an antiseizure
medication (keppra) and a steroid medications (dexamethasone)
and you had no further seizures. Please follow-up with ___
on ___ at 9 AM to start your radiation therapy and
bring your records and the disc with your MRI to your visit.
Followup Instructions:
___
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2131-01-25 13:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Ms. ___ is a ___ year-old woman with
breast cancer metastatic to bone on methadone and ___
transfered from ___ due to altered mental status followed by
unresponsiveness. Per EMS report the patient had overdosed on
methadone and Percocet. She was seen in the emergency department
at ___ for somnolence and unresponsiveness and was given 0.4mg
Narcan after which she had florid altered mental status and was
combative, requiring sedation with 5mg droperidol and 2mg ativan
and subsequent need for intubation. A head CT was limited by
movement artifact but negative for gross intracranial
abnormality and a tox screen showed methadone but was otherwise
negative. Patient was given ceftriaxone at ___ for UTI given ___
and +Nitrite and no EPIs. She was then transfered to ___ ED.
Initial vitals in the ED were 97.7 60 ___ 98% intubated.
Labs revealed 13.5K WBC 73% PMN, ALT 29, AST 51, AP 123. Serum
Tox +Benzos. UA with 21 RBC, 10 WBC, many bacteria and no
epithelial cells. Vitals on transfer were 97.7 75 ___ 14 100%.
On arrival to the MICU, the patient is ventilated and sedated
and appears comfortable.
Past Medical History:
Breast Cancer with mets to bone (extensive osteoblastic lesions
throughout the skeletal system)
1.6 cm right thyroid nodule
fatty liver on CT
Social History:
___
Family History:
Unknown
Physical Exam:
Admission Physical Exam:
General: intubated and sedated, appears comfortable
HEENT: Fixed dialted 6mm non-responsive puipils bilaterally,
Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge Physical Exam:
General: Extubated, lethargic, unarousable. Makes non-purposeful
movements. No lcalization to pain
HEENT: Anisocoria with r pupil>left pupil. Left eye fixed in
lateral inferior gaze. Pupils non-reactive to light
Pertinent Results:
___ 02:03AM BLOOD WBC-13.5* RBC-4.43 Hgb-14.1 Hct-40.6
MCV-92 MCH-31.8 MCHC-34.7 RDW-16.0* Plt ___
___ 04:12AM BLOOD WBC-14.9* RBC-4.34 Hgb-13.6 Hct-39.9
MCV-92 MCH-31.4 MCHC-34.2 RDW-16.2* Plt ___
___ 04:31AM BLOOD WBC-13.0* RBC-3.56* Hgb-11.1* Hct-32.9*
MCV-92 MCH-31.2 MCHC-33.7 RDW-16.2* Plt ___
___ 05:00PM BLOOD WBC-11.6* RBC-3.40* Hgb-10.6* Hct-31.3*
MCV-92 MCH-31.2 MCHC-33.9 RDW-16.2* Plt ___
___ 04:20AM BLOOD WBC-9.6 RBC-3.24* Hgb-9.9* Hct-30.1*
MCV-93 MCH-30.7 MCHC-33.1 RDW-16.0* Plt ___
___ 02:03AM BLOOD Neuts-73.8* ___ Monos-5.3 Eos-0.6
Baso-0.4
___ 04:12AM BLOOD ___ PTT-26.5 ___
___ 04:31AM BLOOD ___ PTT-31.0 ___
___ 04:20AM BLOOD ___ PTT-31.4 ___
___ 02:03AM BLOOD Glucose-115* UreaN-22* Creat-0.8 Na-136
K-3.4 Cl-96 HCO3-23 AnGap-20
___ 04:12AM BLOOD Glucose-109* UreaN-21* Creat-0.8 Na-136
K-3.2* Cl-97 HCO3-24 AnGap-18
___ 04:31AM BLOOD Glucose-113* UreaN-10 Creat-0.5 Na-140
K-3.9 Cl-101 HCO3-27 AnGap-16
___ 04:20AM BLOOD Glucose-109* UreaN-7 Creat-0.4 Na-143
K-3.3 Cl-104 HCO3-24 AnGap-18
___ 02:03AM BLOOD ALT-29 AST-51* AlkPhos-123* TotBili-0.4
___ 04:12AM BLOOD TSH-14*
Brief Hospital Course:
___ with breast CA metastatic to bone admitted with AMS
intubated without meaningfully responsive and history of likely
methadone and percocet overdose.
# Encephalopathy: Per family she was found unresponsive in bed
with pills scattered around bed and floor including methadone
and percocet. Narcan reversed somnolence and unmasked marked
agitation that required intubation. After short term sedation
for intubation she was weaned off sedation without marked
improvement in mental status to safely extubate. She initially
localized to pain and made spontaneous movements with UE but
eyes continued to be fixed without pupillary reflexes. EEG
non-diagnostic. MRI without contrast showing basal ganglial
effacement concerning for anoxic brain injury versus drug
overdose. Neck film negative for fracture or dislocation and LP
non-diagnostic. Neurology consulted who felt her clinical status
represented most likely anoxic brain injury. After discussion
with family and palliative care decision made to change goals to
CMO as trach and PEG not c/w GoC.
# Metastatic breast cancer: Patient has advanced breast cancer,
recently restarted on Xeloda with some social challenges. MRI
without brain mets. Poor prognosis of anoxic brain injury as
well as terminal breast cancer without hope for cure led to
family decision to move towards comfort care.
Transitional Issues:
- Husband ___ ___
- HCP ___- aunt ___
- Patient is CMO being discharged to ___
Care. Written for Morphine IV and oral solution to maintain
comfort and control respiratory distress
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Methadone 15 mg PO BID
2. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO DAILY:PRN pain
3. Senna 1 TAB PO BID:PRN constipation
4. Milk of Magnesia 30 mL PO Q6H:PRN constipation
5. Capecitabine ___ mg PO DAILY
Every other week
Discharge Medications:
1. Acetaminophen IV 1000 mg IV Q6H:PRN fever
RX *acetaminophen [Ofirmev] 1,000 mg/100 mL (10 mg/mL) 1 gram
Q6hours Disp #*30 Gram Refills:*2
2. Morphine Sulfate (Concentrated Oral Soln) ___ mg PO Q2H:PRN
Pain or RR>20
Please give oral solution if unable to give parenterally
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) ___ mg by mouth
Q2H Disp ___ Milliliter Refills:*2
3. Morphine Sulfate ___ mg IV Q2H:PRN pain or RR>20
Please titrate to comfort and to RR<20
RX *morphine 5 mg/mL ___ IV Q2H Disp ___ Milliliter
Refills:*2
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Anoxic brain injury
Metastatic Breast Cancer
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.
Discharge Instructions:
Ms. ___,
You were admitted to ___ MICU
after being found obtunded at home. You sufferred anoxic brain
injury which is not reversible. After discussion with your
family decision to move towards comfort care. You are being
discharged to ___ Hospice.
Morphine oral solution and intravenous should be used and
titrated to comfort and to maintain RR<20
Followup Instructions:
___
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2138-07-30 00:00:00
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2138-07-30 19:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right arm swelling
Major Surgical or Invasive Procedure:
Clot Lysis ___ by vascular
History of Present Illness:
___ y/o F with no significant PMHx, on OCPs since age ___ who
presents on transfer from ___ with right arm swelling,
found to have right subclavian DVT.
Patient states that she awoke with pain in her right arm and
right back. She states the pain feels like pressure in her arm.
She went ___ and had an ultrasound for a DVT in her
right upper extremity, which was positive for subclavian DVT on
the right. Pain had improved spontaneously in the ___. She was
started on heparin gtt and trasnfered to ___ given possible
need for mechanical thrombolysis. Medications are significant
for OCPs that she has been taking since age ___. She has no
history of central lines. Complete ROS was otherwise negative.
Denies CP. SOB.
In the ___, initial vitals were:
98.7, 57, 111/77, 16, 98% RA
Exam notable for: right arm swelling, otherwise reassuring hand
exam
Labs notable for:
- CBC: 7.7/12.2/38.8/222
- Chem7: ___
- HCG: negative
- PTT 74.9
Imaging notable for:
- CTA: Right lower lobe segmental filling defects concerning
for pulmonary emboli
Patient was given: Continued on IV heparin
On the floor, patient does not endorse pain, just abnormal
sensation in the right arm. Feels well. Denies chest pain or
SOB. Denies any family history of blood clots. Non smoker. Takes
OCP, recently switched from ___ brand to ___ but
cannot remember the brand. No recent flight or prolonged
immobilization. No surgery.
Past Medical History:
None
Social History:
___
Family History:
No family history of blood clots. No bleeding disorders.
Grandmother with leukemia.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vital Signs: 98.1, 118 / 79, 64, 16, 100 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses. Right upper extremity with
edema from shoulder to wrist, 2+ radial pulse and sensation
preserved, grip strength preserved, non tender to palpation,
minimal erythema overlying skin.
Neuro: Grossly in tact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
DISCHARGE PHYSCICAL EXAM:
=========================
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses. Right upper extremity less
edematous, superficial veins less prominent, 2+ radial pulse and
sensation preserved, grip strength preserved, non tender to
palpation, minimal erythema overlying skin.
Neuro: Grossly in tact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
Pertinent Results:
ADMISSION LABS:
================
___ 12:55PM BLOOD WBC-5.6 RBC-3.76* Hgb-11.4 Hct-36.4
MCV-97 MCH-30.3 MCHC-31.3* RDW-13.7 RDWSD-49.1* Plt ___
___ 04:47AM BLOOD WBC-7.1 RBC-3.95 Hgb-11.7 Hct-36.0 MCV-91
MCH-29.6 MCHC-32.5 RDW-13.4 RDWSD-45.1 Plt ___
___ 05:01PM BLOOD WBC-7.7 RBC-4.14 Hgb-12.2 Hct-38.8 MCV-94
MCH-29.5 MCHC-31.4* RDW-13.5 RDWSD-46.6* Plt ___
___ 05:01PM BLOOD Neuts-48.0 ___ Monos-5.5 Eos-2.1
Baso-0.8 Im ___ AbsNeut-3.68 AbsLymp-3.33 AbsMono-0.42
AbsEos-0.16 AbsBaso-0.06
___ 04:47AM BLOOD ___ PTT-78.8* ___
___ 05:01PM BLOOD ___ PTT-74.9* ___
___ 04:47AM BLOOD Glucose-79 UreaN-9 Creat-1.0 Na-136 K-3.7
Cl-102 HCO3-23 AnGap-15
___ 05:01PM BLOOD Glucose-81 UreaN-9 Creat-1.0 Na-138 K-4.5
Cl-104 HCO3-21* AnGap-18
___ 12:55PM BLOOD ___ 04:47AM BLOOD Calcium-8.7 Phos-5.1* Mg-2.1
___ 05:01PM BLOOD Calcium-9.3 Phos-3.7 Mg-2.3
___ 05:01PM BLOOD HCG-<5
CTA ___:
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is moderately
opacified to the segmental level. There is a right lower lobe
segmental filling defect
concerning for acute pulmonary embolus (102:231). An additional
filling
defect in an adjacent segmental branch may also represent acute
pulmonary
embolism versus artifact (___). There is no CT evidence of
right heart strain. 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. Attenuation
of the right axillary and subclavian are compatible with known
thrombosis, without extension into the central veins.
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: Included portion of the upper abdomen is unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no
acute fracture.
IMPRESSION:
Right lower lobe segmental filling defects concerning for
pulmonary emboli. Known thrombus within the right axillary and
peripheral subclavian veins is better evaluated on ultrasound.
Brief Hospital Course:
___ without significant PMHx who presents with unprovoked right
upper extremity subclavian DVT and likely right segmental PE she
was transferred to our service for clot lysis She received tPA
thrombolysis for 24h and she had Right upper extremity venogram
with Selective catheterization of the superior vena cava and
Balloon angioplasty of the right subclavian vein. The procedure
went uneventfully. and the edema is slowly subsiding.
The patient switched from Heparin to Xeraldo and was discharged
home to be scheduled for 1st rib extraction and possibly stent
placement.
Medications on Admission:
None
Discharge Disposition:
Home
Discharge Diagnosis:
DVT of upper extremity
s/p RLL pulmonary embolus
Thoracic outlet synd.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___ was a pleasure taking care of you at ___
___. you ___ transferred from ___
with a diagnosis of Rt upper extremity Deep vein thrombosis (
which is a clot in a vein that drains blood from your rt hand).
the vascular surgery team introduce a catheter to your Rt upper
extremity vein to infuse clot dissolving agent for 24h, after
which a dilatation of the stenosis was done by a balloon. (You
were also found to have pulmonary embolus as a part of the clot
in your arm traveled to the lung vasculature.)
To do this treatment, a small puncture was made in one of your
___. The puncture site heals on its own: there are no
stitches to remove. You tolerated the procedure well and are
now ready to be discharged from the hospital. Please follow
the recommendations below to ensure a speedy and uneventful
recovery.
Puncture Site Care
For one week:
Do not take a tub bath, go swimming or use a Jacuzzi or hot
tub.
Use only mild soap and water to gently clean the area around
the puncture site.
Gently pat the puncture site dry after showering.
Do not use powders, lotions, or ointments in the area of the
puncture site.
You may remove the bandage and shower the day after the
procedure. You may leave the bandage off.
You may have a small bruise around the puncture site. This is
normal and will go away one-two weeks.
Activity
For the first 48 hours:
Do not drive for 48 hours after the procedure
For the first week:
Do not lift, push , pull or carry anything heavier than 10
pounds
Do not do any exercises or activity that causes you to hold
your breath or bear down with abdominal muscles. Take care not
to put strain on your abdominal muscles when coughing, sneezing,
or moving your bowels.
After one week:
You may go back to all your regular activities, including
sexual activity. We suggest you begin your exercise program at
half of your usual routine for the first few days. You may
then gradually work back to your full routine.
Medications:
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!
For Problems or Questions:
Call ___ in an emergency such as:
Sudden, brisk bleeding or swelling at the groin puncture site
that does not stop after applying pressure for ___ minutes
Bleeding that is associated with nausea, weakness, or
fainting.
Call the vascular surgery office (___) right away if
you have any of the following. (Please note that someone is
available 24 hours a day, 7 days a week)
Swelling, bleeding, drainage, or discomfort at the puncture
site that is new or increasing since discharge from the hospital
Any change in sensation or temperature in your legs
Fever of 101 or greater
Any questions or concerns about recovery from your angiogram
a surgery is needed to relive the pressure excreted on the vein
in this surgery the Rt 1st rib is removed and a stent might be
used to keep the vein open.
Followup Instructions:
___
|
10648140-DS-11
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2179-02-01 00:00:00
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2179-02-01 17:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo w/metastatic lung Ca presents from ___ ED
s/p fall. Pt is ___ speaking, history taken with translator
and supplimented with OSH records. Pt lost her balance and fell
about 30min prior to inital presentation. +Head trauma, no LOC.
Pt reported pain in head, neck and back initally. Reported back
pain present for weeks. She had CT without ICH or c-spine fx.
On arrival to ___ ED pt had XR which showed L1 compression fx
of unknown chronicity. She had a normal neuro exam and so MR
spine was deferred.
On arrival to floor pt complains of central low back pain with
questionable radiation. Reports pain started yesterday
afternoon. Denies weakness, HA, abd pain.
ROS: unable to obtain
Past Medical History:
HTN
HLD
Cervical spinal stenosis
Breast cancer s/p R mastectomy, XRT and chemo in ___
PUD
CVA
Palpitations
Thyroid cancer
Post Surgical hypothyroidism
Stage 4 Lung adenocarcinoma
- mets to brain and spine
pAfib
Social History:
___
Family History:
unknown
Physical Exam:
Vitals: T:98 BP:142/94 P:97 R:18 O2:93%ra
PAIN: 0
General: nad
Lungs: clear anteriorly
HEENT: hematoma on posterior scalp
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
Ext: no e/c/c
Skin: no rash
Neuro: alert, difficult to cooperate with exam, unclear if pt
understands commands, pt able to move all extremities, unable to
perform formal strength testing
Pertinent Results:
___ 11:30PM GLUCOSE-117* UREA N-25* CREAT-0.4 SODIUM-141
POTASSIUM-3.3 CHLORIDE-100 TOTAL CO2-25 ANION GAP-19
___:30PM ALT(SGPT)-84* AST(SGOT)-35 ALK PHOS-67 TOT
BILI-0.5
___ 11:30PM LIPASE-17
___ 11:30PM ALBUMIN-3.9
___ 11:30PM WBC-5.6 RBC-2.97* HGB-10.1* HCT-31.0*
MCV-104* MCH-34.1* MCHC-32.7 RDW-17.5*
___ 11:30PM NEUTS-90.7* LYMPHS-5.0* MONOS-3.2 EOS-0.6
BASOS-0.4
___ 11:30PM PLT COUNT-110*
___ 12:15AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 12:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 12:15AM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
XR Lspine IMPRESSION:
1. Compression deformity of L1 of unclear acuity.
2. Multiple sclerotic lesions, which are not well
appreciated may represent bony metastases. CT or MRI
would provide better evaluation.
CXR IMPRESSION:
Moderate left pleural effusion with compressive
atelectasis. Underlying consolidation cannot be excluded.
CT: left parietal soft tissure swelling but no evidence of acute
intracranial pathology. Decrease in the size of right caudate
mass. No evidence of cervical spine fracture. Small sclerotic
and lucent lesions throughout the cervical spine, likely
representing metastases in this patient with lung cancer.
Brief Hospital Course:
___ year old woman with metastatic lung cancer admitted with back
pain after a fall.
Back pain: MRI of the spine revealed numerous bony metastases
and an L1 compression fracture of unknown chronicity. The
patient was treated with oxycodone for pain and physical therapy
evaluation. I did discuss her case with her radiation oncologist
Dr. ___ at ___. He will plan to see her later
this week for palliative radiation.
Of note, it was quite difficult to assess the patient's pain
level while she was hospitalized. With the ___ interpreter
she frequently denied pain, but acknowledged pain when her
daughter was present. I did encourage her daughter to treat her
pain with oxycodone, and I did inform her that she might need a
longer acting medication in the future, but this was not started
in the hospital due to the difficulty with assessing the
patient's pain.
The patient was able to ambulate with a walker on discharge, but
physical therapy did recommend home with 24-hour care. The
patient's family was aware of this recommendation and planned to
stay with her.
Lung cancer: The patient will follow up with Dr. ___ as
planned.
CONTACT: ___ daughter ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Ranitidine 150 mg PO BID
2. Acetaminophen 500 mg PO Q6H:PRN pain/fever
3. Dexamethasone 2 mg PO DAILY
4. Diltiazem Extended-Release 180 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Ondansetron 4 mg PO Q8H:PRN nausea
7. Prochlorperazine 10 mg PO Q6H:PRN nausea
8. Simvastatin 20 mg PO QPM
9. Vitamin D 1000 UNIT PO DAILY
10. Levothyroxine Sodium 125 mcg PO DAILY
11. Benzonatate 100 mg PO BID:PRN cough
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain/fever
2. Dexamethasone 1 mg PO DAILY
3. Diltiazem Extended-Release 180 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Levothyroxine Sodium 125 mcg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Ranitidine 150 mg PO DAILY
8. Simvastatin 20 mg PO QPM
9. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % (700 mg/patch) apply one patch to back every
morning remove after 12 hours Disp #*2 Box Refills:*0
10. Vitamin D 1000 UNIT PO DAILY
11. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Do not administer if patient is sleeping.
RX *oxycodone 5 mg ___ tablet(s) by mouth q4hr Disp #*60 Tablet
Refills:*0
12. Senna 1 TAB PO BID:PRN constipation
If patient does not have a bowel movement for 3 days please
give.
RX *sennosides [senna] 8.6 mg 1 tab by mouth bidprn Disp #*60
Capsule Refills:*0
13. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Metastatic lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with back pain after a fall. You had an MRI of
the spine that showed a compression fracture at L1, and mutiple
metastases to the vertebral bones in the spine. You were
evaluated by physical therapy and they recommended that you have
24 hour supervision.
Followup Instructions:
___
|
10648147-DS-18
| 10,648,147 | 29,998,288 |
DS
| 18 |
2136-01-06 00:00:00
|
2136-01-07 13:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
episodes concerning for seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old right-handed woman with PMH
significant for Sjogren's (she said she is asymptomatic and was
dx after evaluation for HR abnormalities during prior pregnancy)
as well as vasculits (she says this is being monitored by
rheumatology; there is question of lupus but she says she has
not
met criteria for this) who is 5 months pregnant and presents for
evaluation of episodes concerning for seizure. The first of
these
episodes occurred last night; she believes sometime between 3
and
5 AM. She is unsure if she was sleeping at symptom onset or if
was laying awake in bed, but describes onset of "weird thoghts,"
which she describes as visualizing past dreams (no actual visual
hallucinations). This lasted for about 10 seconds and was
followed by a head-to-toe feeling of heat and was accompanied by
diaphoresis, nausea, lightheadedness and generalized weakness,
which lasted for about 20 seconds. She subsequently felt unwell
but fell back asleep. Then, she was getting ready to go to work
and was reaching for her phone over the bed around 6:30 AM, when
she developed the same symptoms of visualizing a prior dream
(she
says this involved the same people and believed to be doing the
same acitivites, though she is unable to recall the dream)
followed by feeling overall flushed, nauseated and fatigued. The
next thing she recalls is waking up with her feet still on the
floor but her upper body bent over the bed (she is unsure how
long she remained like this but believes it ___ have been
between
___ minutes). A similar thing happened later in the morning,
around 7:30 AM, when she was driving her son to daycare. She
said
she had the same dream visualization and then subsequent
symptoms. There also appears to be a period of time that she
lost
while driving; she does not recall driving for about ___ mile on
___, but does recall making the turn on the street of her
son's daycare; no accidents during this time while driving. None
of the episodes were associated with tongue biting or
incontinence of urine or stool. She says she went to work and
called her OBGYN, who recommended she come to the ED for
evaluation. Of note, she has never had any similar symptoms in
the past. She has no history of seizures and no family history
of
seizures.
Neuro ROS: Positive for 3 episodes concerning for seizure as per
HPI. She also notes that she occasionally feels lightheaded
going
from a laying to a standing position. No headache, loss of
vision, blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness, vertigo, tinnitus or hearing difficulty. No
difficulties producing or comprehending speech. No focal
weakness, numbness, parasthesiae. No bowel or bladder
incontinence or retention. No difficulty with gait.
General ROS: Positive for pregnancy; she is currently 5 months
pregnant and notes preganancy has been uncomplicated. No fever
or
chills. No cough, shortness of breath, chest pain or tightness,
palpitations, nausea, vomiting, diarrhea, constipation or
abdominal pain. No dysuria. No rash.
Past Medical History:
-Sjogren's
-vasculitis (uncharacterized, followed by a Rheumato___)
Social History:
___
Family History:
Mother is ___ and Father is ___ years old. No family
history of seizures. No family histroy of any neurologic
conditions.
Physical Exam:
Vitals: T: 98.3 P: 73 R: 16 BP: 122/74 SaO2: 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated.
Pulmonary: lcta b/l
Cardiac: RRR, S1S2, II/VI systolic murmur
Abdomen: nontender, +BS
Extremities: warm, well perfused
Neurologic:
Mental Status: Awake, alert, oriented to person, place and date.
Able to relate history without difficulty. Attentive, able to
name ___ backward without difficulty. Able to follow both
midline
and appendicular commands. No right-left confusion. Able to
register 3 objects and recall ___ at 5 minutes. No evidence of
apraxia or neglect
Language: speech is clear, fluent, nondysarthric with intact
naming, repetition and comprehension.
Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5
Sensory: No deficits to light touch, pinprick, proprioception
throughout. Vibratory sensation 14 seconds at right great toe
and
15 seconds at left great toe. No extinction to DSS.
DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 3 2
R 3 3 3 3 2
Plantar response was flexor bilaterally.
Coordination: No intention tremor or dysmetria on finger-nose,
FNF or HKS bilaterally. RAMs intact b/l.
Gait: Good initiation. Narrow-based, normal stride and arm
swing.
Romberg absent.
Pertinent Results:
___ 11:25AM PLT COUNT-328
___ 11:25AM NEUTS-87.6* LYMPHS-10.1* MONOS-2.0 EOS-0.3
BASOS-0.1
___ 11:25AM WBC-7.0 RBC-3.30* HGB-10.1* HCT-31.6* MCV-96#
MCH-30.5 MCHC-31.8 RDW-13.9
___ 11:25AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 11:25AM CALCIUM-8.0* PHOSPHATE-3.1 MAGNESIUM-2.0
___ 11:25AM estGFR-Using this
___ 11:25AM GLUCOSE-78 UREA N-12 CREAT-0.7 SODIUM-135
POTASSIUM-3.9 CHLORIDE-108 TOTAL CO2-21* ANION GAP-10
___ 01:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 01:15PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 01:15PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 01:15PM URINE UCG-POS
___ 01:15PM URINE HOURS-RANDOM
___
MRI Brain:
FINDINGS: There is no evidence of acute or subacute
intracranial hemorrhage,
mass, mass effect, or shifting of the normally midline
structures. The
ventricles and sulci are normal in size and configuration for
the patient's
age. No diffusion abnormalities are detected. The major
vascular flow voids
are present and demonstrate normal distribution. The orbits are
unremarkable.
The paranasal sinuses are notable for bilateral opacities in the
maxillary
sinuses with heterogeneous signal, possibly representing
inspissated
secretions. The visualized aspect of the craniocervical
junction appears
unremarkable.
IMPRESSION:
1. Essentially normal MRI of the brain with no evidence of
acute or subacute
intracranial pathology.
2. Bilateral opacities at the maxillary sinuses, possibly
representing
inspissated secretions.
EEG:
___:
IMPRESSION: This is a normal awake and sleep EEG. There were a
few left
temporal sharp transients that did not meet the criteria for
epileptic
discharges.
___:
IMPRESSION: This is an abnormal video-EEG monitoring session due
to a
few left posterior temporal epileptiform discharges during sleep
indicative of a potential underlying epileptogenic focus.
Otherwise
background activity was normal. There were no electrographic
seizures.
None of the patients typical events were recorded.
___:
This is a normal 24 hour EEG telemetry.
Brief Hospital Course:
Ms. ___ is a ___ year old right-handed woman with PMH
significant for Sjogren's (she said she is asymptomatic and was
dx after evaluation for HR abnormalities during prior pregnancy)
as well as vasculits (she says this is being monitored by
rheumatology; there is question of lupus but she says she has
not
met criteria for this) who is 5 months pregnant and presents for
evaluation of episodes concerning for seizure. Since the middle
of the night last night, she has had 3 stereotyped episodes
involving visualization of a dream that she has previously had
(though no actual visual hallucinations) followed by a period of
feeling hot, nauseated and weak. With two of these episodes,
there was loss of time. Her neurologic exam is currently intact
and nonfocal. Though she has no history of seizures, the
stereotyped nature of the episodes and the loss of time is
concerning for possible seizure activity. Her history of
Sjogren's and unspecified vasculitis raises possibility of CNS
vasculitis, which can potentially result in seizure activity, so
will ___ evaluate this possibility with MRI head (will also
look for mesial temporal sclerosis). As she had 3 episodes over
a
___ hour period, will admit her for observation and further
evaluation.
__________________________
Neuro:
Ms. ___ was placed on long term monitoring for evaluation of
these possible seizure events. She was maintained on seizure
precautions throughout the hospital stay. She did not experience
any of these events during her hospital stay but her EEG did
show some sharp waves intermittently as noted in her EEG
reports. Based on Ms. ___ history and the risk of seizure
during pregnancy, it was decided to start Ms. ___ on Keppra
500mg BID on the day of discharge. The plan was for rapid
titration up to 750mg BID on ___ and 1000mg BID on ___. She
will continue on 1000mg BID with a level to be drawn on ___ and
the results to be faxed to Dr. ___. Further titration
will be determined by Dr. ___ Dr. ___ in follow
up. We also discussed ambulatory eeg in order to capture events
after discharge as the hospital is at times not the ideal
environment to capture seizure episodes. At this time, Ms. ___
decided to defer the ambulatory eeg but willing to pursue this
in the future. Her exam remained nonfocal throughout her
hospital course.
Cardio/Pulm:
Ms. ___ was maintained on telemetry but there were no
significant cardiac events. She was stable on RA throughout her
course.
FENGI:
She was maintained on a regular diet. Electrolytes were within
normal limits and did not require supplementation
ID:
No signs of acute infection requiring antibiotics.
Dispo:
Ms. ___ will be discharged home to follow up with Dr. ___
Dr. ___ in ___. She will have a keppra level drawn on
___. We also discussed that she will not be able to drive for 6
months from the time of this event based on ___
law as long as she remains seizure free, as her events do impair
her consciousness and put her at risk of injuring herself or
others if she were to drive. She is also to follow up with her
Ob/Gyn in the next few days after discharge and was in
communiation with them during her hospital stay.
Medications on Admission:
-prenatal vitamins
-Iron
Discharge Medications:
1. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): on ___ please take 1.5 tabs (750mg) twice daily
and on ___ please take 2 tabs (1000mg) twice daily. Continue at
this dose until further advised by your neurologist.
Disp:*120 Tablet(s)* Refills:*2*
2. Outpatient Lab Work
Please draw Keppra (Levtiracetam) level on ___
Fax results to ___ Attention: Dr. ___
___ Disposition:
Home
Discharge Diagnosis:
Seizure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ on ___ for evaluation of events concerning for seizure. You
were placed on long term monitoring to try to identify if there
was any abnormal electrical activity that supported the
diagnosis of seizures. While you did not have any events similar
to those that brought you to the hospital, your EEG did show
some abnormal brain waves. This abnormality in combination with
the description of the events, (starting with ___, then
feeling of flushing and warmth then a loss of time) are
supportive of likely seizure activity and we chose to start you
on an antiepileptic medication.
You will follow with one of epileptologists, Dr. ___
to help determine further changes in medication dosage as needed
throughout your pregnancy.
We made the following changes to your medications:
Started Keppra 500mg twice daily, to increase to 750mg Twice
daily on ___ and 1000mg twice daily on ___. On ___ please
have a Keppra level drawn and faxed to us (the phone number to
fax the results is provided on the perscription for the lab
draw). We also discussed the option of obtaining 48 hours of
further ambulatory eeg after discharge as the hospital is an
unnatural environment for capturing these episodes. You decided
to defer this for now but this ___ be helpful for further
management decision in the future.
If you experience any of the below listed danger signs, please
call your doctor or go to the nearest Emergency Department.
Fever greater than 101
Chills
Any other symptoms that concern you
Dizziness or lightheadedness
Numbness or tingling
Change in vision
Confusion
Headache
Weakness in arm, leg, or face
Difficulty walking
Difficulty talking
Loss of balance
Incontinence of urine or stool
It was a pleasure taking care of you during your hospital stay.
Followup Instructions:
___
|
10648617-DS-5
| 10,648,617 | 29,698,278 |
DS
| 5 |
2188-08-27 00:00:00
|
2188-08-27 16:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMHx of CLL, L neck mass c/w DLBCL (richters) s/p dose
adjusted EPOCH on ___, HTN, and Hep B who presents with
chills and Tmax at home of 100.8. Pt denies any subjective
fevers or night sweats. He has been taking it easy at home
since
discharge and denies any sick contacts. He has been taking po
well and having normal BMs.
VS on arrival to ED: T 99, HR 116, BP 111/60, 18, 99% on RA. Tm
of 100.4 in the ED. UA and CXR Pa/lat were unrevealing for a
source of infection. Pt was given Cefepime 2grams and
Vancomycin
prior to transfer to ___.
On arrival to the floor, pt reports feeling tired and hungry.
He
denies any CP, SOB, abd pain, N/V/D, dysuria, joint pains,
rashes, sore throat, nasal congestion, HA or LH. He reports
stable cough over last month with clear sputum. He was feeling
otherwise well at home when he noted the chills and called the
triage RN. He reports that his left neck swelling has decreased
and denies any voice changes, intermittent hoarse voice has been
present for the last month. He endorses feeling anxious and has
been taking Ativan twice daily at home.
Past Medical History:
PAST ONCOLOGIC HISTORY:
-___ diagnosed with chronic lymphoid leukemia stage IIIB
-___ Developed bulky lymphadenopathy of neck and groin. Treated
with Rituximab/Fludarabine. Maintenance rituximab stopped due to
flare of hepatitis B. Patient again placed on surveillance.
-___: Rising WBC, increasing adenopathy.
-___: started Ibrutinib with significant improvement in
adenopathy and WBC count.
-___: noted to have rapidly growing, painful L sided neck
mass
-___: underwent excision biopsy of L cervical LN which
showed
DLBCL on background of CLL, c/w Richter's transformation.
PAST MEDICAL/SURGICAL HISTORY:
Hepatitis B
Hyperlipidemia
Hypertension
Social History:
___
Family History:
Aunt - "leukemia" in her ___
Mother - cerebral hemorrhage
Father - died of MI at ___
Brother - ___ yrs old, hx CABG
Physical Exam:
Admission:
VS 98.7 136/74 103 20 97 RA
GEN: male in NAD, appears younger than stated age
HEENT: left neck surgical wound well healed, palpation mass at
left neck base, minimal cervical adenopathy, MMM
CV: RR mildly tachy, no apprec murmurs
RESP: CTAB no w/r
ABD: thin, soft, NABs, no TTP, no rebound
GU: no foley
EXTR: warm, no edema
DERM: no rashes appreciated
PSYCH: alert, interactive, anxious and appropriate
NEURO: ambulating independently
Discharge:
___ 0453 Temp: 98.2 PO BP: 120/73 HR: 88 RR: 18 O2 sat: 96%
O2 delivery: ra
GEN: Well appearing, in no acute distress. Horse voice.
HEENT: Conjunctiva clear, PERRL, MMM
NECK: No JVD. Cervical/SC LA +
LUNGS: CTAB
HEART: RRR, nl S1, S2. No m/r/g.
ABD: NT/ND, normal bowel sounds.
EXTREMITIES: No edema.
SKIN: No rashes.
NEURO: AOx3.
Pertinent Results:
Admissions:
___ 07:25PM PLT SMR-LOW* PLT COUNT-129*
___ 07:25PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-OCCASIONAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
___ 07:25PM NEUTS-1* BANDS-0 LYMPHS-94* MONOS-1* EOS-0
BASOS-0 ATYPS-1* ___ MYELOS-0 OTHER-3* AbsNeut-0.02*
AbsLymp-1.71 AbsMono-0.02* AbsEos-0.00* AbsBaso-0.00*
___ 07:25PM WBC-1.8* RBC-3.92* HGB-11.3* HCT-34.1* MCV-87
MCH-28.8 MCHC-33.1 RDW-14.4 RDWSD-45.7
___ 07:25PM ALBUMIN-4.0 CALCIUM-8.7 PHOSPHATE-2.9
MAGNESIUM-2.2
___ 07:25PM ALT(SGPT)-50* AST(SGOT)-17 ALK PHOS-87 TOT
BILI-0.8
___ 07:25PM GLUCOSE-112* UREA N-27* CREAT-1.1 SODIUM-138
POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-26 ANION GAP-14
___ 08:13PM URINE RBC-3* WBC-2 BACTERIA-NONE YEAST-NONE
EPI-0
___ 08:13PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 09:08PM ___ PTT-27.1 ___
Discharge Labs:
___ 06:15AM BLOOD WBC-3.6* RBC-3.14* Hgb-8.8* Hct-27.7*
MCV-88 MCH-28.0 MCHC-31.8* RDW-14.7 RDWSD-47.3* Plt ___
___ 06:15AM BLOOD Neuts-61 Bands-8* Lymphs-13* Monos-3*
Eos-5 Baso-0 ___ Metas-2* Myelos-3* Other-5* AbsNeut-2.48
AbsLymp-0.47* AbsMono-0.11* AbsEos-0.18 AbsBaso-0.00*
___ 06:15AM BLOOD Plt Smr-LOW* Plt ___
___ 06:15AM BLOOD Glucose-118* UreaN-21* Creat-1.0 Na-147
K-4.4 Cl-108 HCO3-26 AnGap-13
___ 06:45AM BLOOD ALT-39 AST-12 LD(LDH)-248 AlkPhos-96
TotBili-0.3
___ 06:15AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.2
Studies:
CXR ___
No acute cardiopulmonary abnormality. Redemonstration of
probable large left
thyroid goiter resulting in rightward tracheal deviation.
Brief Hospital Course:
Outpatient Providers: Mr ___ is a ___ y/o M with PMH of CLL
(on Ibrutinib),
complicated by DLBCL/Richter transformation, s/p dose adjusted
EPOCH regimen (started ___ who presents for febrile
neutropenia. He was started on cefepime and a broad infectious
workup was completed and was negative. His fevers resolved and
he had recovery of his ANC from 0 to greater than 1500. He will
be discharged home with plan for second round of chemo likely
the week of ___.
ACTIVE ISSUES:
=============
# Febrile Neutropenia:
Pt presented with acute onset of chills and Tm of 100.8 without
any other
localizing symptoms or exam findings suggestive of localizing
infection. His ANC was 20 at presentation. He was started on
cefepime. Complete infectious disease work up was negative. He
since has been without fever and his ANC has risen 1500,
uptrending. Cefepime was discontinued and he has remained
without fever.
# DLBCL s/p dose adjusted EPOCH:
C1 started on ___ (currently day 15). He will continue on home
ppx with acyclovir 400mg BID and Bactrim SS daily. He will
remain on allopurinol ___ daily. He received Neupogen daily
until his counts raised >1500.
# CLL on Ibrutinib:
Held home Ibrutinib 420mg qhs, which will be discussed further
with Dr ___ in clinic regarding restarting.
CHRONIC ISSUES:
===============
# Chronic Hepatitis B:
Continued home Entecavir 0.5mg daily
# HTN:
The patient will continue home losartan, HCTZ at discharge
Transitional Issues:
====================
[ ] Discuss placing port for patient given multiple upcoming
cycles of chemotherapy
[ ] Will need to consider restarted ibrutinib therapy for CLL
[ ] F/u blood pressures (patient may not require low dose HCTZ
going forward as BP were well controlled in house on just
losartan)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Filgrastim-sndz 300 mcg SC Q24H
2. Losartan Potassium 50 mg PO DAILY
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. Acyclovir 400 mg PO Q12H
5. Entecavir 0.5 mg PO DAILY
6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
7. Allopurinol ___ mg PO DAILY
8. ibrutinib 420 mg oral DAILY
9. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
dyspepsia
10. Pantoprazole 40 mg PO Q24H
11. LORazepam 0.5 mg PO BID:PRN anxiety
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. Allopurinol ___ mg PO DAILY
3. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
dyspepsia
4. Entecavir 0.5 mg PO DAILY
5. Hydrochlorothiazide 12.5 mg PO DAILY
6. LORazepam 0.5 mg PO BID:PRN anxiety
7. Losartan Potassium 50 mg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Febrile Neutropenia
CLL
DLBCL
Secondary:
Hypertension
Anxiety
Chronic Hepatitis B
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___
___ was a pleasure caring of you at ___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital because of fevers
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were found to have low WBC count, which was expected after
chemotherapy
- You received antibiotics and tests to determine if you have an
infection
- Your counts recovered and no infection was found
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10649122-DS-19
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| 19 |
2131-07-01 00:00:00
|
2131-07-01 15:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Keflex / Iodinated Contrast Media - IV Dye / Bactrim /
vancomycin
Attending: ___.
Chief Complaint:
wound infection
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Per admitting resident: Ms. ___ is a ___ year old lady who
had a laparoscopic adjustable gastric band placed in ___. This initial operation was complicated by cellulitis
requiring a course of PO augmentin. Her band was removed on
___ at ___ and she was subsequently admitted to ___
for two days for treatment of midline port site cellulitis. She
received vancomycin while in the hospital and has now completed
a 10 day course of clindamycin (450 mg Q6H). She was seen in
clinic on ___ for new cellulitis at her lateral port. She was
started on 300 mg Q6H. She failed to progress, thus her
clindamycin was increased to 450 mg Q6H and a wick was placed on
___. She now presents today because she has developed
progressive erythema beyond the prior markings. She is also
having intermittent abdominal pain that is stabbing and burning
at the site of her skin erythema and is experiencing subcostal
bilateral abdominal pain.
She endorses subjective fevers, chills and bloating after meals.
She denies any nausea, vomiting, diarrhea or constipation.
Past Medical History:
PMH
1. Morbid obesity
2. OSA
3. GERD
4. Gestational diabetes
5. Psoriasis
6. Fatty liver
PSH
1. S/P Laparoscopic adjustable band removal ___. S/P Laparoscopic band ___
3. S/P C section ___. S/P BTL
5. S/P Repair of mandibular fracture ___
6. S/P spinal fusion ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
VS: T 98.3 P 84 HR 113/70 RR 16 02 99%RA
Constitutional: NAD
Neuro: Alert and oriented x 3
Cardiac: RRR, NL S1,S2; no murmurs appreciated
Resp: CTA B
Abd: Soft, non-tender, no rebound tenderness or guarding
Wounds: left port with crusting, no periwound erythema or
drainge; other incisions appear well healed
Ext: No edema, 2+ DP pulses, bilaterally
Pertinent Results:
LABS:
___
08:10AM BLOOD WBC-7.1 RBC-4.46 Hgb-12.5 Hct-37.3 MCV-84 MCH-28.1
MCHC-33.6 RDW-14.2 Plt ___
___
02:00PM; BLOOD WBC-8.5# RBC-4.62 Hgb-13.0 Hct-38.5 MCV-83
MCH-28.0 MCHC-33.6 RDW-14.3 Plt ___ Neuts-67.0 Lymphs-27.7
Monos-3.9 Eos-1.0 Baso-0.5 Glucose-90 UreaN-8 Creat-0.8 Na-139
K-3.8 Cl-102 HCO3-27 AnGap-14 ALT-16 AST-16 AlkPhos-60
TotBili-0.2 Albumin-4.0
02:22PM: BLOOD Lactate-1.6
05:16PM BLOOD: ALT-16 AST-17 AlkPhos-59 TotBili-0.3 Albumin-3.9
IMAGING:
___
US ABD LIMIT, SINGLE ORGAN
IMPRESSION:
No evidence of fluid collection in region of the port site.
Brief Hospital Course:
The patient presented to the Emergency Department on ___ after reporting worsening periwound erythema of her left
port site despite placement of a wick and an increase of her
antibiotic dose. Pt was evaluated by the ___ service upon
arrival to ED and noted to have periwound erythema with
induration and pain at this site; pt afebrile without
leukocytosis. Intravenous vancomycin was administered, however,
the patient appeared to develop red man syndrome prompting
discontinuation of the vancomycin and adminstration of IV
diphenhydramine. She was subsequently transferred to the
general surgery ward for further observation and treatment.
Upon arrival to the floor, IV vancomycin adminstration was
attempted x 2 at a slower rate following premedication with
famotidine and diphenhydramine, however, red man syndrome
recurred and the antibiotics were discontinued; pt remained
hemodynamically stable throughout episodes. ID was consulted
for further input give previous course of antibiotics and
current reaction to vancomycin. Recommendations included
administration of two doses daptomycin, which were given on HD3
& 4, followed by oral clindamycin for an additional eight days.
Given resolution of erythema, hemodynamic stability and complete
resolution of erythema the patient was discharged to home on HD4
on the above regimen. The patient received discharge teaching
and follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Topiramate (Topamax) 25 mg PO BID
2. Venlafaxine XR 225 mg PO DAILY
3. Acetaminophen 500 mg PO Q6H:PRN pain
4. Famotidine 10 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Senna 8.6 mg PO DAILY
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
11. Clindamycin 450 mg PO Q6H
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Omeprazole 40 mg PO DAILY
3. Topiramate (Topamax) 25 mg PO BID
4. Venlafaxine XR 225 mg PO DAILY
5. Clindamycin 450 mg PO Q6H
RX *clindamycin HCl 150 mg 3 capsule(s) by mouth every six (6)
hours Disp #*24 Capsule Refills:*0
6. Docusate Sodium 100 mg PO BID
7. Famotidine 10 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
10. Senna 8.6 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Cellulitis
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 due to an infection of your
incision. You have received intravenous antibiotics and
improved, therefore, you are ready for discharge home. Please
take the oral antibiotics as prescribed and follow up in clinic
with Dr. ___.
Please note these additional instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*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:
___
|
10649145-DS-20
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2124-03-21 00:00:00
|
2124-03-21 14:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin / Penicillins
Attending: ___.
Chief Complaint:
Trauma/Syncope
Major Surgical or Invasive Procedure:
___: Open reduction, internal fixation, posterior pelvic ring,
sacral ala fracture with 7.3 mm screws.
History of Present Illness:
Mr. ___ is a pleasant ___ year old gentleman who
presents in transfer today from ___ for
evaluation of a pelvic fracture. Patient reports that
approximately 09h00 this morning, he was riding his scooter with
his son in the back seat. He went to make a right turn when he
reportedly started "shaking violently" and "blacked out".
Patient
remains amnestic to events thereafter. He reportedly crashed his
scooter into a street sign. He was presumed to be at least
briefly unconscious at the scene and did strike his head. He was
taken to ___ where preliminary work-up was
completed and the patient was found to have pelvic fractures
with
a retroperitoneal hematoma. He was subsequently transferred to
___ for further evaluation and management. Upon arrival here,
patient was reportedly hypotensive. He underwent resuscitation
and is currently hemodynamiccaly stable. He currently complains
primarily of right groin and buttock pain. He denies any pain in
any other joint or extremity. He denies any numbness or
paresthesias in the bilateral lower extremities.
Past Medical History:
Left distal radius fracture after a fall while dirt-biking s/p
operative fixation
Left patella fracture s/p operative fixation
Lower lumbar spine fractures after a fall while dirt-biking,
managed conservatively
Denies any seizure history.
Denies history of heart disease.
Social History:
___
Family History:
No hx of siezure
Physical Exam:
ADMISSION PE:
In general, the patient is a pleasant middle aged gentleman
resting comfortably on the ED stretcher in no apparent distress.
He is currently hemodynamically stable.
Right upper extremity:
Skin intact
Soft, non-tender arm and forearm
Full, painless AROM/PROM of shoulder, elbow, wrist, and digits
+EPL/FPL/DIO (index) fire
+SILT axillary/radial/median/ulnar nerve distributions
+Radial pulse
Left upper extremity:
Skin intact
Soft, non-tender arm and forearm
Full, painless AROM/PROM of shoulder, elbow, wrist, and digits
+EPL/FPL/DIO (index) fire
+SILT axillary/radial/median/ulnar nerve distributions
+Radial pulse
Right lower extremity:
Skin intact
There is tenderness to palpation at the right groin. No
tenderness to palpation at the lateral aspect of the right hip,
thigh, knee, lower leg, ankle or foot.
Soft, non-tender thigh and leg
Full, painless AROM/PROM of hip, knee, and ankle
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
Left lower extremity:
Skin intact
Soft, non-tender thigh and leg
Full, painless AROM/PROM of hip, knee, and ankle
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
Pelvis - stable to AP compression. There is tenderness to
palpation with lateral compression.
DISCHARGE PE:
VS: 98.3; 126/70; 98; 18; 97RA
GENERAL: NAD, alert, interactive
HEENT: NC/AT, sclerae anicteric, MMM
LUNGS: Clear to auscultation bilaterally, otherwise no w/r/r
HEART: RRR, no MRG
ABDOMEN: NABS, soft/NT/ND.
EXTREMITIES: WWP
NEURO: awake, A&Ox3, moving all extremities, RLE with increasing
strength/mobility
Pertinent Results:
ADMISSION LABS:
___ 06:10PM BLOOD WBC-9.4 RBC-3.67* Hgb-12.5* Hct-37.7*
MCV-103* MCH-34.0* MCHC-33.1 RDW-13.6 Plt ___
___ 06:10PM BLOOD Neuts-84.7* Lymphs-6.4* Monos-8.7 Eos-0.1
Baso-0.2
___ 06:10PM BLOOD ___ PTT-30.3 ___
___ 06:10PM BLOOD Glucose-121* UreaN-15 Creat-0.8 Na-139
K-4.2 Cl-104 HCO3-23 AnGap-16
___ 06:10PM BLOOD Calcium-8.1* Phos-3.2 Mg-2.0
___ 06:29PM BLOOD Lactate-1.8
DISCHARGE LABS:
___ 04:50AM BLOOD WBC-5.9# RBC-2.79* Hgb-9.3* Hct-27.1*
MCV-97 MCH-33.5* MCHC-34.4 RDW-14.2 Plt ___
___ 04:35AM BLOOD Glucose-122* UreaN-7 Creat-0.6 Na-135
K-3.6 Cl-101 HCO3-29 AnGap-9
MICRO: none this admission
STUDIES/IMAGING:
CT Cystogram: No bladder rupture. Stable appearance of the
fractures and multiple retroperitoneal and extraperitoneal
hematomas.
Retrograde Urethrogram: No evidence of urethral injury
identified, however, assessment of the posterior urethra is
slightly limited due to spasm.
EEG: IMPRESSION: This telemetry captured no pushbutton
activations. It showed an alpha frequency background posteriorly
during wakefulness. There were also occasional bursts of
generalized slowing, suggesting a deficit in midline function,
but this is quite nonspecific with regard to etiology. Further,
the bursts were brief and infrequent. There were no epileptiform
features or electographic seizures.
MR Head: Periventricular hyperintensities on FLAIR suggest
chronic small vessel ischemic disease. Otherwise normal study.
Brief Hospital Course:
___ with no PMH who presented following trauma from a moped
accident transferred to medicine service for workup of syncope
found to have history suspicious for seizure.
HOSPITAL COURSE ON SURGICAL SERVICE:
Patient admitted initially as trauma patient to ___ under care
of ACS. CT torso, Head, C-spine from OSH reviewed and cystogram
and retrograde urethrogram performed. Patient noted to have the
following injuries:
1) large retroperitoneal hematoma without active extravasation
2) extraperitoneal hematoma around bladder without bladder
rupture
3) comminuted right anterior acetabular column fracture
4) b/l superior and inferior right pubic rami fractures
5) bilateral sacral fractures
6) right posterior iliac bone fracture
7) L3 compression body fracture (acute vs chronic)
Neurosurgery and Orthopedic Surgery Consulted. Neurosurgery did
not feel that neurosurgical intervention required and did not
feel that patient required a brace.
Ortho felt that the patient's pelvic fracture warranted surgical
intervention. Per orthopedic operative note:
"The patient is a ___ gentleman who was involved in a
motor vehicle injury in which he was riding a scooter. He now
presents for surgical management.The decision for surgery was
taken given the significant amount of pain that he was on while
at the floor when supine and trying to sit. The lateral
compression fracture (type 1 pelvic fracture) is usually
stable. However he has significant pain and was percutaneous
stabilization will help stabilize the pelvis for eearly
mobilization."
ACS service had concern for possible urethral trauma therefore
placed foley and request that it be maintained for 2 weeks. The
patient will follow up with ACS in clinic to have the foley
removed. The patient was transferred the medicine service for
workup of syncope.
HOSPITAL COURSE ON MEDICINE SERVICE:
# Syncope - history of event with shaking prior to syncope as
well as siezure-like episode that occured 5 days prior to
admission made siezure highest on differential for syncope this
admission. EKG showed NSR with normal QTc. Patient without
recorded arrythmias on telemetry this admission. Neurology was
consulted and felt that history most consistent with siezure.
MRI brain without lesions or mass effect. EEG performed. While
only ~6 hours were recorded, no sign of epileptiform activity
and neurology felt that anti-epileptic treatment warranted based
on history. Patient initiated on lacosamide 100mg BID this
admission. Etiology of siezure unclear in this patient. Denies
significant EtOH history, however labs notable for mild AST
elevation relative to ALT and MCV elevated. No family hx of
siezure and would be abnormal to develop epilepsy later in life.
Will follow up with neurology as an outpatient.
# Thrombocytopenia - Resolving. patient with plts of 150 on
admission. This dropped to a low of 80 this admission. Felt ___
to consumptive process given patient's RP bleed. 4T score low at
___ for HIT so felt HIT antibody testing not needed. Platelets
recovered and stabilized at 150 at time of discharge.
# Anemia - patient with Hgb 9.4 on transfer to medicine which
appears stable after admission RP bleed but down trending. Hgb
remained stable with level of 8.4 on day of discharge. Patient
did not require any transfusions this admission. Should repeat
CBC after discharge to ensure stable Hgb.
# Pain - patient maintained on PO oxycodone and bowel regimen
while in patient. Will be discharge on short course of oxycodone
as described in transitional issues.
TRANSITIONAL ISSUES:
#Anticoagulation - patient should complete 2 weeks of 40mg SQ
lovenox daily from date of surgery (end date ___
#Seizure: patient initiated on lacosamide 100mg BID. Will
continue as outpatient and follow up with neurology.
#Foley: maintain for 2 weeks as concern for urethral injury
while on ACS service. F/U with ACS to remove foley in 2 weeks.
#Repeat CBC - patient should have repeat labs on ___ to ensure
that Hgb stable. Was 9.3 on day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Docusate Sodium (Liquid) 100 mg PO BID
2. Enoxaparin Sodium 40 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
End Date ___. LACOSamide 100 mg PO BID
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Senna 8.6 mg PO BID:PRN Constipation
6. Multivitamins 1 TAB PO DAILY
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth q4H: PRN Disp #*30
Tablet Refills:*0
8. Outpatient Lab Work
CBC (ICD-9 808)
Fax results to:
Dr. ___: ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- Seizure
- Pelvic Fracture
Secondary Diagnosis:
1) large retroperitoneal hematoma without active extravasation
2) extraperitoneal hematoma around bladder without bladder
rupture
3) comminuted right anterior acetabular column fracture
4) b/l superior and inferior right pubic rami fractures
5) bilateral sacral fractures
6) right posterior iliac bone fracture
7) L3 compression body fracture (acute)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your
hospitalization. You were admitted following a trauma on your
moped. You were initially admitted to the surgical service. The
orthopedic and neurosurgical teams were consulted. The
orthopedic team operated on your pelvic fractures. You were then
sent to the medicine service for workup of the syncope that led
to your accident. Given your history, the neurologists were
consulted and feel that you most likely had a seizure. You will
need to continue to take a medication to prevent seizures in the
future. You also should not drive until advised to do so by your
doctor. You will need to follow up with the neurologists as well
as the orthopedic surgeons.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10649183-DS-10
| 10,649,183 | 21,849,613 |
DS
| 10 |
2161-05-11 00:00:00
|
2161-05-11 15:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Alendronate Sodium / Pravastatin / Sulfa (Sulfonamide
Antibiotics) / Propafenone / Bisphosphonates / Sotalol /
Hydralazine / Pravachol / nitrofurantoin
Attending: ___.
Chief Complaint:
left upper/lower extremity weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ ___, and
___ female with PMHx stroke (details below), AF on
coumadin, CHF, HTN, HL, MI, and ?T2DM (per chart; patient
denies) who presents from ___ with fatigue,
lightheadedness, LUE and LLE weakness, and disequilibrium.
She was in her USOH until 3pm. At that time, she came home from
her grandson's birthday party and felt unwell (tired,
lightheaded, no vertigo). Checked BP, which was 168/84 (normally
150s/80s). She took 30mg isosorbide at 330pm (normally takes it
at 4pm or 5pm). Then, she took a nap for half an hour (awoke
4pm). When she tried to stand, she lost her balance. Had to hold
on to objects to get to bathroom. Not falling to left or right.
Left leg and arm heavy. She was able to move both, and she was
able to hold a telephone in the left hand without dropping it.
The left leg was dragging. Was very thirsty. She started seeing
black spots in right and left visual fields starting at 1230am.
At the time of interview, there have been no changes to her
symptoms. She has never had these sx before.
She presented to ___, where a CT was negative and INR was
noted to be 1.3 (of note, Coumadin dose was recently decreased
as noted below). She was given 325mg of aspirin, and her NIHSS
was ___.
Of note, she is supposed to be on cipro for UTI from ___
___ ___ last day, ___ days). "UTI symptoms" started ___, at which time her BP dropped (80/43, HR 41), and felt that
she could not put weight on either leg because she thought she
would fall to the floor. Between ___, she was put on
nitrofurontoin for UTI. She couldn't tolerate the nitrofurontoin
for longer (loss of appetite), so she took 5 of 7 days. No F/C,
dysuria, frequency. She was hospitalized at ___ from
___ for UTI, hypotension, and dehydration.
Her coumadin was decreased on ___ on discharge from 4mg daily
to 2mg daily while on ciprofloxacin. She is not sure if the dose
was decreased before that (as early as ___, the first day of
hospitalization).
Her prior stroke was ___ years ago. Symptoms included vomiting,
vertigo, and left leg>arm weakness. No residual deficits.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus, and hearing difficulty. Denies difficulties
producing or comprehending speech. Denies numbness and
parasthesiae. No bowel or bladder incontinence or retention.
Chronic DOE, no weight gain, no ___ edema. On general review of
systems, the pt denies recent fever or chills. No night sweats
or recent weight loss or gain. Denies cough. 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.
Social History:
___
Family History:
Colon CA--brother, ___. Mother--colon CA. No FHx strokes.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
97.8F HR 70 BP 153/85 RR 20 SpO2 96RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: trace edema
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects (except
called glove a "hand" on stroke card). Able to read without
difficulty. Speech was not dysarthric. Able to follow both
midline and appendicular commands. Pt was able to register 3
objects and recall ___ at 5 minutes. There was no evidence of
apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI except unable
to bury sclera bilaterally. Without nystagmus. Normal saccades.
VFF to confrontation except in left temporal field when right
eye closed where she could not do finger counting (but intact to
finger wiggle).
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. LUE drift without
pronation. Orbitting R around L. No adventitious movements, such
as tremor, noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 3* ___ ___ 5 4** 4** 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
*No effort
**Not giving full effort but seems to be true underlying
weakness
-Sensory: No deficits to light touch, pinprick, cold sensation.
Absent proprio to small movements in ___ ___. No extinction to
DSS.
-DTRs:
___ Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Left toe up, right equivocal.
-Coordination: LUE dysmetria and dysdiadochokinesia. Overshoot
on LUE mirror testing. Abnormal rhythm with finger tap LUE. L
foot tap slow but rhythm normal and LLE H2S limited by
weakness/effort. RUE and RLE intact.
-Gait: patient declined gait testing.
DISCHARGE PHYSICAL EXAM
=======================
Pertinent Results:
LABS ON ADMISSION
=================
___ 09:30AM BLOOD WBC-6.8 RBC-4.55 Hgb-13.7 Hct-41.9 MCV-92
MCH-30.1 MCHC-32.7 RDW-14.6 RDWSD-49.2* Plt ___
___ 09:30AM BLOOD ___ PTT-33.5 ___
___ 09:30AM BLOOD Plt ___
___ 09:30AM BLOOD Glucose-141* UreaN-18 Creat-0.7 Na-142
K-4.0 Cl-106 HCO3-24 AnGap-16
___ 09:30AM BLOOD Calcium-9.3 Phos-3.0 Mg-2.2 Cholest-PND
___ 09:30AM BLOOD %HbA1c-6.2* eAG-131*
___ 01:06AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
PERTINENT IMAGING
=================
1. ___ CHEST (PA & LAT): Severe cardiomegaly with mild
interstitial pulmonary edema and trace pleural effusions.
2. ___ CTA HEAD & NECK: No evidence of acute intracranial
hemorrhage. Approximately 40% stenosis at the origin of the left
internal carotid
artery. No evidence of aneurysm greater than 3 mm, dissection or
vascular
malformation, or significant luminal narrowing. Pulmonary artery
enlargement, which can be seen with pulmonary artery
hypertension.
3. MR HEAD W/O CONTRAST: Two small acute infarcts in the right
frontal lobe Corona radiata. Foci of microhemorrhage in the
bilateral thalami of uncertain chronicity.
ECHO
The left atrium is mildly dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is top normal/borderline dilated.
There is severe regional left ventricular systolic dysfunction
with akinesis of the inferior and inferolateral walls. There is
mild hypokinesis of the remaining segments (LVEF = 25 %). No
masses or thrombi are seen in the left ventricle. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size is normal with
mild global free wall hypokinesis. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is mild
pulmonary arterial systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of ___,
biventricular function appears more depressed. The ascending
aorta is mildly dilated.
Brief Hospital Course:
___ is an ___ F with a PMHx of prior stroke, HL, HTN,
and AF on Coumadin who presents with lightheadedness, LUE and
LLE weakness, and disequilibrium. Exam was notable for LLE>LUE
weakness, left dysmetria, and left dysdiadochokinesia. MRI on
___ demonstrated two small acute infarcts in the right frontal
lobe corona radiata.
Differential included cardioembolic stroke versus
atherosclerotic embolus. Cardioembolic stroke was thought to be
most likely given recent subtherapeutic INR in setting of a
Coumadin decrease and lack of stenosis on CTA head & neck.
However, she has various atherosclerotic stroke risk factors
(elevated HbA1c and LDL as noted below).
Stroke risk factors were investigated while Ms. ___ was
hospitalized. HbA1c was 6.2%; lipid panel demonstrated
cholesterol 196, ___ 90, HDL 52, LDL 126; and TSH was 4.2. An
echocardiogram was also performed and demonstrated decreased
LVEF to 25% which is depressed from previous ECHO on ___. Ms.
___ remained on telemetry which demonstrated atrial
fibrillation with rates between ___.
As Ms. ___ had a recent UTI, she completed her course of
ciprofloxacin while inpatient. Given her new stroke, her
warfarin was increased from 2mg to her home dose of 4mg. For
secondary prevention, she continued on rosuvastatin 5 mg QPM and
aspirin 81 mg daily.
Ms. ___ was evaluated by physical therapy and occupational
therapy while inpatient, and they recommended discharge to
rehab.
TRANSITIONAL ISSUES:
1. Patient on warfarin therapy will need serial INR checks with
goal INR of ___.
2. S/P Blood pressure auto-regulation x 4 days. Consider
re-starting home BP medications on ___.
---- Losartan 50 mg BID and Metoprolol XL 25 mg daily
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 10 mg PO DAILY
2. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
3. LORazepam 1 mg PO QHS:PRN insomnia
4. Losartan Potassium 50 mg PO BID
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Nitroglycerin SL 0.4 mg SL ___ chest pain
7. Rosuvastatin Calcium 5 mg PO DAILY
8. Warfarin 4 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Calcium Carbonate 500 mg PO BID
11. Vitamin D 400 UNIT PO BID
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Ciprofloxacin HCl 250 mg PO Q12H
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 500 mg PO BID
3. Furosemide 10 mg PO DAILY
4. LORazepam 1 mg PO QHS:PRN insomnia
5. Nitroglycerin SL 0.4 mg SL ___ chest pain
6. Rosuvastatin Calcium 5 mg PO DAILY
7. Warfarin 4 mg PO DAILY
8. Acetaminophen 325-650 mg PO Q6H:PRN pain
9. Captopril 12.5 mg PO Q6H:PRN SBP>185
10. Docusate Sodium 100 mg PO BID
11. Multivitamins 1 TAB PO DAILY
12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
13. Multivitamins W/minerals 1 TAB PO DAILY
14. Vitamin D 400 UNIT PO BID
15. Metoprolol Succinate XL 12.5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
- Right frontal lobe ischemic stroke
- congestive heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Ms. ___,
You were transferred to ___ from ___ after you had an
episode of loss of balance. You were found to have weakness and
difficulty with coordination on your left side. Your INR was
found to be low at 1.3. Your brain imaging showed that you had a
new small stroke in the right side of your brain that affects
the left side of your body. The cause of your stroke remains
unclear, but we feel that it was most likely due to a blood clot
in the setting of a low INR.
Due to your congestive heart failure, you should weigh yourself
every morning, and call your primary care physician if your
weight goes up more than 3 lbs.
You were evaluated by physical therapy and occupational therapy,
who felt that you would benefit from rehab.
Best wishes,
Your ___ Stroke Team
Followup Instructions:
___
|
10649183-DS-12
| 10,649,183 | 29,585,768 |
DS
| 12 |
2163-07-10 00:00:00
|
2163-07-10 19:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Alendronate Sodium / Pravastatin / Sulfa (Sulfonamide
Antibiotics) / Propafenone / Bisphosphonates / Sotalol /
Hydralazine / Pravachol / nitrofurantoin
Attending: ___.
Chief Complaint:
Vtach
Major Surgical or Invasive Procedure:
Coronary Angiography ___
VT Ablation ___
History of Present Illness:
Ms. ___ is an ___ with PMH of HLD, HTN, CAD s/p MI ___ s/p
DES to LAD in ___, renal artery stenosis s/p bilateral renal
stent, PVD, AF s/p DCCV on warfarin, H/O CVA, anemia,
osteoporosis and low back pain who presents with VT.
Patient was in her usual state of health, celebrating mother's
day with her family. She went to the cemetery to plant flowers
at
her own mother's grave. On the way home, she noted she was
feeling generally unwell and remarkably thirsty. She checked her
BP and pulse O2 frequently, found to be WNL, but when her
symptoms persisted she called her PCP. He recommended she drink
water to thrist and if not improved in 1 hour present the ED for
further evaluation.
Patient called EMS, found to be wide complex tachycardia.
Initial
cardioversion attempted at 50J, without success. She was
transferred to a referring facility, received 100mg lidocaine
and
repeat cardioversion (both w/o sedation) at 200J with conversion
to atrial fibrillation. She was given amiodarone load, placed on
gtt and transferred to ___ for further evaluation.
In the ED, initial VS were: 98.5 60 129/52 17 98% RA
- Exam notable for: Mentating, perfusing well, Unremarkable
- Labs showed: Trop-T: 0.16, ___: 19.0 PTT: 30.5 INR: 1.8
- Consults: none.
- Patient received: cont on amio gtt at 1mg/mon
Transfer VS were: 47 130/56 18 94% RA
Of note, patient with recent prior admission from ___
with lightheadedness and weakness, found to have VT and AF. She
was started on amiodarone at the time. VT thought to be from
ischemic scar. EP was consulted, agreed with prior dx of VT and
recommended TEE/DCCV for amiodarone. That hospital course was
complicated by bradycardia while sleep with pauses and home
metoprolol held.
On arrival to the floor, patient reports feeling better than
earlier in the day. She denies chest pain currently.
REVIEW OF SYSTEMS: (+) per HPI, all other ROS otherwise negative
Past Medical History:
1. Cardiac risk factors: Diabetes, dyslipidemia, and
hypertension
2. CAD w/ hx of MI in ___, and s/p DES to LAD in ___
3. Renal artery stenosis with bilateral patent renal stents
4. PVD
5. Atrial fibrillation s/p several unsuccessful DCCV, on
warfarin
6. Hx of CVA
7. Anemia
8. Osteoporosis
9. Low back pain
Social History:
___
Family History:
Notable for heart disease in her father who died at the age of
___
of complications of his coronary artery disease. She has a
sister
who has ___ disease. Mother had colon cancer and died at
age
___. Two brothers with colon cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 98.1 142/83 55 18 95 Ra
GENERAL: NAD
HEENT: MMM
NECK: no JVD
HEART: RRR, nl S1 and S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi
ABDOMEN: soft, NT, ND, NABS
EXTREMITIES: no edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: no rash
DISCHARGE PHYSICAL EXAM:
=========================
VS: 24 HR Data (last updated ___ @ 501)
Temp: 98.3 (Tm 99.0), BP: 150/64 (114-153/55-78), HR: 70
(49-79), RR: 18 (___), O2 sat: 92% (91-97), O2 delivery: RA,
Wt: 130.6 lb/59.24 kg
GENERAL: NAD, appears of stated age
HEENT: NT/AT, MMM, PERRL ~ 4mm bilaterally.
NECK: No elevated JVP at 90 degrees
HEART: RRR, loud s2, ___ systolic murmur, no g/r
LUNGS: No increased WOB. Mild, bibasilar crackles.
ABDOMEN: soft, non-tender, non-distended. +BS, no hepatomegaly
or
splenomegaly.
EXTREMITIES: no edema, distal extremities cold to touch.
PULSES: 1+ radial, DP, ___, femoral pulses bilaterally
NEURO: A&Ox3. CN II-XII intact. Moves all extremities. ___ b/l
deltoid, ___ b/l biceps & triceps all symmetrical; 4 & ___
wrist
ext/flexors, finger ext, grip strength L > R respectively.
SKIN: Bilateral ecchymosis in groins by prior access sites.
Pertinent Results:
ADMISSION LABS:
===============
___ 09:30PM BLOOD WBC-9.4 RBC-3.71* Hgb-11.5 Hct-35.6
MCV-96 MCH-31.0 MCHC-32.3 RDW-14.2 RDWSD-49.7* Plt ___
___ 09:30PM BLOOD Neuts-88.3* Lymphs-6.6* Monos-4.3*
Eos-0.1* Baso-0.3 Im ___ AbsNeut-8.28* AbsLymp-0.62*
AbsMono-0.40 AbsEos-0.01* AbsBaso-0.03
___ 09:30PM BLOOD ___ PTT-30.5 ___
___ 09:30PM BLOOD Glucose-151* UreaN-33* Creat-1.1 Na-142
K-4.1 Cl-107 HCO3-23 AnGap-12
___ 09:30PM BLOOD CK(CPK)-143
___ 09:30PM BLOOD CK-MB-14* MB Indx-9.8*
___ 09:30PM BLOOD cTropnT-0.16*
___ 09:30PM BLOOD Calcium-8.7 Phos-2.9 Mg-2.2
___ 09:40PM URINE Color-Straw Appear-Clear Sp ___
___ 09:40PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-70* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 09:40PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
___ 09:40PM URINE CastHy-1*
PERTINENT/DISCHARGE LABS:
=========================
___ 07:50AM BLOOD WBC-7.7 RBC-3.51* Hgb-10.9* Hct-34.4
MCV-98 MCH-31.1 MCHC-31.7* RDW-14.8 RDWSD-52.8* Plt ___
___ 07:50AM BLOOD ___ PTT-29.9 ___
___ 07:50AM BLOOD Glucose-125* UreaN-22* Creat-0.9 Na-144
K-4.8 Cl-106 HCO3-26 AnGap-12
___ 07:50AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.1
___ 07:50AM BLOOD Free T4-1.7
___ 08:05AM BLOOD TSH-15*
___ 07:55AM BLOOD Triglyc-84 HDL-50 CHOL/HD-2.4 LDLcalc-53
___ 08:08AM BLOOD %HbA1c-5.8 eAG-120
___ 09:30PM BLOOD CK-MB-14* MB Indx-9.8*
___ 09:30PM BLOOD cTropnT-0.16*
___ 08:00AM BLOOD CK-MB-25* cTropnT-0.61*
___ 03:15PM BLOOD CK-MB-16* cTropnT-0.43*
MICROBIOLOGY:
=============
___ 9:40 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
IMAGING/STUDIES:
================
Coronary Angiography ___:
FINDINGS:
Hemodynamics: State: Baseline
Pressures
Site Systolic Diastolic EDP A Wave V Wave Mean HR
LV 185 25 51
AO 185 72 111 52
Coronary Anatomy
Dominance: Right
* Left Main Coronary Artery
The LMCA is with proximal eccentric 20%.
* Left Anterior Descending
The LAD is calcified, with 50% mid stent restenosis.
There is a large branching septal with severe origin disease
The ___ Diagonal is small caliber with mild irregularities.
The ___ Diagonal is with 50% origin stenosis.
* Circumflex
The Circumflex is calcified, with mild irregularities.
The ___ Marginal is tortuous, without significant disease.
* Right Coronary Artery
The RCA is with 100% proximal chronic total occlusion.
There are right-to-right and robust left-to-right collaterals
present that fill back to the mid vessel.
Intra-procedural Complications: None
Impressions:
Two vessel coronary artery disease
Elevated left ventricular filling pressure
Severe systemic arterial hypertension
NSTEMI presentation likely due to demand
CTAP ___:
1. No retroperitoneal hematoma is identified.
2. Infrarenal abdominal aortic aneurysm measuring 3.___s a 2.7 cm right common iliac artery aneurysm.
3. Age indeterminate but chronic appearing compression fracture
T12.
CTA HEAD/CTA NECK ___:
1. No evidence for acute intracranial abnormalities. MRI would
be more
sensitive for an acute infarction if clinically warranted.
2. Chronic right centrum semiovale, bilateral basal ganglia and
right superior
cerebellar infarcts.
3. Approximately 50% stenosis of the proximal left internal
carotid artery by
NASCET criteria, unchanged.
4. Irregular mixed plaque in the proximal left subclavian artery
without left
vertebral artery origin narrowing, unchanged.
5. No evidence for flow-limiting stenosis in the major
intracranial arteries.
6. Partially visualized right pleural effusion. Visualized
visceral pleural
surface is irregular, and loculation cannot be excluded.
7. Borderline enlargement of the main pulmonary artery, which
may indicate
borderline or mild pulmonary arterial hypertension. Please
correlate
clinically.
8. Nonspecific 6 mm hyperenhancing nodule in the superficial
lobe of the right
parotid gland.
9. Multiple dental caries in the mandible. Periapical
lucencies, and
periodontal lucencies in the mandible and maxilla. Please
correlate with
dental exam.
RECOMMENDATION(S): If clinically warranted, the right parotid
subcentimeter
hyperenhancing lesion may be better assessed by ultrasound.
___ ___:
1. No acute intracranial abnormality on noncontrast head CT.
Specifically no large territory infarct or intracranial
hemorrhage.
2. Right cerebellar and right corona radiata infarcts.
Additional
periventricular and deep white matter hypodensities are
nonspecific, but
likely represent sequela of chronic small vessel ischemic
disease.
3. Given degree of white matter changes, superimposed acute
infarct may not be
well visualized and if there are no contraindications, MRI head
without
contrast would be more sensitive for detection of acute infarct.
MR HEAD W & W/O CONTRAST ___:
1. Numerous small acute to early subacute infarcts involving the
cortex and
white matter of bilateral frontal, parietal, and occipital
lobes, possibly the
posterior temporal lobes, and a single similar infarct in the
left cerebellum.
These suggest a bulk etiology.
2. Triangular T1 hyperintensity in the posterior left lentiform
nucleus with
high T2/FLAIR signal, low gradient echo signal, and CT
hypodensity, most
likely nonspecific mineralization related to a subacute infarct.
3. Multiple chronic infarcts within the bilateral basal ganglia
and right
centrum semiovale, progressed since ___. Stable chronic
moderate right
cerebellar and multiple small chronic left cerebellar infarcts.
4. Stable chronic microhemorrhages in the left medial cerebellum
and bilateral
thalami, most likely hypertensive.
5. 3D T2 weighted images demonstrate no focal abnormalities
along the courses
of the cranial nerves.
Brief Hospital Course:
___ with a past medical history of HLD, HTN, renal artery
stenosis s/p bilateral renal stent, PVD, CAD s/p MI ___ and DES
to LAD ___, AF s/p DCCV on Warfarin, and recurrent ventricular
tachycardia who presented with ventricular tachycardia s/p
cardioversion with conversion to AFib then Amiodarone loaded and
transferred to ___ for further management which included VT
ablation that was complicated by TIA.
#Monomorphic VT
Tracings from OSH were consistent with monomorphic VT. The
etiology is unclear: possibly NSTEMI or degeneration of Afib
into VT due to tachycardia and scar tissue from previous MI. She
also may have been under-medicated for VT treatment with
Amiodarone however this medication was primarily for management
of AFib. She underwent VT ablation on ___ complicated by a
TIA and mild femoral access bleeding (details below). No
episodes of VT were ever observed on telemetry during this
admission, in particular, after the ablation. She was observed
to have intermittent slow AFib while on Amiodarone.
#TIA
Patient had transient neurological symptoms that included right
eye ptosis and stuttering/difficult speech. Neurology was
consulted. A ___ was without intracranial hemorrhage or stroke
grossly evident. CTA without evidence for flow-limiting stenosis
in the major intracranial arteries. MRI revealed multiple small
acute infarcts involving the cortex and white matter of
bilateral frontal, parietal, and occipital lobes, possibly the
posterior temporal lobes, and a single similar infarct in the
left cerebellum consistent with embolism. This may have occurred
in the setting of periprocedure vascular access or less likely
holding anticoagulation for ~30hr in awaiting for the VT
ablation procedure and delay in restarting due to post-procedure
bleeding at the access site. It is unlikely that a intra-atrial
thrombus may be responsible given appropriate anticoagulation
and small window w/o anticoagulation. Neurological symptoms
resolved within 48hrs of onset with some mild residual weakness
in her right hand/wrist. Her anticoagulation was switched from
Warfarin to Apixaban on ___ without evidence of bleeding.
She meets requirements for the full dose of Apixaban (5mg BID);
she is ___ but Cr <1.5 and her weight >60kg.
#Type II NSTEMI
She has a hx of CAD w/ MI in ___ and is s/p DES to LAD in ___.
She was found to have elevated troponin and MB
(0.16/14->0.61/25->0.43/16) concerning for NSTEMI. Repeat EKG
since showing ectopic atrial bradycardia without acute ST-T
changes from baseline. It is unclear whether NSTEMI precipitated
VT or VT caused her NSTEMI. Cath report in ___ showed two
vessel CAD(90% septal, 100% proximal). Repeat cath on ___
was showed unremarkable disease (chronic RCA 100% occlusion with
collaterals, LMCA 20%, mid LAD 50%, D2 with 50% origin).
Therefore, these elevated trops may be more related to demand.
She was maintained on Aspirin and Rosuvastatin 10mg (not maxed
due to pt reported complications including myopathy). Metoprolol
held since ___ admission due to recurrent bradycardia.
# ___ TEE w/ EF=25%)
During this admission she was found to have mild crackles on
exam without hypoxia without other overt signs of acute
exacerbation of heart failure. She was diuresed with 40mg IV
Lasix with good response to euvolemia. Due to hypotension, her
fractionated Isosorbide was held indefinitely and her home
Losartan was restarted at a lower dose (25mg daily). She was
discharged on 20mg oral Lasix daily. Reintroduction of heart
failure medications will be needed as her blood pressure
tolerates.
# Atrial Fibrillation
Difficult to control as outpatient, s/p DCCV on last admission.
Her INR was slightly subtherapeutic (on Warfarin at home). She
was bridged to Heparin gtt from Warfarin due to scheduled
procedures. She was continued on gtt then oral Amiodarone,
however, she continued to have slow pAfib noted on telemetry
during the current admission. Rate was well controlled with
episodes of intermittent bradycardia with pauses. She was
switched from Warfarin to Apixaban on ___ without evidence
of bleeding.
# HTN
Blood pressures ranged primarily 110-160's during this
admission. She did experience some lower BPs in proximity to her
TIA that may have contributed to symptoms. Therefore, some
medications were held including Losartan, Isosorbide, and Lasix
to allow for permissive HTN iso of TIA for 48hrs to improve
perfusion. Before discharge, she was restarted on 25mg of
Losartan and 20mg of Lasix. Her Isosorbide was continued to be
held at discharge. Losartan dose and Isosorbide will need to be
titrated as blood pressure warrants.
#Anemia
Her HgB in ___ ranged ___ and has recently trended lower in
the ___ but stable during this admission. This most likely is
related to illness, however, she was noted to have Giuiac +
stools without melena or hematochezia. Further workup is
warranted. She experienced mild left femoral access bleeding on
___ with ~30 cc blood loss. CT abd/pelvis without RP bleed.
It was stabilized with pressure without further bleeds and
stable H/H. She was switch from Warfarin to Apixaban with
evident bleed.
#Elevated TSH:
During this admission her TSH was elevate at 15 with a normal
free T4. This is likely due to acute illness, or Amiodarone side
effect. Will need follow up recheck of TSH/FT4 when outside of
acute setting.
#Neuropathy:
Takes Gabapentin 200mg qHs which was continued during admission
with good control.
#Incidental Finding:
During a CTAP a 3.5cm infrarenal AAA and a 2.7 cm right common
iliac aneurysm was noted. Will need follow up and monitoring.
#CODE: Full confirmed
#CONTACT:
Name of health care proxy: ___
Relationship: daughter
Phone number: ___
Cell phone: ___
TRANSITIONAL ISSUES:
====================
[ ] She was on Amiodarone for AFib and was found to be
intermittently still in (slow) AFib. Recommend discontinuing
Amiodarone and consider other intervention including
cardioversion.
[ ] She experienced some episodes of hypotension. Her isosorbide
mononitrate ER 30mg daily was held and her Losartan 50mg BID
restarted at a lower dose of 25mg daily. She may not be able to
tolerate a BB given her low HR. Note that her GFR is 59 d/t her
age and wt. Will need to restart these medications as blood
pressure requires.
[ ] Apixaban was started during this admission. Monitor her
weight and renal function carefully. If she falls below 60kg or
Cr >1.5 then discussion with her Cardiologist about the dosing
of Apixaban will be needed. For those ___ years old with either
a Cr >1.5 or weight < 60kg a 2.5mg BID dosing is recommended.
[ ] She was found to have elevated TSH with normal FT4, please
recheck TFT in several months outside of the acute event.
[ ] Noted to be anemic this visit without clear source; will
need anemia workup.
[ ] She was found to have Giuiac + stools without melena or
hematochezia; will need further workup particularly in the
setting of recent anemia.
[ ] Incidental finding on CTAP: A 3.5cm intrarenal AAA and a 2.7
cm right common iliac artery aneurysm that will require
monitoring.
[ ] Incidental finding of a nonspecific 6 mm hyperenhancing
nodule in the superficial lobe of the right parotid gland. If
clinically warranted an U/S is recommended.
[ ] She has follow up with a neurologist in the Stroke Division
in ___ mos.
[ ] She has f/u scheduled w/Dr. ___ in 1 mo.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Furosemide 20 mg PO 5X/WEEK (___)
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
5. Losartan Potassium 50 mg PO BID
6. Rosuvastatin Calcium 5 mg PO QPM
___ MD to order daily dose PO DAILY16
8. Gabapentin 100 mg PO BID
9. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg oral DAILY
10. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral DAILY
11. Furosemide 40 mg PO 2X/WEEK (___)
12. Lidocaine 5% Patch 1 PTCH TD QPM
13. Pregabalin 25 mg PO QHS
14. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
2. Ramelteon 8 mg PO QHS:PRN insomnia
Should be given 30 minutes before bedtime
RX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet 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. Gabapentin 200 mg PO QHS
RX *gabapentin 100 mg 2 capsule(s) by mouth at bedtime Disp #*60
Capsule Refills:*0
5. Losartan Potassium 25 mg PO DAILY
RX *losartan 25 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. Rosuvastatin Calcium 10 mg PO QPM
RX *rosuvastatin 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
7. Amiodarone 200 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral DAILY
10. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg oral DAILY
11. Lidocaine 5% Patch 1 PTCH TD QPM
12. HELD- Isosorbide Mononitrate (Extended Release) 30 mg PO
DAILY This medication was held. Do not restart Isosorbide
Mononitrate (Extended Release) until advised to restart by your
care providers.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
========
Ventricular Tachycardia
Atrial Fibrillation
Transient Ischemic Attack
Acute on Chronic Systolic Heart Failure
Type II NSTEMI
SECONDARY:
==========
Anemia
Hypertension
Hyperlipidemia
Neuropathy
Infrarenal Abdominal Aneurysm
Right Iliac Aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___,
You were admitted to ___
due to an abnormally fast heart rate called ventricular
tachycardia (VT). This heart rate can be fatal. You underwent a
procedure called ventricular tachycardia ablation to stop this
fatal heart rate. The procedure worked well, however, this was
complicated by serious but transient neurological defect called
a Transient Ischemic Attack (TIA). These neurological symptoms
resolved and you have minimal residual issues. You also have
another abnormal heart rate called Atrial Fibrillation (AFib)
for which you take Amiodarone. You were taking Warfarin to
prevent stroke from AFib; this medication was changed to Eliquis
(also known as Apixaban). Lastly, you were given extra diuretic
(Lasix) to allow you to urinate off extra fluid that was noted.
No evidence of the dangerous heart rate, VT, was noted while
monitoring you continuously after the ablation procedure but you
were found to have intermittent AFib. You are feeling better and
will be going to rehab to become stronger.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
===========================================
- Work on getting stronger in rehab.
- Please take your medications as directed.
- Follow up at the listed appointments.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10649731-DS-18
| 10,649,731 | 27,139,181 |
DS
| 18 |
2165-04-09 00:00:00
|
2165-04-12 17:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Confused
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ man w/PMHx prostate cancer s/p cyberknife, DM type 2, Stage
III CKD, dementia, recent admission for toxic metabolic
encephalopathy discharged to nursing facility on ___
presenting
with altered mental status.
Per discussion with nursing, patient was found speaking to a
remote control as it was a phone this morning. Over the day had
increasing confusion, minimal responsiveness, dyspraxia when
trying to pick up utensils and difficulty ambulating. No
witnessed falls. No recent fever or chills per facility. He had
been taking all his medications as scheduled. Sent in for workup
of altered mental status.
Past Medical History:
- prostate ca s/p cyberknife
- dementia
- type 2 diabetes
- hypothyroidism
- gout
- stage 3 CKD
- glaucoma
Social History:
___
Family History:
Unable to obtain given encephalopathy
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
___ Temp: 98.2 PO BP: 181/79 HR: 79 RR: 16 O2
sat: 97% O2 delivery: RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Corneal arcus. Sclera anicteric and
without injection. MMM.
NECK: No cervical lymphadenopathy.
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.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: Warm. Cap refill wnl. No rash.
NEUROLOGIC: Alert, oriented to self, ___, ___
(although nursing just asked him and told him answers 3 mins
prior to my exam). speech often unintelligible or nonsensical.
DISCHARGE PHYSICAL EXAM
========================
24 HR Data (last updated ___ @ 2213)
Temp: 98.8 (Tm 98.8), BP: 158/77 (110-164/68-77), HR: 68
(68-77), RR: 16 (___), O2 sat: 97% (97-100), O2 delivery: Ra
GENERAL: Awake, alert, A&Ox3
CARDIAC: RRR, normal s1/s2, diastolic murmur
LUNGS: Clear to auscultation posteriorly, no wheezes or crackles
ABDOMEN: Soft, nontender, nondistended
BACK: No point tenderness, no paraspinal tenderness, negative
leg
raise bilaterally
EXTREMITIES: Warm, no edema
Pertinent Results:
ADMISSION LABS
===============
___ 04:45PM BLOOD WBC-4.9 RBC-3.44* Hgb-11.3* Hct-33.3*
MCV-97 MCH-32.8* MCHC-33.9 RDW-14.6 RDWSD-51.8* Plt ___
___ 04:45PM BLOOD Neuts-56.1 ___ Monos-9.3 Eos-1.2
Baso-0.6 Im ___ AbsNeut-2.72 AbsLymp-1.58 AbsMono-0.45
AbsEos-0.06 AbsBaso-0.03
___ 04:45PM BLOOD Glucose-122* UreaN-30* Creat-2.4* Na-140
K-4.6 Cl-103 HCO3-22 AnGap-15
___ 04:45PM BLOOD ALT-10 AST-23 AlkPhos-47 TotBili-0.5
___ 04:45PM BLOOD Albumin-4.3 Calcium-9.6 Phos-3.9 Mg-2.2
___ 04:45PM BLOOD VitB12-743
___ 04:45PM BLOOD TSH-18*
___ 04:45PM BLOOD T3-49* Free T4-0.7*
___ 05:25PM BLOOD Lactate-0.8
DISCHARGE LABS
==============
___ 05:50AM BLOOD WBC-5.3 RBC-3.14* Hgb-10.2* Hct-30.4*
MCV-97 MCH-32.5* MCHC-33.6 RDW-14.5 RDWSD-51.4* Plt ___
___ 05:50AM BLOOD Plt ___
___ 09:07AM BLOOD Glucose-144* UreaN-23* Creat-2.1* Na-141
K-4.6 Cl-105 HCO3-22 AnGap-14
___ 05:50AM BLOOD ALT-12 AST-30 CK(CPK)-1288* AlkPhos-47
TotBili-0.8
___ 09:07AM BLOOD Calcium-9.4 Phos-3.5 Mg-2.1
PERTINENT IMAGING
=================
CT A/P
1. Small amount of nonspecific perinephric fluid bilaterally,
but very likely incidental in this age group. The kidneys appear
normal on this noncontrast CT, although the parenchyma is not
well evaluated without contrast. No renal stones are identified.
No hydronephrosis.
2. No acute intra-abdominal findings.
3. Two subtle subsolid nodules in the right middle lobe,
measuring up to 6 mm. For incidentally detected multiple
subsolid nodules smaller than 6mm, CT follow-up in 3 to 6 months
is recommended. If the nodules are stable, CT follow-up in 2 and
___ years should be considered.
Brief Hospital Course:
BRIEF HOSPITAL SUMMARY
======================
Mr. ___ is an ___ man with past history of prostate cancer
s/p cyberknife, type 2 diabetes, stage III CKD, and recent
admission for toxic metabolic encephalopathy who presented again
with acute altered mental status, found to be hypothyroid and
with ___. He required chemical and physical restraints given
severe agitation but rapidly improved and per family, was back
to mental baseline. A CT A/P was done given his complaint of
left flank pain, and the imaging showed no acute abnormalities.
His pain was well controlled with Tylenol and he was discharged
back to his facility.
ACUTE ISSUES
============
# TOXIC METABOLIC ENCEPHALOPATHY
# DEMENTIA
Mr. ___ has dementia, thought to be Alzheimers per his
longtime PCP who has followed him since ___, who reports that
he has had significant decline over the past few years. There
was also thought ___ Body dementia per psychiatry evaluation
on his last hospital admission. This admission he presented with
acute encephalopathy, per family and nursing report at his
rehab. Two days prior to admission he became more confused, was
unable to walk, didn't know how to eat on his own, and was
yelling at the television and using his remote control like a
telephone. A few days prior he had started complaining of
intermittent left flank pain. At ___ he was very agitated on
arrival, requiring significant amounts of haloperidol. He was
subsequently somnolent the following day, then woke up confused
but calm. His mental status rapidly cleared with resolution of
his ___. A CT A/P was done to evaluate his left flank pain, and
it showed no nephrolithiasis or any other acute process. He was
also found to be significantly hypothyroid and his levothyroxine
was uptitrated. This encephalopathic episode was likely
multifactorial, secondary to his poor substrate exacerbated by
___ and ___. CTH showed no intracranial process, CXR showed no
infection, and UA showed no infection. Serum and utox were
negative, and though on last admission there was concern for
alcohol misuse, this time his nurse and family report he has no
access to alcohol at rehab and his B12 levels were normal.
# BACK PAIN
Likely musculoskeletal given no spinal or paraspinal tenderness
and negative leg raise. The pain comes and goes and is well
controlled with Tylenol. It will be important to control his
pain given his vulnerability to developing encephalopathy.
# ___ ON CKD
Likely prerenal given consistent FeNa and improvement with
fluids.
# HYPOTHYROIDISM
Has been on 75mcg levothyroxine for several years. TSH and free
T4 consistent with hypothyroidism. Uptitrated to 88mcg
levothyroxine daily.
TRANSITIONAL ISSUES
===================
[ ] Mr. ___ complained of intermittent left flank pain that is
well controlled with Tylenol. The CT A/P showed no acute
abnormalities. This pain is likely musculoskeletal. If it
persists and does not improve, it may warrant further workup.
Please treat his pain with Tylenol three times a day, scheduled,
for 5 days. Afterwards, please continue the Tylenol as needed.
[ ] Mr. ___ has severe hypothyroidism, likely contributing to
his mental status. He has been taking 75mcg levothyroxine for
several years, per his refill history. We uptitrated his
levothyroxine to 88mcg. He will need continued TSH monitoring
and titration.
#CODE: Full (presumed)
#CONTACT:
Name of health care proxy: ___
___: daughter
Phone number: ___
Rehab facility: ___ ___
Prior PCP: Dr. ___ ___
Time spent coordinating discharge > 30 minutes
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
4. FoLIC Acid 1 mg PO DAILY
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Memantine 10 mg PO DAILY
7. Thiamine 100 mg PO DAILY
8. Ramelteon 8 mg PO QHS
9. Losartan Potassium 50 mg PO DAILY
10. Januvia (SITagliptin) 100 mg oral DAILY
11. Travatan 0.004% Ophth Soln (*NF*) 1 drop Other BID
12. QUEtiapine Fumarate 12.5 mg PO QHS
Discharge Medications:
1. Acetaminophen 650 mg PO TID
RX *acetaminophen 650 mg 1 tablet(s) by mouth three times a day
Disp #*15 Tablet Refills:*0
2. Levothyroxine Sodium 88 mcg PO DAILY
RX *levothyroxine 88 mcg 1 tablet(s) by mouth daily Disp #*90
Tablet Refills:*0
3. Allopurinol ___ mg PO DAILY
4. Cyanocobalamin 1000 mcg PO DAILY
5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
6. FoLIC Acid 1 mg PO DAILY
7. Januvia (SITagliptin) 100 mg oral DAILY
8. Losartan Potassium 50 mg PO DAILY
9. Memantine 10 mg PO DAILY
10. QUEtiapine Fumarate 12.5 mg PO QHS
11. Ramelteon 8 mg PO QHS
12. Thiamine 100 mg PO DAILY
13. Travatan 0.004% Ophth Soln (*NF*) 1 drop Other BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
TOXIC METABOLIC ENCEPHALOPATHY
DEMENTIA
BACK PAIN
___ ON CKD
HYPOTHYROIDISM
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was our pleasure to care for you at ___. You came to the
hospital because you were very confused.
WHAT HAPPENED IN THE HOSPITAL?
- You were very agitated and required medications to help you
relax.
- You had a CT scan of your abdomen and pelvis, which showed
nothing abnormal.
- You were found to have a kidney injury, which improved with
fluids.
- Your thyroid levels indicated that you need higher doses of
levothyroxine.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- Please come back to the hospital if you feel very confused
again.
- Be sure to eat and drink every day to maintain your hydration.
This is important for your kidneys.
- We recommend that you see a geriatrician and a geriatrician
psychiatrist. You can make an appointment by calling
___.
- We agree that it is important to fix your hearing aids. This
will help you better communicate with your caregivers and your
family.
We wish you the best!
Sincerely,
Your care team at ___
Followup Instructions:
___
|
10649932-DS-18
| 10,649,932 | 20,867,100 |
DS
| 18 |
2182-10-08 00:00:00
|
2182-10-08 16:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ female with a past medical history
of right breast cancer status post bilateral mastectomy,
adjuvant
chemo and most recent delay bilateral ___ reconstruction who
presents from clinic with shortness of breath and new finding of
PE.
Patient reports that she first started noticing shortness of
breath around a week ago, and it has worsened over time. She
notes that this only occurs with exertion, and that she feels
fine at rest. It was especially noticeable when walking up
stairs
- feels severely short of breath by the time she reached the
top.
This is in the setting of left calf pain, which also started
fairly recently with no known trauma. No chest pain, fevers or
chills. She had a scheduled postop visit today in the plastic
surgery clinic. After hearing about her symptoms, she was sent
for a CTA which revealed bilateral segmental and subsegmental
pulmonary embolisms involving the right lower and upper and left
lower lobes without radiographic signs of pulmonary
hypertension.
In addition, showed postoperative changes related to bilateral
breast reconstruction with 1.4 x 13 cm fluid collection inferior
to the right pectoralis muscle, could represent postoperative
seroma however abscess cannot be excluded given the partial rim
enhancement. Given these findings, she was sent to the ED.
On review of records, patient was admitted from ___ through
___ for a bilateral breast reconstruction surgery, which was
without complication.
In the ED:
Initial vital signs were notable for: T 98.9, HR 77, BP 137/79,
RR 20, 99% RA
Exam notable for: Resp: No incr WOB, CTAB.
Labs were notable for:
- CBC: WBC 5.0, hgb 11.5, plt 205
- Lytes:
140 / 103 / 13 AGap=18
--------------- 83
5.0 \ 19 \ 0.8
- Trop-T: <0.01
- BNP 205
Studies performed include: No further studies were performed.
Consults: Pastic surgery was consulted given findings on CT
chest. Plan to observe this fluid collection for now. No need
for
abx for this or the lower abdominal incision.
Patient was started on a heparin gtt.
Vitals on transfer: T 98.0, HR 67, BP 118/76, RR 14, 96% RA
Upon arrival to the floor, patient recounts history as above.
She
is hungry and has a mild headache.
Past Medical History:
-H/o skin cancer
-H/o R breast cancer (___) s/p bilateral mastectomy, ALND,
adjuvant XRT/chemo and silicone implant-based reconstruction,
now
s/p delayed bilateral ___ reconstruction (___)
-s/p oophorectomy (___)
Social History:
___
Family History:
No family history of breast cancer, ovarian cancer, melanoma,
DVTs or other blood clots
Physical Exam:
Admission Physical Exam:
========================
VITALS: T 98.4, HR 76, BP 132/95, RR 18, 96% Ra
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Left calf mildly tender to palpation, slightly swollen
compared to right. No erythema. Full ROM of ankle joint without
pain
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Discharge Physical Exam:
========================
VITALS: see Eflowsheets
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended
GU: No foley
MSK: Left calf mildly tender to palpation, minimally swollen
compared to right. No erythema. Full ROM of ankle joint without
pain
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
Admission Labs:
===============
___ 04:58PM BLOOD WBC-5.0 RBC-3.96 Hgb-11.5 Hct-36.4 MCV-92
MCH-29.0 MCHC-31.6* RDW-12.5 RDWSD-41.8 Plt ___
___ 04:58PM BLOOD Neuts-53.0 ___ Monos-7.8 Eos-4.6
Baso-0.6 Im ___ AbsNeut-2.63 AbsLymp-1.67 AbsMono-0.39
AbsEos-0.23 AbsBaso-0.03
___ 04:58PM BLOOD Glucose-83 UreaN-13 Creat-0.8 Na-140
K-5.0 Cl-103 HCO3-19* AnGap-18
___ 04:58PM BLOOD cTropnT-<0.01 proBNP-205*
Imaging:
========
CTA Chest:
1. Left lobar and bilateral segmental and subsegmental pulmonary
embolisms.
No signs of right heart strain or pulmonary hypertension.
2. Postoperative changes related to bilateral breast
reconstruction with 1.4 x 13 cm fluid collection inferior to the
right pectoralis muscle, could represent postoperative seroma
however abscess cannot be excluded given the partial rim
enhancement.
3. 2 mm right lower lobe nodule.
Discharge Labs:
===============
___ 06:30AM BLOOD ___ PTT-81.4* ___
___ 06:30AM BLOOD Glucose-88 UreaN-11 Creat-0.7 Na-142
K-4.3 Cl-107 HCO3-22 AnGap-13
___ 06:30AM BLOOD Calcium-8.8 Phos-4.6* Mg-2.3
Brief Hospital Course:
Ms. ___ is a ___ female with a past medical history
of right breast cancer status post bilateral mastectomy,
adjuvant chemotherapy and most recent delay bilateral ___
reconstruction who presented from clinic with shortness of
breath and new finding of PE.
ACUTE/ACTIVE PROBLEMS:
# Acute bilateral pulmonary embolism: presented with shortness
of breath and calf pain after recent ___ reconstruction and was
found that have left lobar and bilateral segmental and
subsegmental pulmonary embolisms. There was no evidence of right
heart strain on EKG (mild T wave inversions were present in III
but not clearly different from priors). Troponin was negative.
BNP was only very slightly elevated (205, upper limit of normal
195). Given history of malignancy she was admitted overnight for
monitoring. She remained hemodynamically stable with no oxygen
requirement.
Patient confirms that her breast cancer is in remission. Her PE
was likely provoked by recent breast reconstruction
surgery/immobility, and she may have also been at increased clot
risk due to tamoxifen use. Given no evidence of any active
malignancy, decision was made to initiate anticoagulation with
rivaroxaban.
Tamoxifen was held at discharge given increased clot risk with
this medication (this was discussed with ___ oncology since
patient's own oncologist was unable to be reached). She will
discuss with her oncologist whether or not to restart tamoxifen.
# s/p breast reconstruction
# Post operative fluid collection - likely seroma
Found to have a post-operative breast fluid collection on CTA,
seroma vs. abscess. She had no infectious signs or symptoms. She
was seen by plastic surgery who felt that fluid was consistent
with post-operative seroma with no concern for infection at this
time.
Aspirin had been started post-operatively to prevent clot
formation at site of breast reconstruction. Aspirin was stopped
this admission after initiation of full dose anticoagulation for
PE.
# History of breast cancer: held home tamoxifen as above
CHRONIC/STABLE PROBLEMS:
# Depression: continued home sertraline
> 30 minutes spent on discharge coordination and planning
Transitional Issues:
====================
- discharged on rivaroxaban dose pack
- tamoxifen held at discharge. Requires discussion with
outpatient oncologist about whether or not to restart
- held aspirin at discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H pain, HA, T>100 degrees
2. Sertraline 75 mg PO DAILY
3. Aspirin 121.5 mg PO DAILY
4. Tamoxifen Citrate 20 mg PO DAILY
5. Ibuprofen 800 mg PO BID:PRN Pain - Mild
Discharge Medications:
1. Rivaroxaban 15 mg PO BID
with food
RX *rivaroxaban [Xarelto] 15 mg 1 tablet(s) by mouth twice a day
Disp #*42 Tablet Refills:*0
2. Acetaminophen 650 mg PO Q6H pain, HA, T>100 degrees
3. Sertraline 75 mg PO DAILY
4. HELD- Tamoxifen Citrate 20 mg PO DAILY This medication was
held. Do not restart Tamoxifen Citrate until discussing with
your oncologist
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Pulmonary embolism, acute
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were sent to the emergency room from the plastic surgery
clinic after you reported shortness of breath. You were found to
have several blood clots in your lungs. You were started on an
IV blood thinner to treat the clots, and then switched to an
oral blood thinner that you will need to take at home.
It is very important to take the blood thinner (rivaroxaban)
twice a day with food and to not miss any doses.
Please call your primary doctor on ___ to schedule follow up
for next week. You should also stop taking tamoxifen for now
until you discuss more with your oncologist.
It was a pleasure taking care of you, and we are happy that
you're feeling better!
Followup Instructions:
___
|
10650001-DS-24
| 10,650,001 | 21,380,960 |
DS
| 24 |
2136-11-24 00:00:00
|
2136-11-24 17:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Anesthesia IV Set-Clamp / Flagyl
Attending: ___.
Chief Complaint:
slurred speech, right facial droop
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Ms. ___ is a ___ year-old right-handed woman with h/o
atrial fibrillation on coumadin who presents with slurred speech
and R facial droop.
The patient was last seen normal at 13:00. She was at home with
her son. At 13:30 he noticed her speech suddenly became slurred.
She was speaking in full sentences and making senses, no
incorrect words, but the speech was difficult to understand due
to slurring. He also noticed the R lower face was drooping. This
lasted for 30 minutes, and then improved. She was not tired or
confused afterwards. She was able to walk with her walker as
usual. At 14:30, the same symptoms recurred. The patient c/o R
face numbness. She denies any numbness, tingling or weakness of
the arm or leg. This time the son called ___, EMS noted R
pronator drift and otherwise R facial droop and dysarthria only.
The patient was able to move arm and leg and squeeze hands
strongly.
On arrival to the ED, the patient still had dysarthria and R
facial droop, but no pronator drift. She underwent NCHCT as code
stroke. Given creatinine and age, CTA/P was not done. INR was
low
at 1.7. Infectious workup negative.
She has never had TIA or stroke in the past.
ROS:
(+)
(-) headache, loss of vision, blurred vision, diplopia,
dysphagia, vertigo, difficulties producing or comprehending
speech, difficulty with gait.
No fever, chills, cough, shortness of breath, chest pain or
tightness, palpitations, nausea, vomiting, diarrhea,
constipation
or abdominal pain.
Past Medical History:
-PAF
-polycythemia ___
-postprandial hypotension
-HTN
-___ edema
-R rotator cuff tear
-mitral regurgitation
-osteoporosis
-osteoarthritis
-diverticulosis
-s/p R TKR
-s/p hysterectomy
Social History:
___
Family History:
Non-contributory
Physical Exam:
Physical Exam on Admission:
Vitals: afebrile HR: 58 BP: 180/78 Resp: 18 O(2)Sat: 98 Normal
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: irregular, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was mildly dysarthric. Able
to follow both midline and appendicular commands. Pt. was able
to
register 3 objects and recall ___ at 5 minutes ___ with
multiple
choice). There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. Possible R superior visual
deficit
but inconsistent on exam.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch and pinprick.
VII: R lower facial droop and decreased excursion, full strength
eye closure.
VIII: Hearing intact to voice bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally (cannot supinate R very well due to rotator cuff)
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 5 ___ 5 5- 5 5 4+ 5 5
R 5 ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
proprioception throughout. No extinction to DSS. Intact cortical
sensory modalities (graphethesia)
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 0
R 2 2 2 1 0
Plantar response was extensor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: deferred
Physical Exam on Discharge:
Significant for fluctuating orientation with occasional
confusion, otherwise normal mental status with fluent speech and
intact comprehension, follows commands well. Pupils equal and
reactive, EOMI, +R lower facial droop. +R pronator drift,
strength otherwise full and symmetric. Slow finger tapping on R.
Sensation intact to light touch. Toes upgoing bilaterally.
Pertinent Results:
___ 11:39PM PTT-98.1*
___ 04:42PM GLUCOSE-90 NA+-143 K+-5.1 CL--104 TCO2-23
___ 04:25PM UREA N-36*
___ 04:25PM CREAT-1.6*
___ 04:25PM estGFR-Using this
___ 04:25PM CK(CPK)-37
___ 04:25PM CK-MB-3
___ 04:25PM cTropnT-<0.01
___ 04:25PM WBC-9.6 RBC-5.79* HGB-15.9 HCT-52.5* MCV-91
MCH-27.5 MCHC-30.4* RDW-17.7*
___ 04:25PM ___ PTT-51.4* ___
___ 04:25PM PLT COUNT-272
___ 07:09AM URINE Color-Yellow Appear-Hazy Sp ___
___ 07:09AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
___ 07:09AM URINE RBC-1 WBC-33* Bacteri-MOD Yeast-NONE
Epi-<1
Noncontrast CT head ___:
IMPRESSION: Focal hypodensity within the left external capsule
of indeterminate age, but most likely chronic. No acute
intracranial hemorrhage. If there remains a high clinical
suspicion for acute ischemia, MRI is more sensitive.
MRI/A head and neck: ___:
IMPRESSION:
1. Acute infarct in the left perirolandic region as described
above.
2. Small vessel ischemic disease.
3. High-grade stenosis of proximal P2 segment of left posterior
cerebral
artery. Otherwise, unremarkable MRA of the head.
4. Unremarkable MRA of the neck.
Carotid US ___:
Impression: Right ICA <40% stenosis.
Left ICA <40% stenosis.
Transthoracic echo ___:
IMPRESSION: No ASD seen. Mild symmetric LVH with normal global
and regional biventricular systolic function. Moderate mitral
regurgitation. Mild pulmonary hypertension.
CXR ___:
IMPRESSION: Mild pulmonary edema and presumed small left pleural
effusion, new since ___.
Brief Hospital Course:
___ year-old right-handed woman with h/o atrial fibrillation on
coumadin who presents with slurred speech and R facial droop.
The patient developed dysarthria and R facial droop transiently
for 30 minutes, improved for about 30 minutes, then again
developed the same symptoms which persisted this time. Neuro
exam demonstrated mild dysarthria, R UMN facial droop, mild R
finger ext and ham weakness but no pronator drift, and upgoing
toes bilaterally, likely due to cervical stenosis. INR was
subtherapeutic at 1.7 and patient is in A fib, thus the most
likely etiology is cardioembolic. CTA could not be performed
given elevated creatinine. She was admitted to the stroke
service for further work-up.
Neuro:
MRI showed multiple small infarcts, largest in L ___
area with smaller infarcts in L occipital lobe and R cerebellum.
MRA showed high grade L P2 stenosis. She was started on a
heparin drip with goal PTT 40-50 for bridging until her INR
became therapeutic. She was continued on her home coumadin
regimen. Carotid US showed <40% stenosis b/l. Lipid panel
revealed total chol 176, ___ 111, HDL 54, LDL 100. A1c was 5.5%.
She was continued on her home propranolol and lasix; lisinopril
was initially held to allow for autoregulation and then
restarted at 10mg daily ___ her home dose). She will resume
taking her home dose of 20mg daily upon discharge.
Her dysarthria resolved but she continued to have a R lower
facial droop as well as mild weakness of her R arm with a R
pronator drift and slowed finger tapping. She was cleared for a
regular diet by speech therapy. She was seen by ___ and OT who
felt that she was safe to return home with her current home
services as well as home ___ and OT. She will also require close
24-hour supervision by her family.
On the morning of ___ she was noted to be confused with
apparent visual hallucinations. This episode resolved on its own
and she returned to baseline. Per her son this has been
happening nearly daily for the last few months. She was
afebrile; UA was positive and she was started on ceftriaxone IV.
CXR showed mild pulmonary edema - she received an extra dose of
Lasix 20mg IV. She subsequently had a second episode of mild
confusion and lethargy, complained of feeling tired with some
stomach discomfort. She was triggered for BP 194/89. EKG was
unchanged and cardiac markers were negative. She was restarted
on lisinopril 10mg daily. She was given maalox for her stomach
discomfort with some improvement.
Her confusion improved with treatment of her UTI. She received
seroquel 12.5mg x 1 for agitation overnight on ___. She did not
require any further medication and subsequently returned to her
baseline.
She has a follow up appointment scheduled with Dr. ___ in
stroke clinic on ___.
CV:
She was maintained on telemetry monitoring. BP was managed as
above. She was restarted on her home lisinopril upon discharge.
ID:
UTI was treated with 3 days of ceftriaxone IV. She lost her IV
prior to her third dose and it was unable to be replaced; she
received one dose of PO cefpodoxime 200mg. She remained afebrile
with no additional signs of infection.
Heme:
Hematology was consulted given her history of polycythemia ___
in the setting of acute stroke. Hct was 52 on admission.
Therapeutic phlebotomy was performed x 2. CBC was monitored
closely with a goal Hct < 45%. Hct upon discharge was 37.8. She
should follow up with her hematologist Dr. ___ discharge.
Endo:
She was maintained on fingersticks ACHS and humalog SSI.
Prophylaxis:
She was maintained on coumadin for DVT prophylaxis. She was
maintained on a bowel regimen for GI prophylaxis. Fall and
aspiration precautions were observed.
Dispo:
She was discharged home in good condition on ___. She will
require home nursing services via ___ as well as home ___ and OT.
Transitional care issues:
INR will need to be monitored closely in order to ensure that it
stays within the goal range of ___. Coumadin was held on ___
due to supratherapeuic INR of 3.3. She was instructed to have a
repeat INR checked on ___.
She will need continued ___ and OT to regain her prior level of
functioning. She will also require home nursing services as well
as 24-hour supervision from her family.
Medications on Admission:
Medications - Prescription
AMIODARONE - 200 mg Tablet - half Tablet(s) by mouth once a day
CALCIUM WITH VITAMIN D - - by mouth twice a day
FUROSEMIDE - (Dose adjustment - no new Rx) - 20 mg Tablet - 1
Tablet(s) by mouth once a day take an additional 20mg if weight
>
110.5 pounds
HYDROXYUREA - (Dose adjustment - no new Rx) - 500 mg Capsule -
1
Capsule(s) by mouth on ___,
and ___ each week beginning ___.
___ STOCKINGS - - Support hose as directed (ultrasheer)
daily
as tolerated knee-high length
LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth twice a day
PROPRANOLOL - 60 mg Capsule,Extended Release 24 hr - 1
Capsule(s)
by mouth twice a day
WARFARIN - (Prescribed by Other Provider) - 1 mg Tablet - 2.5
Tablet(s) by mouth five days /week and 1.25mg on ___ & ___
Medications - OTC
ACETAMINOPHEN [ACETAMINOPHEN EXTRA STRENGTH] - (Prescribed by
Other Provider) - 500 mg Tablet - 2 Tablet(s) by mouth ___ times
a day as needed for headache or R shoulder pain
MULTIVITAMIN [MULTIPLE VITAMIN] - Tablet - 1 (One) Tablet(s)
by mouth daily
RANITIDINE HCL - (OTC) - 75 mg Tablet - 1 Tablet(s) by mouth
once a day
SENNOSIDES-DOCUSATE SODIUM [___] - 8.6 mg-50 mg Tablet -
1 (One) Tablet(s) by mouth twice a day
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: 0.5 Tablet PO twice a day.
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily): ___,
and ___.
5. ranitidine HCl 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. propranolol 60 mg Capsule,Extended Release 24 hr Sig: One (1)
Capsule,Extended Release 24 hr PO BID (2 times a day).
7. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO 5X/WEEK
(___): SHOULD BE HELD ___. INR should be
rechecked ___.
8. warfarin 2.5 mg Tablet Sig: 0.5 Tablet PO 2X/WEEK (TH,SA).
9. lisinopril 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day.
11. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for redness/yeast: apply to areas of
redness under breasts
.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Cardioembolic infarcts (left perirolandic area, left occipital
lobe, right cerebellum)
UTI
Delirium
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neurologic: Significant for fluctuating orientation with
occasional confusion, otherwise normal mental status with fluent
speech and intact comprehension, follows commands well. Pupils
equal and reactive, EOMI, +R lower facial droop. +R pronator
drift, strength otherwise full and symmetric. Slowed finger
tapping on R. Sensation intact to light touch. Toes upgoing
bilaterally.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ on
___ after two episodes of slurred speech and right
facial droop. You were found to have several small strokes
likely related to your atrial fibrillation. Your INR (coumadin
level) was low at 1.7 on your admission. You were started on an
intravenous blood thinner called heparin until your INR level
was at goal between ___. It is very important that your INR be
monitored closely to keep it within this goal range in order to
prevent future strokes. You also had ultrasounds of your carotid
arteries which showed no significant narrowing. You also had an
echocardiogram which was normal and showed no cardiac source for
your stroke.
During your admission you were also found to have a urinary
tract infection which was treated with 3 days of an IV
antibiotic called ceftriaxone. You had some confusion during
your hospital stay likely related to this infection; this has
now improved.
You were seen by physical therapy who felt that you are safe to
return home with the services you have in place along with home
___ and OT. You will also require close 24-hour supervision by
your family.
We made the following changes to your home medications:
HELD comuadin ___ you should have a repeat INR checked
tomorrow ___ and will be advised whether to restart your
coumadin at that time based on your INR.
You should continue to take the rest of your medications as
prescribed. Our hematology team recommended that you do not take
any vitamins or supplements containing iron.
If you experience any of the below listed danger signs, please
call your doctor or go to the nearest Emergency Department.
It was a pleasure taking care of you during your hospital stay.
Followup Instructions:
___
|
10650197-DS-3
| 10,650,197 | 26,106,492 |
DS
| 3 |
2177-08-04 00:00:00
|
2177-08-04 15:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Gait unsteadiness and right hemisensory disturbance
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with T2DM, HTN, prior SVT, bladder ca s/p TURBT, gout
presents with acute onset light-headedness and right-sided
weakness with right hemisensory disturbance.
Patient had been in his usual state of health until the am of
___ had awoken normally and after eating breakfast
noted
at roughly 07:30 that he was light-headed. This was then
associated with gait difficulties (unsteady and slow) note by
his
wife and patient noticed right-sided weakness and that he was
tending to the left. His wife called his PCP and was ___
for stroke and patient noted that he could not lift his right
arm
as high as left. At this time he als noticed right face, arm and
leg sensory duisturance and decreased sensation. Patient
described this as a feeling on this side of everything being
"swollen".
He presented for evaluation at ___.
He still notes right-sided weakness and right sensory
disturbance
has persisted an dlaso notes dysarthria.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysphagia, vertigo, tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech. No bowel or bladder incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
Transitional cell bladder ca s/p TURBT
HTN
T2DM on metformin
RBBB
SVT
Gout
Left total knee replacement
Colonic polyps
memory loss
Social History:
___
Family History:
Mother - died old age ___
Father - kidney problems die ___
Sibs - ___ died ___ of ca off urinary tract
Children - 1 son died of AIDs others well
There is no history of seizures, developmental disability,
learning disorders, migraine headaches, strokes less than 50,
neuromuscular disorders, or movement disorders.
Physical Exam:
ADMISSION
Physical Exam:
Vitals: T:98.6 P:66 sinus pauses vs intermittent HB on monitor
R:18 BP:156/88 SaO2:100% RA
General: Awake, cooperative notes right weakness. Hard of
hearing.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, bilateral transmitted murmur in carotids. No
nuchal
rigidity.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR and period sof pauses ? intermittent HB, nl. S1S2
with liud ESM radiating to carotids loudest at aortic area
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: Mild pitting edema to shins bilaterally. 2+ radial,
DP pulses bilaterally. Calves SNT bilaterally.
Skin: no rashes or lesions noted.
Neurological examination:
___ Stroke Scale score was 4
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 0
5a. Motor arm, left: 0
5b. Motor arm, right: 1
6a. Motor leg, left: 0
6b. Motor leg, right: 1
7. Limb Ataxia: 0
8. Sensory: 1
9. Language: 0
10. Dysarthria: 1
11. Extinction and Neglect: 0
- Mental Status:
ORIENTATION - Alert, oriented x 3
The pt. had good knowledge of current events.
SPEECH
Able to relate history without difficulty.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors.
Speech was mildly dysarthric.
NAMING Pt. was able to name both high and low frequency objects.
READING - Able to read without difficulty
ATTENTION - Attentive, able to name ___ backward without
difficulty.
COMPREHENSION
Able to follow both midline and appendicular commands
There was no evidence of apraxia or neglect.
- Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2.5 to 2mm and brisk. VFF to confrontation.
Funduscopic
exam reveals no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal pursuits and
saccades.
V: Facial sensation decreased tl LT and pinprick on right. Good
power in muscles of mastication.
VII: Slight right NLF flattening.
VIII: Decreased hearing in general.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline with normal velocity movements.
- Motor: Normal bulk, tone throughout. Right pronator drift.
No adventitious movements, such as tremor, noted. No asterixis
noted.
SAbd SAdd ElF ElE WrE FFl FE HipF HipE KnF KnE AnkD AnkP
L 5 5 ___ 5 5 5 5 5 5 5 5
R 4 5 ___ 5 4+ 4 5 4 5 5 5
- Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense in UE and ___ on left. All decreased on right arm
and leg. No extinction to DSS.
- DTRs:
BJ SJ TJ KJ AJ
L ___ 2 0
R ___ 2 0
Reflexes brisker on right in the UE.
There was no evidence of clonus.
___ negative. Pectoral reflexes absent.
Plantar response was mute on the right and flexor on the left.
- Coordination: No intention tremor, clumsy finger tapping on
right. No dysmetria on FNF or HKS bilaterally.
- Gait: Deferred.
Pertinent Results:
___ 07:30PM BLOOD WBC-8.7 RBC-4.16* Hgb-12.3* Hct-38.9*
MCV-94 MCH-29.6 MCHC-31.6 RDW-13.9 Plt ___
___ 07:22AM BLOOD WBC-7.2 RBC-3.81* Hgb-11.0* Hct-35.4*
MCV-93 MCH-28.9 MCHC-31.2 RDW-13.6 Plt ___
___ 07:30PM BLOOD Neuts-76.1* Lymphs-17.2* Monos-3.6
Eos-2.5 Baso-0.6
___ 07:30PM BLOOD ___ PTT-31.5 ___
___ 07:30PM BLOOD Plt ___
___ 09:30AM BLOOD ___ PTT-30.8 ___
___ 07:22AM BLOOD Plt ___
___ 07:30PM BLOOD Glucose-210* UreaN-29* Creat-1.3* Na-139
K-4.2 Cl-99 HCO3-27 AnGap-17
___ 07:22AM BLOOD Glucose-156* UreaN-25* Creat-1.0 Na-140
K-4.0 Cl-101 HCO3-31 AnGap-12
___ 09:30AM BLOOD ALT-15 AST-15 LD(LDH)-133 CK(CPK)-105
AlkPhos-44 Amylase-69 TotBili-0.5
___ 09:30AM BLOOD CK-MB-3 cTropnT-<0.01
___ 09:30AM BLOOD Albumin-3.9 Calcium-9.3 Phos-2.9 Mg-1.6
Iron-58 Cholest-143
___ 07:22AM BLOOD Calcium-9.0 Phos-3.5 Mg-1.8
___ 09:30AM BLOOD calTIBC-299 Ferritn-207 TRF-230
___ 09:30AM BLOOD %HbA1c-7.0* eAG-154*
___ 09:30AM BLOOD Triglyc-54 HDL-37 CHOL/HD-3.9 LDLcalc-95
___ 09:30AM BLOOD TSH-2.3
___ ___
IMPRESSION:
1. Left thalamic lacunar infarct, not present on prior CT of
___, but
appears chronic. Chronic small vessel ischemic changes and
right basal
ganglia lacunar infarcts, unchanged.
2. No acute intracranial hemorrhage.
___ CXR
PA AND LATERAL VIEWS OF THE CHEST: The heart size is normal.
Mediastinal and
hilar contours are unremarkable. The pulmonary vascularity is
not engorged.
Streaky opacities in the lung bases likely reflect atelectasis.
No focal
consolidation is visualized. There is no pleural effusion or
pneumothorax.
No acute osseous abnormality is visualized. There appears to be
an old
fracture deformity of the right second anterolateral rib.
IMPRESSION: No acute cardiopulmonary process.
___ 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. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with basal inferior
hypokinesis. Overall left ventricular systolic function is
normal (LVEF>55%). Doppler parameters are indeterminate for left
ventricular diastolic function. There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The ascending aorta is mildly dilated. The aortic arch
is mildly dilated. The aortic valve leaflets (3) are mildly
thickened. There is moderate aortic valve stenosis (valve area
1.0-1.2cm2). No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
IMPRESSION: Probable mild focal hypokinesis with preserved
systolic function. No cardiac source of embolism seen. Mild
mitral regurgitation.
Compared with the prior study (images reviewed) of ___,
the basal inferior segment appears mildly hypokinetic on the
current study. Mild mitral regurgitation is seen.
___ MRI/A
MRI HEAD:
An area of restricted diffusion is noted in the left thalamus,
corresponding
to the hypodensity seen on the CT dated ___. This
shows FLAIR and T2
hyperintensity and represents early subacute infarct. A focus of
hypointensity
is noted on gradient echo images in the area of infarct in the
left thalamus,
which represents microhemorrhage.
There is mild prominence of ventricles, cortical sulci, and
extra-axial CSF
spaces suggestive of mild generalized cerebral volume loss.
Focal and
confluent T2/FLAIR hyperintensities are noted in periventricular
and
subcortical white matter of bilateral cerebral hemispheres,
which likely
represent changes of chronic small vessel ischemic disease.
Small T2 hyperintensities are noted in the right basal ganglia
and right
external capsule, which may represent old lacunar infarcts or
dilated
perivascular spaces.
Brainstem and cerebellum appear normal.
Punctate foci of hypointensity are noted on gradient echo images
in the left
occipital lobe, right side of pons and left cerebellum, which
likely represent
microhemorrhages.
The major intracranial flow voids are maintained. Mucosal
thickening is noted
in bilateral ethmoid air cells and left maxillary sinus.
Post-cataract
extraction status is noted of bilateral globes. The visualized
mastoid air
cells are clear.
MRA HEAD:
The arteries of the anterior circulation including bilateral
intracranial
internal carotid arteries, anterior and middle cerebral arteries
appear
normal. The arteries of the posterior circulation including
bilateral
vertebral arteries and basilar artery appear normal.
There is high-grade narrowing of the proximal P2 segment of the
right
posterior cerebral artery. Multisegment mild narrowing is noted
of P2 segment
of the left posterior cerebral artery.
MRA NECK:
Three-vessel aortic arch is noted. The origins of the great
vessels and
vertebral arteries appear normal. Bilateral common, external
and internal
carotid arteries appear normal. Bilateral vertebral arteries
are patent.
There is no evidence of stenosis or occlusion in the arteries of
neck.
IMPRESSION:
1. Early subacute infarct in left thalamus with a focus of
microhemorrhage
within.
2. Generalized cerebral volume loss with changes of chronic
small vessel
ischemic disease.
3. Foci of microhemorrhages in left occipital lobe, right pons,
and left
cerebellar hemisphere.
4. High-grade stenosis of proximal P2 segment of the right
posterior cerebral
artery.
5. Mild multisegmental narrowing of the P2 segment of left
posterior cerebral
artery.
Brief Hospital Course:
___ h/o DM2, HTN, prior SVT and RBBB, transitional cell
bladder cancer s/p resection, gout p/w lightheadedness, right
facial and hemibody numbness, mild right hemiparesis, mild right
hemiataxia and dysarthria resulting from an acute ischemic
stroke to the left thalamus, most likely due to small vessel
disease. He notably is an alternative medicine
practitioner/adherent and has some resistance to allopathic
therapies (he previously refused aspirin and statin therapy
prescribed by his PCP). His examination gradually improved
during the course of the hospitalization with occasional
fluctuation (e.g. wavering dysarthria and ataxia). He was found
on NCHCT and MRI to have a left thalamic ischemic stroke, most
likely due to small vessel disease. He did also have an
incidentally noted right PCA stenosis that is unrelated to his
current stroke. His TTE did not reveal a shunt. His A1c was 7
and LDL was 95. He was started on Aspirin and a statin. He was
evaluated by ___, OT, and speech and is going to a rehabilitation
facility.
.
PENDING STUDIES: none
.
TRANSITIONAL CARE ISSUES:
[ ] Blood Pressure - Please add back his Lisinopril 20 mg daily
and Furosemide 20 mg qAM as tolerated (ideally, his goal blood
pressure will be normotensive in an SBP range 100-140, but this
should be lowered gradually as precipitous drops may cause
worsening of his stroke symptoms).
[ ] Please make sure that Mr. ___ continues to take aspirin
and a statin for prevention of recurrent stroke.
[ ] Speech - Please continue to evaluate Mr. ___ swallowing
and speech. This fluctuated to some degree during the
hospitalization but our Speech therapist assessed that he was
okay for a regular diet (no modifications to consistency).
[ ] BP - Ideally, Mr. ___ blood pressure should be in a
normotensive range (100-140) in the long term. Consider starting
antihypertensive therapy if needed noting that this might cause
fluctuations in his neurologic examination.
.
[ AHA/ASA Core Measures for Ischemic Stroke and Transient
Ischemic Attack ]
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 95) - () No
5. Intensive statin therapy administered? (for LDL > 100) (x)
Yes - () No (if LDL >100, Reason Not Given: )
6. Smoking cessation counseling given? () Yes - (x) No (Reason
(x) non-smoker - () unable to participate)
7. Stroke education given? (x) Yes - () No
8. Assessment for rehabilitation? (x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No (if LDL >100,
Reason Not Given: )
10. Discharged on antithrombotic therapy? (x) Yes (Type: (x)
Antiplatelet - () Anticoagulation) - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
Medications on Admission:
Medications - Prescription
ALLOPURINOL - 300 mg Tablet - 1 Tablet(s) by mouth once a day
FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth in the morning
LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth daily
METFORMIN - 1,000 mg Tablet - 1 Tablet(s) by mouth twice a day
METOPROLOL TARTRATE - 50 mg Tablet - 1 Tablet(s) by mouth twice
a
day
Medications - OTC
CALCIUM - (Prescribed by Other Provider) - Dosage uncertain
CHOLECALCIFEROL (VITAMIN D3) - (OTC) - 2,000 unit Capsule - 1
Tablet(s) by mouth once a day
CHROMIUM PICOLINATE - (Prescribed by Other Provider) - Dosage
uncertain
FERROUS SULFATE - (chart conversion) - 325 mg (65 mg iron)
Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day
MULTIVITAMIN - (chart conversion) - Tablet - 1 Tablet(s) by
mouth once a day
SELENIUM - (Prescribed by Other Provider) - 200 mcg Tablet - 1
Tablet(s) by mouth daily
VIT B COMP-C-FA-IRON-VIT E [VITAMIN B COMPLEX] - (Prescribed by
Other Provider) - Dosage uncertain
VITAMIN E - (Prescribed by Other Provider) - 1,000 unit Capsule
- 1 Capsule(s) by mouth daily
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS: Occlusion of a cerebral artery,
unspecified/small vessel occlusion
SECONDARY DIAGNOSIS: Hypertension, Diabetess Mellitus Type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neurologic: Awake, alert, speech fluent but mildly dysarthric,
right arm decreased sensation (improving in face and leg), right
side dysmetria.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of RIGHT-SIDE SENSORY
CHANGES, WEAKNESS, DISCOORDINATION, and SLURRED SPEECH resulting
from an ACUTE ISCHEMIC STROKE, a condition where a blood vessel
providing oxygen and nutrients to the brain is blocked by a
clot. The brain is the part of your body that controls and
directs all the other parts of your body, so damage to the brain
from being deprived of its blood supply can result in a variety
of symptoms. Stroke can have many different causes, so we
assessed you for medical conditions that might raise your risk
of having stroke. In order to prevent future strokes, we plan to
modify those risk factors.
We are changing your medications as follows:
1. Please take ASPIRIN 325 mg one tablet daily for prevention of
future stroke.
2. Please take ATORVASTATIN 40 mg one tablet daily for control
of cholesterol and prevention of future stroke. Your goal LDL is
less than 70 (it is currently 95).
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 medical
attention. In particular, since stroke can recur, please pay
attention to the sudden onset and persistence of these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization.
Followup Instructions:
___
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10650200-DS-15
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DS
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2146-02-15 00:00:00
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2146-02-17 15:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: R ureteral stent placement and foley catheter by
Urology
History of Present Illness:
This patient is a ___ year old male who complains of
Transfer, Bicycle accident. The patient was riding his
bicycle down a hill, almost hit a squirrel. He was helmeted
and riding approximately 25 miles an hour. He fell off his
bike attempting to miss the squirrel and landed on his left
side. He did strike his head and he does report a brief loss
of consciousness. He went home and had left sided abdominal
pain and flank pain so he presented to ___
where he underwent a CT torseo showing a grade 4 left renal
injury with extravasation, left third and fourth rib
fractures, a mesenteric hemorrhage in the left upper
quadrant. His c-collar was cleared clinically and he did not
undergone any head or C-spine imaging. He is on any
anticoagulation. He does take a baby aspirin daily. He does
report a headache as well as left-sided abdominal pain,
flank pain. Got morphine and fentanyl PTA. The date of his
last tetanus shot is unknown.
Past Medical History:
HTN
Allergies and Reactions: NKDA
Social History:
___
Family History:
NC
Physical Exam:
Temp: 96.2 HR: 76 BP: 110/78 Resp: 20 O(2)Sat: 96 Normal
Constitutional: Uncomfortable
HEENT: Superficial abrasion to left forehead
No midline C-spine tenderness, neck without any swelling
Chest: Clear to auscultation. Left chest wall tenderness
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, diffuse tenderness on palpation that is
most pronounced in the left abdomen
Rectal: Normal tone per resident exam
GU/Flank: Left CVA tenderness
Extr/Back: No midline spine tenderness, no step-offs or
deformities, left shoulder with anterior tenderness, DP
pulses 2+ bilaterally, pelvis stable
Skin: Superficial abrasions to left anterior shoulder, left
thigh
Neuro: Speech fluent, sensory and motor intact
Pertinent Results:
___ 11:56AM BLOOD WBC-16.7* RBC-4.69 Hgb-14.5 Hct-43.3
MCV-92 MCH-30.9 MCHC-33.5 RDW-13.2 RDWSD-44.1 Plt ___
___ 11:56AM BLOOD Glucose-142* UreaN-19 Creat-1.1 Na-139
K-4.5 Cl-103 HCO3-20* AnGap-21*
___ 11:56AM BLOOD Calcium-8.2* Phos-3.1 Mg-1.7
___ 12:00PM BLOOD Lactate-2.7*
___ 04:20AM BLOOD WBC-8.4 RBC-3.73* Hgb-11.3* Hct-34.4*
MCV-92 MCH-30.3 MCHC-32.8 RDW-14.0 RDWSD-47.7* Plt ___
___ 04:20AM BLOOD Plt ___
___ 04:20AM BLOOD Glucose-110* UreaN-13 Creat-1.0 Na-140
K-3.6 Cl-100 HCO3-28 AnGap-16
___ 04:20AM BLOOD Calcium-7.8* Phos-3.4 Mg-2.3
Brief Hospital Course:
The patient is a ___ who who was brought to the ED after a
bicycle accident +HS, +LOC w/L renal injury, L ___ rib fx,
and urinoma. A CT CT abd pelv demonstrated:
1. Status post grade 4 left renal laceration with interval
placement of a double-J ureteral stent, demonstrate a persistent
extraluminal urinary contrast extravasation into the
retroperitoneum.
2. Trace left pleural effusion with bibasilar atelectasis, left
greater the right.
3. Colonic diverticulosis.
Urology was consulted and given the patients grade 4 renal
laceration and significant urinary extravasation with inability
to confirm with imaging the continuity of the urinary tract took
the patient to the OR for L retrograde and stent.
Post-operatively the patient continued to have abdominal
distension, pain & typany and a KUB was obtained without any
change noted from prior films. Despite focal positive
peritoneal signs on serial abd. exams and low grade tachy, the
patient remained stable. The patients pain and abdominal
distension began to resolve the following day. A CT abd/pelvis
demonstrated stent in place, urine extravasation. The patient
was started on Ceftriaxone per uro recs and began ___. His
creatinine continued to normalize, 1.6=>1.3. The patient was
discharge to home in stable condition with instructions to keep
foley for 2 weeks per Uro and continue PO Cipro x10 days. Dr.
___ (___) will arrange void trial in 2 weeks
and retrograde pyelogram in 6 weeks.
Medications on Admission:
includes ASA
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
do NOT exceed 3 grams in 24 hours.
2. Amlodipine 5 mg PO DAILY
3. Ciprofloxacin HCl 500 mg PO Q24H Duration: 10 Days
please no strenous exercise while taking this medication
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth Q24H Disp #*10
Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*40 Capsule Refills:*0
5. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
do NOT drive while taking this medication
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
7. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*10
Capsule Refills:*0
8. Senna 8.6 mg PO BID:PRN constipation
9. Simvastatin 10 mg PO QPM
10. Lisinopril 10 mg PO QAM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Left ___ and 4th rib fracture
2. Mesenteric hematoma
3. Left renal injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You presented to ___ on ___ from an outside hospitalafter
sustaining a bicycle accident. At the outside hospital, you had
a CT scan of your torso which showed a left kidney injury with
leaking of fluid. You had an x-ray which showed a left third
and fourth rib fracture, and bleeding within your left upper
abdomen.
At ___, you had CT scans of your head and spine which were
normal. You had a left shoulder x-ray which showed no acute
fracture.
You were admitted to the Trauma/Acute Care Surgery team for
further management of your care. You were also seen by the
Urology team. On ___, you had a cystoscopy where a urethral
stent and a foley was placed. You tolerated this procedure well.
This foley will remain in for a total of 2 weeks and will be
removed at your follow-up appointment. You were transferred to
the surgery floor for further management of your medical care.
While on the surgery floor, you ambulated and tolerated oral
pain medicine. You are now medically cleared to be discharged to
home. You will have a visiting nurse come to your home to assist
you with your foley drain care. Please note the following
discharge instructions:
Rib Fractures:
* Your injury caused left ___ and 4th rib fractures which can
cause severe pain and subsequently cause you to take shallow
breaths because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
General Surgery:
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.
*Your foley catheter will remain in place for a total of 2 weeks
(will be removed on ___ at your follow-up appointment with
Urology). Please take your antibiotics while this drain remains
in place.
Followup Instructions:
___
|
10650522-DS-17
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DS
| 17 |
2190-06-28 00:00:00
|
2190-06-29 08:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Epigastric pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with DM, s/p CABG, now with epigastric
discomfort x 3 hrs, diaphoresis, and inferolateral ST-T changes.
Pateint reports he additionally felt unwell. Epigastic
discomfort began after eating fish at lunch. He denies
associated chest pain, shortness of breath, nausea, vomiting or
diaphoresis. He presented to his cardiologist for regular
follow-up where he was noted to have new inferiolateral ST
segment changes (TWI in II and avF in addition to ST segment
depression inferolaterally). He was therefore sent to the ED for
further evaluation after recieving 325 mg of aspirin. On
presentation he denies chest discomfort, and noted epigastric
discomfort has been steadily decreasing and has nearly resolved.
In the ED, initial vitals were temp=97.4, hr=69, bp= 169/76,
rr=18, O2 sat= 98% RA. Labs were notable for a Cr of 1.7, K of
5.3 and trop negative x 1. CXR was negative. The patient was
started on a heparin gtt and nitro gtt and admitted to ___. On
acceptance patient is pain free and in no acute distress.
Past Medical History:
- Hypercholesterolemia & Hypertriglyceridemia
- Hypertension
- Diabetes mellitus
- CAD status post bypass surgery in ___, status post LAD PTCA
at a site distal to the ___, evident patent grafts
during cardiac catheterization in ___
- s/p cataract surgery
- s/p appendectomy
Social History:
___
Family History:
His mother had a history of coronary artery
disease, died at age ___. There was no other history of coronary
disease in his immediate family.
Physical Exam:
Admission Physical Exam:
VS: T= 98.2 BP= 187/85 HR= 73 RR= 20 O2 sat= 100% RA
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP non elevated
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.
Right: DP 1+
Left: DP 1+
Discharge Physical Exam:
VS: t = 97.7, BP = 128/65, HR = 59, RR = 18, O2 = 97% on RA
GENERAL - Alert, interactive, Caucasian male, well-appearing in
NAD
HEENT - Normocephalic, atraumatic. PERRLA, MMM, OP clear. JVD
nondistended.
HEART - RRR, normal S1-S2, no murmurs, rubs, or gallops.
LUNGS - Symmetric expansion, no increased work of breathing.
Clear bilaterally to auscultation, no rhonchi/ rhales/ wheezing.
ABDOMEN - +BS, soft/NT/ND
EXTREMITIES - Warm and well perfused. 2+ right radial pulse.
Weak distal pulses.
Pertinent Results:
Admission Labs:
___ 05:00PM BLOOD WBC-8.0 RBC-4.09* Hgb-12.5* Hct-36.5*
MCV-89 MCH-30.7 MCHC-34.3 RDW-13.0 Plt ___
___ 05:00PM BLOOD Neuts-65.5 ___ Monos-6.0 Eos-0.7
Baso-0.3
___ 05:00PM BLOOD ___ PTT-29.8 ___
___ 05:00PM BLOOD Glucose-191* UreaN-55* Creat-1.7* Na-136
K-5.3* Cl-100 HCO3-29 AnGap-12
___ 05:00PM BLOOD ALT-27 AST-24 CK(CPK)-176 AlkPhos-91
TotBili-0.2
___ 05:00PM BLOOD CK-MB-8
___ 05:00PM BLOOD cTropnT-<0.01
___ 06:00AM BLOOD CK-MB-6
___ 06:00AM BLOOD cTropnT-<0.01
___ 02:45PM BLOOD CK-MB-6 cTropnT-<0.01
___ 05:00PM BLOOD Albumin-4.3 Calcium-8.6 Phos-3.8 Mg-2.3
Discharge Labs:
___ 07:45AM BLOOD WBC-6.7 RBC-3.98* Hgb-12.2* Hct-35.2*
MCV-88 MCH-30.6 MCHC-34.7 RDW-12.9 Plt ___
___ 07:45AM BLOOD ___ PTT-84.4* ___
___ 07:45AM BLOOD Glucose-179* UreaN-38* Creat-1.5* Na-138
K-5.0 Cl-105 HCO3-24 AnGap-14
Imaging Studies:
EKG (___):
Electrocardiogram shows sinus rhythm at 69 beats per minute with
underlying left atrial abnormality, normal intervals and QRS
axis
of 10 degrees. There are new T-wave inversions as well as mild
ST segment depression inferolaterally compared to prior EKG from
___.
Stress Test (___):
INTERPRETATION: This ___ year old IDDM man, s/p CABG x2 ___ and
multiple PCIs ___ was referred to the lab for evaluation. The
patient
exercised for 7 minutes of ___ protocol and stopped for
fatigue.
The estimated peak MET capacity was 8.2 which represents an
average
functional capacity for his age. No arm, neck, back or chest
discomfort
was reported by the patient throughout the study. At peak
exercise,
there was an additional 0.5 mm of ST segment flattening in the
inferolateral leads with a peaking of the T waves in V1-4. The
rhythm
was sinus with several isolated apbs. Appropriate increase in
systolic
BP with a blunted HR response on high dose beta blocker.
IMPRESSION: Non-specific ST-T wave changes in the absence of
anginal
type symptoms. Nuclear report sent separately. His Duke score is
~5
which has a low CV mortality.
RADIOPHARMACEUTICAL DATA:
10.3 mCi Tc-99m Sestamibi Rest ___
27.3 mCi Tc-99m Sestamibi Stress ___
HISTORY: ___ year old man with history o0f CABG, DM, HTN,
hyperlipidemia, and
dyspnea.
SUMMARY OF DATA FROM THE EXERCISE LAB:
Exercise protocol: ___
___ duration: 7 min
Reason exercise terminated: fatigue
Resting heart rate: 65
Resting blood pressure: 140/68
Peak heart rate: 107
Peak blood pressure: 160/62
Percent maximum predicted HR: 69%
Symptoms during exercise: none
ECG findings: Non-specific ST-T wave changes
METHOD:
Resting perfusion images were obtained with Tc-99m sestamibi.
Tracer was
injected approximately 45 minutes prior to obtaining the resting
images.
At peak exercise, approximately three times the resting dose of
Tc-99m sestamibi was administered IV. Stress images were
obtained approximately 45 minutes following tracer injection.
Imaging Protocol: Gated SPECT
This study was interpreted using the 17-segment myocardial
perfusion model.
INTERPRETATION:
Left ventricular cavity size is moderately enlarged.
Resting and stress perfusion images reveal moderate fixed defect
at the base of the inferior wall.
There is hypokinesis of the inferior base. Septal wall motion
compatible with prior CABG. The calculated left ventricular
ejection fraction is 41%. Compared with the study of ___,
the septum has normalized, and now the inferior base moderate
defect is fixed.
IMPRESSION: 1. Moderate fixed defect at the base of inferior
wall with
hypokinesis.
2. Moderate LV enlargement.
3. EF of 41%.
Brief Hospital Course:
Mr. ___ is a ___ yo male with hx of CAD s/p CABG, DM, HTN,
HL who presented with dyspesia with new inferiolateral ST
changes concerning for acute ischemia. Due to these new
inferiolateral EKG changes, Mr. ___ received a stress MIBI
to assess whether or not he should be sent to the cath lab.
Active Issues During Hospitalization:
# Epigastric pain: Mr. ___ presentation was concerning
for ACS on admission given the changes noted on his EKG.
Additionally, there was particular concern as the patient did
not have significant chest pain with his prior MIs. Serial
troponins were negative. The differential diagnosis for his
epigastric pain included gastritis and peptic ulcer disease on
admission.
- Had negative serial troponins
- Serial EKGs continued to show inferior lateral ST changes, but
were somewhat improved over the course of the hospitalization
- The patient was placed on a heparin gtt throughout the
hospitalization and received a loading dose of Plavix of 300mg,
in case he needed to go to the cath lab
- Patient received a stress MIBI - stress test results showed a
Duke score of 5, indicating low CV mortality
- Patient received a number of medications to help medically
manage his CAD and hypertension: metoprolol 100mg BID,
lisinopril 20mg, amlodipine 10mg, aspirin, and Plavix (300mg
loading dose, 75mg otherwise), Rosuvastatin 20mg
- He was placed on Pantoprazole as an inpatient
- Stress-mibi did not suggest a lesion amenable to stenting, so
Mr ___ was sent home w/ Cardiology f/u.
# PUMP
- Mr. ___ last echo showed a normal EF, with the patient
being euvolemic on exam
- As he had an elevated creatinine on admission, his home Lasix
dose was held during this admission. He was discharged on his
home dose of Lasix.
# HTN
- On admission, patient's blood pressures were elevated (up to
180s systolic)
- Was started on a nitro drip when he was first admitted, then
stopped when BP was under better control
- By discharge, BP was somewhat improved(120s/60s - 140s/70s)
- Medications to help control BP: Metoprolol 100mg BID,
Lisinopril 20mg BID, Amlodipine 10mg
- Lisinopril was initially held on admission (as admission
creatinine was slightly elevated from baseline), but restarted
as Creatinine stabilized
# CKD
- The patient's baseline creatinine is around 1.4
- On admission, creatinine was around 1.7, decreased to 1.5 over
the hospitalization
- Home doses of lasix and lisinopril 20mg BID were originally
held on admission due to slight bump in creatinine, but
lisinopril was restarted shortly after admission as creatinine
stabilized.
# DM
- The patient was on insulin sliding scale while in the hospital
and blood sugars ranged from 130s to low 200s
- Discharge on home doses of Lantus and Humolog
# HL:
- For history of hyperlipidemia, the patient is on Crestor at
home and was started on Rosuvastatin 20mg in the hospital.
- During his hospitalization, home dose of Zetia was held.
- Patient was discharged on his home doses of Crestor and Zetia.
Transitional Issues:
- Outpatient follow up with cardiologist.
- Continue to monitor blood pressure and blood sugar.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Amlodipine 10 mg PO DAILY
hold for SBP < 100
2. Clopidogrel 75 mg PO DAILY
3. NexIUM *NF* (esomeprazole magnesium) unknown Oral daily
4. Furosemide 40 mg PO DAILY
hold for SBP < 100
5. Glargine 40 Units Bedtime
Humalog 20 Units Breakfast
Humalog 20 Units Lunch
Humalog 20 Units Dinner
6. Lisinopril 20 mg PO BID
hold for SBP < 100
7. Metoprolol Succinate XL 50 mg PO DAILY
hold for HR < 60 or SBP < 100
8. Aspirin 81 mg PO DAILY
9. Rosuvastatin Calcium 10 mg PO DAILY
10. Ezetimibe 10 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
hold for SBP < 100
2. Aspirin 81 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Glargine 40 Units Bedtime
Humalog 20 Units Breakfast
Humalog 20 Units Lunch
Humalog 20 Units Dinner
5. Metoprolol Succinate XL 50 mg PO DAILY
hold for HR < 60 or SBP < 100
6. Lisinopril 20 mg PO BID
hold for SBP < 100
7. Rosuvastatin Calcium 10 mg PO DAILY
8. Ezetimibe 10 mg PO DAILY
9. Furosemide 40 mg PO DAILY
hold for SBP < 100
10. NexIUM *NF* (esomeprazole magnesium) 40 mg ORAL DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Epigastric Pain - DDX: Gastritis, GERD, Coronary Artery 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 ___
___. You came in with epigastric pain with some
concerning changes on your EKG. Given your cardiac history, we
decided to perform some tests in the hospital to make sure your
pain was not due to a problem with your heart. As these tests
have shown you do not need a cardiac catheterization, we are
sending you home today. If you do have chest pain, please call
___. Please continue taking your medications that you are
receiving with your discharge, unless a physician tells you to
do otherwise.
Followup Instructions:
___
|
10650522-DS-18
| 10,650,522 | 20,785,822 |
DS
| 18 |
2192-04-17 00:00:00
|
2192-04-18 18:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
new onset Afib, noticed at ___ office
Major ___ or Invasive Procedure:
None.
History of Present Illness:
___ w/PMH sig for CAD s/p CABG (___), PAD, DM, HTN, HL,
presenting from clinic with new atrial fibrillation and concern
for w/ TWI in V5/V6.
Patient was at ___ office this morning, found to be in a-fib w/
T-wave inversions on V5/V6; was sent here by ambulance. Reports
feeling fairly normal. However, does have some feeling of "grit"
in the back of his throat and an ongoing non-productive cough
for the past few months due to construction near his building.
Does not have any problems swallowing or pain with swallowing.
Does not report any chest pain, SOB, or abdominal pain. Denies
any symptoms of palpitations, anxiety, heat intolerance. Denies
any fatigue, lightheadedness, episodes of syncope. Denies prior
history of TIA or stroke.
In the ED initial vitals were: 97.9 70 154/75 16 99% ra
- Labs were significant for Cr 1.7, trops negative, H&H
10.5/39.9.
- Patient was given 1L NS, amlodipine 5mg x1 for SBP 188-190.
Vitals prior to transfer were: 98.2 72 186/78 16 100% RA
EKG notable for Afib, LVH, LBBB, T-wave inversion in V6 has been
present in previous EKG's.
On the floor, pt is no acute distress. VS are 98.3 199/89 80 18
100% on RA with FSG 272. He cannot recall whether he took all
his antihypertensive or just some. He denies chest pain,
palpitations, dyspnea, orthopnea, PND, ___ edema, or syncopal
episodes. He reports throat discomfort
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:
1. Moderate, asymptomatic carotid stenosis ___ 40-59%)
2. Peripheral Artery Disease with mild claudication symptoms
3. Insulin dependent diabetes mellitus
4. Coronary Artery Disease s/p CABG ___
5. Dyslipidemia
6. Hypertension
7. s/p cataract surgery
8. s/p appendectomy
Social History:
___
Family History:
His mother had a history of coronary artery
disease, died at age ___. There was no other history of coronary
disease in his immediate family.
No history of PAD, CVA, AAA, vasculitis in the family.
Physical Exam:
PHYSICAL EXAM ON ADMISSION
Vitals - 98.3 199/89 80 18 100% on RA with FSG 272.
GENERAL: obese male in NAD, slow in recall and answering
questions, A&Ox3
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD, b/l carotid bruit
CARDIAC: irregular, S1/S2, no murmurs, gallops, or rubs
LUNG: crackles bibasilar
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: faint pulses b/l
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
PHYSICAL EXAMINATION ON DISCHARGE:
VS: T= 98.3 BP=161/83 HR= 69 RR=18 O2 sat= 98% on RA
GENERAL: appears stated age, lying in bed in no acute distress
HEENT: Sclera anicteric. PERRL, EOMI. Mucus membranes moist
NECK: No JVD, supple with full ROM
CARDIAC: Regular Rate, normal S1, S2. No m/r/g. No thrills,
lifts. No S3 or S4.
LUNGS: Bibasilar mild crackles. No wheezing. Good air movement
to bases.
ABDOMEN: Soft, Tender to palpation above inguinal ligaments
bilaterally and in suprapubic area. No masses palpaed. No HSM.
No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Decreased pulses throughout periphery. 2+ and even
brachial pulses, surgically absent left radial pulse. Bilateral
DP pulses were dopplered, +/- palpated.
Pertinent Results:
Labs on admission:
___ 11:45AM BLOOD WBC-7.1 RBC-3.34* Hgb-10.5* Hct-30.9*
MCV-93 MCH-31.5 MCHC-34.0 RDW-13.1 Plt ___
___ 11:45AM BLOOD Neuts-63.5 ___ Monos-7.3 Eos-1.4
Baso-0.4
___ 11:45AM BLOOD Glucose-154* UreaN-39* Creat-1.7* Na-134
K-4.5 Cl-102 HCO3-28 AnGap-9
___ 11:45AM BLOOD cTropnT-<0.01
Labs on Discharge:
___ Guaiac negative x 2.
___ 04:20PM BLOOD WBC-6.7 RBC-3.67* Hgb-11.1* Hct-33.9*
MCV-93 MCH-30.2 MCHC-32.6 RDW-12.7 Plt ___
___ 12:08PM URINE Color-Straw Appear-Clear Sp ___
___ 12:08PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 12:08PM URINE RBC-<1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
Imaging:
CXR:
No change in comparison with the previous radiograph. Normal
lung volumes. No evidence of pulmonary edema. No pulmonary
fibrosis. Borderline size of the cardiac silhouette without
pulmonary edema. No pleural effusions. Status post CABG.
Brief Hospital Course:
Mr. ___ is a ___ w/PMH sig for CAD s/p CABG (___), PAD,
DM, HTN, HL, presenting from clinic with new atrial fibrillation
with concern for ischemia and found to have a new anemia.
# new onset Afib: Noted incidentally today in clinic. Rate
controlled with metoprolol XL 50mg bid. CHADS2 score 3 (CHF,
HTN, DM), however given decreased Hgb/Hct and concern for a GIB,
AC initiation will be deferred. He converted to NSR in the ER
spontaneously and Amiodarone was initiated for rhythm control.
Plan for Amiodarone initiation: 400mg Amio TID x 3 days ___
noon - ___, then 400mg BID x 1 week [___], followed by
200mg BID thereafter. Home metoprolol succ 50mg BID was
converted to labetalol 200mg BID for better blood pressure
control. Troponin in ER = negative, stable EKG, no ACS symptoms.
UA/CXR with no evidence of infection, and he remained afebrile.
TSH was elevated to 5.58, but free T4 was WNL. This was
believed to represent possible subclinical hypothyroidism, not
likely to be the etiology of his atrial fibrillation.
# HTN: hypertensive upon admission 190/80's. Likely due to
inadherence with medications. Home regimen of lisinopril, and
amlodipine were continued and the metoprolol was changed to
labetalol.
# Anemia: Normocytic. Admission hgb down to 10.5 from 12.2 in
___, however up to 11.1 on repeat. Guaiac negative x 2. No
symptoms of GI bleed (hematochezia, melena, hemetemesis, etc).
Mr. ___ follow up as an outpatient for anemia work up.
Will defer AC until anemia workup complete.
# Throat pain: Pt has history of GERD and symptoms c/w GERD as
described as epigastric pain associated with reflux. He was
given omepraxzole 20mg daily, as well as maalox PRN.
# Acute-on-chronic kidney disease: Cr on admission 1.7, up from
baseline 1.5. Most likely due to poor po intake. UA consistent
with changes of chronic kidney disease, with protein of 100. He
was ecouraged to increase po intake.
# CAD s/p CABG in ___: EKG at baseline, lateral T wave
inversions seen in past EKGs (from ___. Troponin was
negative in the ER. His home ASA and crestor were continued,
but his plavix was held pending outpatient decision about
anticoagulation for atrial fibrillation.
# PAD: followed by Dr. ___. carotid bruit heard b/l and
peripheral pulses diminished. TP pulses palpated bilaterally,
DP's were present and equal qualitatively by doppler,
extremities were warm and well perfused with <1 second cap
refill. Statin, and ASA were continued; plavix was held (See
above).
# DMII: Hyperglycemic on presentation with POC Blood glucose
>400, was given 10units humalog x 2. Missed home lantus dose
the morning of admission. His UA was negative for ketones.
============================================================
TRANSITIONAL ISSUES
[ ] Anemia: Stable, of unknown etiology. No symptoms of GI
bleed, no known bleeding/bruising. Guaiax negative x 2.
[ ] Anticoagulation in the setting of Atrial Fibrillation:
CHADS2 score of 3. Initiation of anticoagulation was deferred
to his outpatient cardiologist after longer-term stability of
his anemia demonstrated.
[ ] Outpatient ECHO
[ ] Plavix: Was held due to concern about decreased
hemoglobin/hematocrit and pending anticoagulation decision.
[ ] Partner has concern about Mr. ___ exhibiting anhedonia
as well as paranoid behaviors and beliefs. He asked that his
stool be tested for wood chips. She was also surprised that he
closed his school. Mood disorder should be explored
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Rosuvastatin Calcium 20 mg PO DAILY
3. Lantus (insulin glargine) 30 units subcutaneous QHS
4. HumaLOG (insulin lispro) ___ units subcutaneous before each
meal
5. Furosemide 40 mg PO DAILY
6. Lisinopril 20 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Amlodipine 10 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Clopidogrel 75 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Furosemide 40 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Rosuvastatin Calcium 20 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Amiodarone 400 mg PO TID Atrial fibrillation
RX *amiodarone 400 mg 1 tablet(s) by mouth three times a day
Disp #*25 Tablet Refills:*0
9. Labetalol 200 mg PO BID Hypertension
RX *labetalol 200 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
10. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
11. HumaLOG (insulin lispro) ___ units SUBCUTANEOUS BEFORE
EACH MEAL
12. Lantus (insulin glargine) 30 units SUBCUTANEOUS QHS
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Atrial fibrillation
Normocytic anemia
SECONDARY DIAGNOSIS:
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 ___
___. You were admitted because of an abnormal heart
rhythm found by your primary care physician, called atrial
fibrillation. Your heart converted back to a normal rhythm while
you were in the hospital. We started a new medication called
amiodarone to keep your heart in a normal rhythm. You should
take this as follows: amiodarone 400mg 3 times per day for 3
days (___), 400mg 2 timers per day for 1 week (___),
then 200mg 2 times per day thereafter.
We also changed one of your medications, metoprolol, to
labetolol for better blood pressure control. As we discussed,
atrial fibrillation puts you at an increased risk for stroke. We
generally start patients with irregular heart rhythm on a blood
thinner. However, your labs showed anemia. You did not have any
signs of bleeding on exam. We recommend you talk to your primary
care physician about work up for gastrointestinal bleeding, as
well as starting a blood thinner to prevent strokes.
Followup Instructions:
___
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10650522-DS-19
| 10,650,522 | 25,264,793 |
DS
| 19 |
2192-05-16 00:00:00
|
2192-05-16 15:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Endotracheal intubation ___, reintubated ___
Arterial line placement ___
Bronchoscopy w/ BAL ___
R PICC line placement
History of Present Illness:
___ with PMH significant for CAD s/p CABG (___), Afib,
peripheral arterial disease, DM, HTN, and HLD who presents with
hypoxia. The patient was at a ___ when he walked to
his car and suddenly felt dyspneic, lightheaded, and had
palpitations. EMS was activated and he was found to be hypoxic
to 89-91%. His symptoms resolved on their own. He denies fever,
chills, cough, chest pain, lower extremity edema, and weight
gain. He feels this episode was somewhat similar to his
presentation during his last hospitalization.
The patient was hospitalized at ___ from ___. He was
found to have new onset atrial fibrillation. He converted to
sinus rhythm spontaneously, and was discharged on amiodarone
with a plan to taper. Initiation of anticoagulation was deferred
to his outpatient cardiologist after longer-term stability of
his anemia was demonstrated. The patient saw his cardiologist on
___, with the plan of continuing amiodarone at 400mg daily.
In the ED, initial vitals were: T98.9 P58 BP104/57 RR16 SpO295%
4L NC. Labs were notable for H/H 8.6/25.5 (baseline 33), Na 132,
BUN 46, Cr 2.5 (1.7), Tn 0.03, CKMB 4, and BNP 11,778. Guiaic
negative. EKG showed sinus bradycardia (HR57), Rt axis
deviation, interventricular delay. No ST-changes. CXR showed
pneumonia in the right mid lung with small bilateral effusions.
Possible mild pulmonary edema. He was given lasix 20mg IV with
700cc output. Vancomycin/cefepime were given for PNA. Vitals
prior to transfer were: T98.2 P66 BP130/48 RR19 98% NC.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. Moderate, asymptomatic carotid stenosis ___ 40-59%)
2. Peripheral Artery Disease with mild claudication symptoms
3. Insulin dependent diabetes mellitus
4. Coronary Artery Disease s/p CABG ___
5. Dyslipidemia
6. Hypertension
7. s/p cataract surgery
8. s/p appendectomy
Social History:
___
Family History:
His mother had a history of coronary artery disease, died at age
___. There was no other history of coronary disease in his
immediate family. No history of PAD, CVA, AAA, vasculitis in the
family.
Physical Exam:
On Admission:
VS: Wt=170.2 T=98.4 BP=144/90 HR=87 RR=20 O2 sat= 95 on 2L
General: in no apparent distress, nontoxic appearing
HEENT: MMM
Neck: no LAD, no thyromegaly. JVP to ear.
CV: RRR, no murmurs, rubs, or gallops.
Lungs: egophony more pronounced R >L. Bibasilar crackles.
Decreased breath sounds, v. coarse.
Abdomen: soft, nontender, and nondistended. +BS
Ext: warm and well perfused with <1 second cap
Skin: decreased hair growth of toes.
PULSES: DP's were present and equal
On Discharge:
98.0 HR 75 BP 146/48 98% RA
General: well appearing, NAD
HEENT: Flaky white plaques throughout posterior oropharynx,
tongues and gums.
Neck: JVD approximately 5-6 cm over sternal angle. No LAD.
CV: RRR. ___ LLSB systolic murmur. ___ holosystolic murmur at
apex.
Lungs: Crackles ___ way up bilaterally, much improved from
weekend.
Abdomen: Soft, NT, ND. +Normoactive BS
Ext: WWP, no peripheral edema.
Neuro: Alert/awake, answers questions appropriately.
Pertinent Results:
On Admission:
=============
___ 03:55PM BLOOD CK-MB-4 ___
___ 03:55PM BLOOD cTropnT-0.03*
___ 09:12PM BLOOD CK-MB-4 cTropnT-0.04*
___ 03:55PM BLOOD LD(LDH)-233 CK(CPK)-474* TotBili-0.4
___ 03:55PM BLOOD Glucose-145* UreaN-46* Creat-2.5* Na-132*
K-4.8 Cl-98 HCO3-26 AnGap-13
___ 03:55PM BLOOD ___ PTT-27.9 ___
___ 03:55PM BLOOD Neuts-80.1* Lymphs-12.6* Monos-7.0
Eos-0.1 Baso-0.1
___ 03:55PM BLOOD WBC-10.5# RBC-2.76* Hgb-8.6* Hct-25.5*
MCV-92 MCH-31.0 MCHC-33.6 RDW-13.3 Plt ___
DISCHARGE:
==========
___ 06:27AM BLOOD WBC-16.8* RBC-2.98* Hgb-9.1* Hct-27.3*
MCV-92 MCH-30.6 MCHC-33.3 RDW-14.7 Plt ___
___ 06:27AM BLOOD Glucose-29* UreaN-72* Creat-2.1* Na-139
K-4.4 Cl-107 HCO3-23 AnGap-13
___ 06:27AM BLOOD Calcium-7.9* Phos-3.9 Mg-2.6
___ 02:50PM BLOOD ANCA-NEGATIVE B
___ 02:50PM BLOOD ___ dsDNA-NEGATIVE
___ 10:35AM BLOOD PEP-NO SPECIFI
Imaging/Studies:
================
___ CXR
Pneumonia in the right mid lung with small bilateral effusions.
Possible mild pulmonary edema.
___ TTE
Moderate mitral regurgitation. Pulmonary artery systolic
hypertension. Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function.
___ CT Chest w/o contrast
Status post sternotomy and CABG. Severe coronary
calcifications. Bilateral right more than left pleural effusions
with subsequent dependent atelectasis. In addition,
peribronchial parenchymal opacities and consolidations in the
right upper lobe, the middle lobe and the lower lobe that are
likely representing infection. No evidence of pulmonary
fibrosis. Borderline mediastinal lymph nodes. No extrathoracic
lymphadenopathy.
___ CT Abd/Pelvis w/o contrast
1. No evidence of acute infectious or inflammatory process in
the abdomen or pelvis to explain patient's pain.
2. Dense airspace consolidations in the lung bases with
bilateral pleural
effusions, consistent with pneumonia. For further details,
please consult the separate report on the CT chest from the same
date.
___ CXR
Previous extensive pulmonary opacification continues to clear,
although lung volumes remain low. Pleural effusion is small if
any. Heart size top-normal unchanged. No endotracheal tube is
visible of the mandible obscures the cervical trachea. Right
PIC line ends in the low SVC.
Two views show successive positioning of the feeding tube first
in the mid
esophagus, than in the distal stomach. No pneumothorax.
Microbiology:
=============
___ urine legionella - negative
___ stool cultures - negative
___ BAL
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000
CFU/ml.
LEGIONELLA CULTURE (Final ___: NO LEGIONELLA
ISOLATED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
___: NEGATIVE for Pneumocystis jirovecii
(carinii).
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
___ BAL
RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000
CFU/ml.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
___: NEGATIVE for Pneumocystis jirovecii
(carinii).
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
No Cytomegalovirus (CMV) isolated.
CYTOMEGALOVIRUS ANTIGEN TEST (SHELL VIAL METHOD) (Final
___:
Negative for Cytomegalovirus early antigen by
immunofluorescence.
blood/urine Cx from ___ were no growth at time of discharge.
Brief Hospital Course:
___ M with PMH significant for CAD s/p CAB, DM2, HTN, newly
diagnosed AFib(started Amiodarone ___ who presented with
hypoxemic respiratory failure and ARDS course complicated by
ATN.
Active Issues
# Hypoxemic Respiratory Failure: Initially with clear RML, RLL
infiltrates admitted to the MICU. Afebrile, HD stable, in sinus
rhythm, no elevation in WBC count, and not grossly volume
overloaded one examination. Treated initially for HCAP with
vanc, cefepime. TTE revealed moderate MR, TR, and mild pulm HTN,
but normal biventricular function and normal right sided
pressures. Diuresis was attempted but with minimal improvement
in his oxygenation. He had refractory hypoxemia with P/F ratios
in the ARDS range and required low TV mechanical ventilation.
Bronchoscopy and BAL x2 were unremarkble for an infectious
etiology of his symptoms; did not increase macrophages on the
diff in the lavage fluid. His oxygenation did not improve until
starting high dose methylprednisolone and discontinuing his
amiodarone. Hypoxemia thought most likely related to Amiodarone.
He was treated with a prednisone taper and an 8 day course of
Vanc/Cefepime.
# Acute on chronic renal failure: Related to ARN. Cr 2.5 on
admission from baseline of 1.7. Worsened to >4 with diuresis
with BUN>140. Urine sediment consistent with ATN. He was not
oliguric in the ICU. Renal was consulted for assistance in
management. Lisinopril and home lasix were held.
# Hypertension: Admitted on a regimen of Labetolol, amlodipine,
lisinopril. After first extubation he developed severe
hypertension and pulmonary edema requiring re-intubation.
Initially controlled with IV medications while NPO - he was on a
nitroglycerin drip and IV labetalol then changed to PO
labetalol, PO hydralazine, and PO clonidine which were all
uptitrated to achieved SBP < 160s. On the floor, his
anti-hypertensives were downtitrated as tolerated. He was
discharged on a regimen of Labetolol 300 bid (from 200 bid on
admission) amlodipine 10mg (unchanged from admission), clonidine
0.3 mg TID, and hydralazine 25 mg Po q8H. His lisinopril and
lasix were held on discharge because of his tenuous renal
function. Restarting these medications should be discussed with
his outpatient cardiologist.
# AFib: Intermittently in Afib in the ICU. Amiodorone was
discontinued and added to his list of allergies given concern
for pulmonary toxicity. Rate controlled with labetolol. He has
a CHADS2 score of 2 but he did not receive systemic
anticoagulation for thromboembolic prophylaxis secondary to
unexplained anemia. Given his anemia was stable and not c/w Fe
deficiency, he was discharged on coumadin without a bridge.
# Thrush: Likely acquired in the setting of high dose steroids.
Treated with Nystatin swish/swallow to complete a 14 day course
(day 1 = ___, end ___.
# Leukocytosis: Started ___, several days after starting
steroids. WBC bumped from ___, with 90% neuts). No
fevers and cultures negative of the blood and urine have been
negative. Likely related to steroid administration. On the day
of discharge, his leukocytes began to trend up again but it was
unclear if this was related to infection. We recommend that a
CBC be checked at rehab on ___. If WBCs > 20, please culture
patient and triage per rehab protocol.
# Type II Diabetes
He has poorly controlled diabetes. This was complicated by
hyperglycemia while in the ICU requiring an insulin drip. He was
weaned back to his home glargine and insulin sliding scale. On
AM of discharge, his AM sugars were in the ___. He was
asymptomatic and his sugars recovered to >100 with breakfast.
For this reason his home Lantus was decreased to 40mg qAM from
45 mg qAM. Additionally, his home short acting insulin bed-time
sliding scale was discontinued on discharge to prevent early
morning hypoglycemia. His insulin regimen should be adjusted as
needed at rehab and by his PCP for better control.
# Toxic Metabolix Encephalopathy
He developed significant delirium while in the ICU. His partner
did note that he had expressed paranoid thoughts in the months
prior to his hospitalization. This was felt to be multifactorial
from ICU delirium, infection, possible uremia, and steroid
effect. While in the ICU, he was treated with a Precedex drip
which was weaned to clonidine once extubated. He also receieved
haloperidol which was weaned on the floor and discontinued prior
to discharge. His mental status improved by day of discharge.
# Abdominal pain
He complained of bandlike, epigastric pain without radiation
that occurred intermittently, most noticable when he coughed.
Given his history of paroxysmal atrial fibrillation, there was
concern for mesenteric ischemia, but he stated that food
improved his pain, painting a more likely picture for gastric
ulcers. He underwent abdominal CT on ___, without evidence of
acute infectious or inflammatory process in the abdomen or
pelvis to explain patient's pain.
# Chronic Diastolic heart failure with acute exacerbation
Echocardiogram on ___ was significant for moderate mitral
regurgitation, as well as pulmonary artery systolic
hypertension. He had normal biventricular cavity sizes with
preserved regional and global biventricular systolic function.
He was diuresed initially, which was limited by rising
creatinine and additionally he did not have adequate urine
output to further diuresis.
# NSTEMI: Relted to ___ ischemia in the setting of hypoxemic
respiratory failure in the ICU. Slight troponin leak (<.1) with
sub-mm lateral ST depression on EKG. He had no symptoms and the
EKG changes resolved.
---------Chronic Issues-----------------
#CAD: Came in on ASA, statin, Plavix. Was off plavix after CABG,
but restarted because it improved anginal symptoms. His ASA was
continued but plavix was held while in house over concerns of
worsening anemia. He should follow up with his outpatient
cardiologist as to whether his plavix should be restarted. Of
note, his outpatient cardiologist Dr. ___ was contacted
the day of discharge ___ by both email and page without
response in regards to resuming his plavix.
# Normocytic anemia: This was subacute and detected during
previous hospitalization, but appears to have worsened in ___
to a new baseline HCT of mid ___ from a previous baseline of
low-mid ___. He was last seen by GI ___ to schedule upper/lower
endoscopy for further evaluation of GI blood loss. Last
colonoscopy was performed in ___-- no polyps. Nl Fe studies at
that time. Repeat Fe studies not consistent with iron
deficiency. Pt denied symptoms of GI bleed including
hematochezia, melena, hemetemesis. Two guiac stools were
negative and his H/H remained stable.
Transitional Issues:
- Continue prednisone taper
- Recommend PFTs to eval for residual oxygen diffusion deficits.
- Discharged on labetolol 300 bid, clonidine .3mg PO TID,
hydralazine 25 mg q8H, amlodipine 10 mg. His clonidine and
hydralazine need to be weaned off and Lisinopril restarted as
his renal function improved.
- Monitor INR levels
- Check CBC on ___, if WBCs > 20, please culture and triage
per rehab protocol.
- Check daily INR at rehab until therapeutic at warfarin dose
for 2 consecutive days then manage per protocol.
- Please discuss restarting plavix with outpatient cardiologist
who could not be reached regarding this issue on the day of
discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Furosemide 40 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Rosuvastatin Calcium 20 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Amiodarone 400 mg PO DAILY Atrial fibrillation
9. Labetalol 200 mg PO BID Hypertension
10. Omeprazole 20 mg PO DAILY
11. HumaLOG (insulin lispro) ___ units SUBCUTANEOUS BEFORE
EACH MEAL
12. Lantus (insulin glargine) 30 units SUBCUTANEOUS QHS
13. Clopidogrel 75 mg PO EVERY OTHER DAY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Labetalol 300 mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. Rosuvastatin Calcium 20 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. CloniDINE 0.3 mg PO TID
8. Docusate Sodium 100 mg PO BID
9. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
10. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
11. Glucose Gel 15 g PO PRN hypoglycemia protocol
12. Heparin 5000 UNIT SC TID
Please continue until you are out of bed and ambulating 3x
daily.
13. HydrALAzine 25 mg PO Q8H
14. Nystatin Oral Suspension 5 mL PO QID Duration: 13 Days
Please stop taking this medication after ___.
15. PredniSONE 20 mg PO DAILY Duration: 3 Days
16. Senna 8.6 mg PO BID
17. Omeprazole 20 mg PO DAILY
18. Glargine 40 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
19. Polyethylene Glycol 17 g PO DAILY constipation
20. Warfarin 5 mg PO DAILY16
21. Bisacodyl 10 mg PR HS:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
amiodarone-induced lung toxicity
acute kidney injury in the setting of chronic renal
insufficiency
Secondary:
atrial fibrillation
Diabetes mellitus type 2
coronary artery disease
hypertension
Discharge Condition:
Alert, oriented, clear and coherent. Ambulating to the bathroom
with assistance.
Discharge Instructions:
Mr. ___, you were admitted to the hospital with severe
difficulty breathing and worsening renal failure. This was most
likely caused by your new medication for your atrial
fibrillation, called Amiodarone. It is unclear if any other
medical conditions suech as pneumonia or congestive heart
failure played a role in your respiratory difficulties. Because
of this uncertainty, we treated you for both pneumonia and a
heart failure exacerbation upon admission. We feel your
breathing problem was most consistent with damage from your
amiodarone. We have stopped this medication. Your renal failure
is improving at discharge, but we are stopping any medications
that can be toxic to your kidneys. For your hypertension, we
have adjusted your medication regimen as indicated below. We are
stopping your Lisinopril and your lasix for your renal failure.
We have also started you on a blood-thinner, coumadin, for your
atrial fibrillation.
You were evaluated by our physical therapists and they felt that
you would get the most benefit from spending time getting
stronger in a rehab. You are being discharged to the rehab of
your choice so that you can continue to get physical therapy and
get stronger.
Please continue to take all your other medications as
prescribed. Please follow up with your primary care doctor and
make an appointment to see her once you are ready to leave the
rehab. We have scheduled an appointment with your cardiologist
on ___. This information is listed below.
Thank you for allowing us to participate in your care. Good
luck!
Sincerely,
Your ___ medical team
Followup Instructions:
___
|
10650522-DS-20
| 10,650,522 | 24,155,998 |
DS
| 20 |
2192-05-31 00:00:00
|
2192-05-31 16:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
amiodarone
Attending: ___.
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M with hx MI, CABG, CHF, DM, HTN presenting with lower
extremity edema. Patient was dicharged 1 week ago from a 3-week
admission for hypoxemic respiratory failure s/p intubation,
thought to be secondary to amiodarone and CHF. Was also treated
on 8 day course of vancomycin and cefepime during admission.
Patient in rehab this past week. Had shortness of breath at
rehab. Physician at rehab noticed patient Hct 23 and concerned
for hemorrhage, per patient urine and stool their negative for
blood. Patient sent to his cardiologist where he was noted to
have bilateral lower extremity swelling and crackles up to his
mid lung bilaterally. 93% on RA. Sent to the ED for further
management. Here, patient denies f/c/n/v, chest pain, shortness
of breath, cough, calf pain. patient has been receiving DVT
prophylaxis at rehab.
In the ED initial vitals were: 99.0 58 150/70 16 97% 2L NC
- Labs were significant for Trop-T: 0.05, BUN/Cr 37/2.0, ___:
11980, Alb: 3.0, H/H: 7.6/22.6, INR: 1.3.
- Patient was given nothing.
Vitals prior to transfer were: 98 62 123/66 14 94% Nasal Cannula
On the floor, the aptient reports that he has had difficulty
breathing ___ laying down flat. He reports that he has increase
DOE as well.
Past Medical History:
1. Moderate, asymptomatic carotid stenosis ___ 40-59%)
2. Peripheral Artery Disease with mild claudication symptoms
3. Insulin dependent diabetes mellitus
4. Coronary Artery Disease s/p CABG ___
5. Dyslipidemia
6. Hypertension
7. s/p cataract surgery
8. s/p appendectomy
Social History:
___
Family History:
His mother had a history of coronary artery disease, died at age
___. There was no other history of coronary disease in his
immediate family. No history of PAD, CVA, AAA, vasculitis in the
family.
Physical Exam:
ON ADMISSION:
Vitals - T:98 BP:140/68 HR:61 RR:18 02 sat:99%2LNC
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM
NECK: nontender supple neck, no LAD, JVP 4-5cm elevated above
the clavical when sitting upright.
CARDIAC: RRR, S1/S2, systolic murmer
LUNG: crackles up to the scapula bilaterally.
ABDOMEN: nondistended, +BS, nontender in all quadrants, no r/g
EXTREMITIES: moving all extremities well. 1+ pitting edema up to
the knee bilaterally.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
ON DISCHARGE:
VS: Tc 98.1, BP 125-155/56-70 HR 56-64 RR 18 O2sat 98-100% on RA
Dry weight: 78.5kg (dry weight ~77.5kg)
GENERAL: No acute distress, comfortable at rest, alert and
oriented x3, mood and affect appropriate.
HEENT: NCAT, anicteric sclera, EOMI, PERRLA, clear oropharynx
NECK: Supple, JVP flat
CARDIAC: RRR, normal S1/S2, no MRG
LUNGS: Breathing comfortably without accessory muscle use.
Bilateral dry crackles at bases L>R, no wheezes or rhonchi
ABDOMEN: Soft, protuberant, NTND, no masses, guarding or rebound
EXTREMITIES: No cyanosis or clubbing. Pedal edema resolved. 2+
DP pulses b/l
Pertinent Results:
ADMISSION LABS:
___ 07:21PM BLOOD WBC-5.3# RBC-2.37* Hgb-7.6* Hct-22.6*
MCV-95 MCH-31.9 MCHC-33.4 RDW-14.2 Plt ___
___ 07:21PM BLOOD Neuts-73.8* Lymphs-17.4* Monos-5.8
Eos-2.7 Baso-0.2
___ 07:21PM BLOOD ___ PTT-27.7 ___
___ 07:21PM BLOOD Ret Aut-2.0
___ 07:21PM BLOOD Glucose-103* UreaN-37* Creat-2.0* Na-138
K-5.0 Cl-106 HCO3-24 AnGap-13
___ 07:21PM BLOOD ALT-22 AST-14 LD(LDH)-273* AlkPhos-65
TotBili-0.4
___ 07:21PM BLOOD CK-MB-4 ___
___ 07:21PM BLOOD cTropnT-0.05*
___ 07:21PM BLOOD Albumin-3.0*
___ 07:21PM BLOOD Hapto-362*
.
TRENDS:
CBC
___ 06:20AM BLOOD WBC-4.5 RBC-2.34* Hgb-7.1* Hct-22.0*
MCV-94 MCH-30.3 MCHC-32.2 RDW-14.7 Plt ___
___ 06:10AM BLOOD WBC-3.6* RBC-2.93* Hgb-8.7* Hct-26.3*
MCV-90 MCH-29.6 MCHC-33.0 RDW-14.9 Plt ___
___ 06:25AM BLOOD WBC-3.4* RBC-3.01* Hgb-9.0* Hct-27.5*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.4 Plt ___
.
Chemistry
___ 06:50PM BLOOD Glucose-296* UreaN-40* Creat-2.0* Na-133
K-5.1 Cl-100 HCO3-24 AnGap-14
___ 06:20AM BLOOD Glucose-43* UreaN-43* Creat-2.1* Na-136
K-4.6 Cl-100 HCO3-25 AnGap-16
___ 07:10PM BLOOD Glucose-260* UreaN-41* Creat-2.2* Na-133
K-5.1 Cl-98 HCO3-23 AnGap-17
___ 06:40AM BLOOD TotProt-5.2* Calcium-7.6* Phos-3.4
Mg-2.1.
Cardiac enzymes
___ 05:25AM BLOOD CK-MB-4 cTropnT-0.05*
.
Anemia workup
___ 02:44PM BLOOD calTIBC-231* Hapto-420* Ferritn-210
TRF-178*
___ 06:40AM BLOOD VitB12-758 Folate-11.9
___ 06:40AM BLOOD TSH-4.1
___ 06:40AM BLOOD PEP-SLIGHT HYP IgG-325* IgA-97 IgM-70
IFE-NO MONOCLO
___ 12:30PM BLOOD FreeKap-36.7* FreeLam-42.0* Fr K/L-0.87
___ 02:44PM BLOOD CRP-60.1*
___ 06:20AM BLOOD ESR-108*
.
DISCHARGE LABS
___ 06:25AM BLOOD WBC-3.4* RBC-3.01* Hgb-9.0* Hct-27.5*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.4 Plt ___
___ 06:25AM BLOOD Glucose-181* UreaN-41* Creat-2.1* Na-134
K-4.8 Cl-98 HCO3-25 AnGap-16
___ 06:25AM BLOOD Calcium-8.4 Phos-3.9 Mg-2.2
IMAGING
CXR ___
Bilateral parenchymal opacities and small effusions potentially
due to
worsening congestive failure and edema noting superimposed
infection is
possible.
Brief Hospital Course:
___ yo M with history of CAD status post CABG in ___, diastolic
CHF(EF58%), atrial fibrillation, insulin-dependent DM, PAD and
HTN, recently discharged after 3-week hospitalization for
hypoxemic respiratory failure possibly due to amiodarone
toxicity, who presented with fatigue and ___ edema, likely due to
an acute diastolic CHF exacerbation.
#Acute on Chronic Diastolic heart failure (EF58%): Mr. ___
presented with dyspnea, 4L supplemental oxygen requirement and
signs of volume overload on exam, found to have 10lb weight
gain, elevated BNP and pulmonary vascular congestion on CXR
consistent with an acute disastolic CHF exacerbation. Most
recent ECHO (___) demonstrated EF58%, moderate MR and moderate
pulmonary artery hypertension. This exacerbation was most likely
precipitated by being off lasix for 9 days in combination with
dietary indiscretions at rehab. Lasix had been stopped on
discharge from last hospitalization in ___ due to rising Cr and
was never restarted. After admission Mr. ___ was diuresed
with IV lasix with good urine output and improvement of
symptoms. Cr remained stable. His shortness of breath
subjectively improved over several days and he was able to come
off supplemental oxygen. He appeared euvolemic and was
transitioned to oral regimen of 40mg lasix. His weight went up
1kg from 77.5kg to 78.5kg on the day of dsicharge so he diuresis
was increased to torsemide 40mg daily to be started on ___. His
home amlopdipine, labetalol and hydralazine were continued. His
hydralazine was briefly increased during this admission for
afterload reduction however his blood pressure did not tolerate
this so he remains on his previous home dose. He will ___
as an outpatient with Dr. ___.
#Normocytic Anemia: On admission Hct was noted to have been
gradually declining over the past month. Hgb 9.1 on last
discharge on ___, down to 7.6 on admission. Hgb further
downtrended to 7.1 and was treated with 1uPRBC on ___ with
improvement to 8.7. Etiology of anemia is still being worked up
by Hematology. Likely component of underlying anemia of chronic
disease due to CKD although this is unlikely to explain the
acute decline. Most likely cause is bone marrow suppression
either due to malignancy or other inflammatory process given
elevated inflammatory markers (ESR/CRP). Free kappa and lambda
light chains both elevated, although ratio normal. EPO still
pending. Iron studies were consistent with anemia of chronic
disease. Guaiac negative during this admission. Pt is scheduled
for endoscopy/colonoscopy in ___. Hgb remained stable at 9.0
on the day of discharge. Pt will follow up with Heme/Onc as an
outpatient.
#Atrial fibrillation: Pt was diagnosed with new-onset atrial
fibrillation in ___. Pt had been scheduled to start coumadin
without heparin bridge (due to dropping HCT and concern for
bleed) on discharge from last hospitalization, however based on
INR he had not been receiving warfarin. Following negative stool
guaiac warfarin was restarted during this admission on ___, with
increase from 5mg daily to 7.5mg on the day of discharge (___)
given that INR remained subtherapeutic at 1.1. He remained in
sinus rhythm and rate remained well-controlled on home
labetalol. He will need to have INR trended and coumadin
adjusted following discharge.
#Possible environmental inhalation-induced lung injury: Pt
describes that he has had recent exposure to environmental
inhalants at work site near his school. He describes significant
decline in his breathing and lung function since this exposure
and has some asymmetric dry crackles at lung bases on exam even
when dry that suggest underlying ILD. He was recently admitted
for possible amiodarone-induced respiratory failure, although
the evidence for this diagnosis remains unclear. Pt should be
further evaluated by Pulmonology as an outpatient.
#Hypertension: Pt remained normotensive throughout
hospitalization. Home amlodipine, labetalol and hydralazine were
continued.
#Type 2 diabetes (insulin-dependent): Blood glucose elevated to
___ over last several days of the admission. Lantus was
adjusted to 28U nightly (from 25) and sliding scale was
increased. Pt will need PCP ___ for medication adjustment.
#Acute on Chronic Kidney Disease: Cr remained relatively stable
between 2.0 and 2.3 during admission. Cr 2.1 on discharge, which
likely represents a new baseline for him. CKD likely due to
chronic hypertension.
#CAD status post CABG in ___: Troponin found to be elevated to
0.05 x 2, patient remained chest pain free and without ischemic
findings on EKG, so most likely due to CKD. Home ASA,
atorvastatin and labetalol were continued.
#Thrush: Pt was being treated for thrush on admission. Completed
treatment with nystatin on ___. Oropharynx clear on discharge
exam.
# Continue low-sodium diet and 2L fluid restriction
# Evalute volume status, weight increased from 77.5 to 78.5kg on
the day of discharge diuretic was increased to torsemide 40mg to
start on ___, adjust as needed
# Recheck Hgb/Hct 48 hours after discharge (Hgb 9.0 on
discharge)
# EPO pending at discharge
# Pt will ___ with Heme/Onc for further anemia work-up
# Restarted on coumadin 5mg on ___, INR remains subtherapeutic
at 1.1 on discharge so coumadin was increased to 7.5mg daily on
___. Will need to trend INR and adjust dosing PRN. Pt should
remain on SQ heparin at rehab until INR in goal range ___.
# Pt will have an appointment with Pulm as an outpatient
# Blood sugars elevated during last several days of
hospitalization to ___, Glargine adjusted to 28U nightly,
please adjust PRN
# Code status: full
# Emergency Contact: ___ ___ HCP
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Labetalol 300 mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. Rosuvastatin Calcium 20 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. CloniDINE 0.3 mg PO TID
8. Docusate Sodium 100 mg PO BID
9. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
10. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
11. Glucose Gel 15 g PO PRN hypoglycemia protocol
12. HydrALAzine 25 mg PO Q8H
13. Nystatin Oral Suspension 5 mL PO QID
14. Senna 8.6 mg PO BID
15. Omeprazole 20 mg PO DAILY
16. Polyethylene Glycol 17 g PO DAILY constipation
17. Warfarin 5 mg PO DAILY16
18. Bisacodyl 10 mg PR HS:PRN constipation
19. Glargine 30 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Bisacodyl 10 mg PR HS:PRN constipation
4. CloniDINE 0.3 mg PO TID
5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
6. Docusate Sodium 100 mg PO BID
7. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
8. Glucose Gel 15 g PO PRN hypoglycemia protocol
9. HydrALAzine 25 mg PO Q8H
10. Glargine 28 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
11. Labetalol 300 mg PO BID
12. Multivitamins 1 TAB PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Polyethylene Glycol 17 g PO DAILY constipation
15. Rosuvastatin Calcium 20 mg PO DAILY
16. Senna 8.6 mg PO BID
17. Vitamin D 1000 UNIT PO DAILY
18. Warfarin 5 mg PO DAILY16
19. Furosemide 40 mg PO DAILY
20. Heparin 5000 UNIT SC TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Acute decompensated diastolic heart failure
Secondary:
Chronic normocytic anemia
Atrial fibrillation
Hypertension
Type 2 diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___
because of shortness of breath and leg swelling due to an acute
worsening of your heart pumping function. While you were here
you were treated with intravenous lasix (diuretic) that helped
remove some of the extra fluid in your lungs and legs. We also
found that you had some low blood counts so you received a unit
of blood and were seen by the Hematology/Oncology team while you
were here. We did not find any evidence of bleeding but please
keep your appointment with gastroenterology to have your
colonoscopy this fall.
Please continue taking your lasix (water pill) after you leave
in addition to your other home medications. You should follow up
with your outpatient Cardiologist, Dr. ___. You will
also have outpatient appointments with Pulmonology (lung doctor)
and a ___ with Hematology. It was a pleasure taking care
of you.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10650537-DS-27
| 10,650,537 | 23,831,277 |
DS
| 27 |
2158-03-22 00:00:00
|
2158-03-22 16:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Demerol / morphine
Attending: ___
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
R Subclavian line placement
hemodialysis, ___, weds, ___
History of Present Illness:
___ with h/o ESRD on ___ HD, type 1 DM, borderline HTN, who
presented with acute onset of right-sided weakness followed by
slurred speech ___, found to have a large L basal ganglia
hemorrhage in the setting of SBP ~200. Mental status
deteriorated at ___ so she was emergently intubated
and transferred to ___ where ___ showed expansion of
hemorrhage with intraventricular extension and evolving right
hydrocephalus.
Past Medical History:
DM1
Gastroparesis
Neuropathy
Nephropathy, renal failure
--s/p failed renal transplant in ___, now on dialysis (MWF via
LUE AVF, dry weight 133 lbs, at ___)
--s/p failed islet cell transplants ___
--s/p therapeutic plasma exchange & IVIg for rejection
right Charcot foot
depression
osteoporosis
B12 deficiency
right shoulder fracture s/p pinning
prior distal right femur fracture s/p ___ plate ___
Femoral rod after a fracture in ___
Social History:
___
Family History:
father - DM ___
PGM - breast ca
son - bipolar disorder
Physical Exam:
ADMISSION PHYSICAL EXAM:
- Vitals: BP 168/80, P 60
- General: intubated, sedated on propofol
- Head: NC/AT
- Neck: supple, no bruits
- Pulm: diffusely rhonchorous
- Cardiac: RRR
- ___: SNTND
- Extrem: WWP no C/C/E
- Skin: no rashes/lesions noted
NEURO EXAM (off propofol x5 minutes):
- Mental status: intubated, off propofol. Eyes open
occasionally,
forced leftward gaze deviation. Grimaces and moves extremities
to
noxious stim. Inconsistently follows commands to open eyes and
squeeze left hand.
- Cranial nerves: pupils irregularly/ovoid shaped, right 3mm and
left 2mm, both minimally reactive. Forced leftward gaze
deviation. Corneal reflex present on left, absent on right. Face
symmetric. +Gag, +cough (per nurse).
- Motor: normal bulk, decreased tone in right arm. Can hold left
arm up with antigravity strength. Right arm is flaccid
proximally, weak flexion of right hand to strong noxious stim.
Lower extremities move spontaneously and briskly withdraw to
noxious, L>R. No adventitious movements noted.
- Sensory: grimaces to noxious throughout.
- DTRs: areflexic throughout. Toes downgoing.
- Coordination: unable to assess
- Gait: unable to assess
DISCHARGE PHYSICAL EXAM ************
Pertinent Results:
ADMISSION LABS
___ 08:50PM TYPE-ART PO2-195* PCO2-25* PH-7.56* TOTAL
CO2-23 BASE XS-2 COMMENTS-ABG ADDED
___ 08:50PM freeCa-1.15
___ 08:42PM GLUCOSE-151* UREA N-69* CREAT-5.7* SODIUM-135
POTASSIUM-3.5 CHLORIDE-93* TOTAL CO2-21* ANION GAP-25*
___ 08:42PM ALT(SGPT)-20 AST(SGOT)-31 CK(CPK)-207* ALK
PHOS-245* TOT BILI-0.5
___ 08:42PM CK-MB-8 cTropnT-0.20*
___ 08:42PM CALCIUM-9.7 PHOSPHATE-5.1* MAGNESIUM-2.6
___ 05:48PM TYPE-ART PO2-66* PCO2-32* PH-7.49* TOTAL
CO2-25 BASE XS-1 INTUBATED-INTUBATED
___ 04:16PM GLUCOSE-154* LACTATE-1.0 NA+-136 K+-3.7
CL--93* TCO2-26
___ 04:05PM GLUCOSE-159* UREA N-64* CREAT-5.5* SODIUM-137
POTASSIUM-3.8 CHLORIDE-93* TOTAL CO2-24 ANION GAP-24*
___ 04:05PM estGFR-Using this
___ 04:05PM LIPASE-26
___ 04:05PM cTropnT-0.21*
___ 04:05PM CALCIUM-10.0 PHOSPHATE-6.6* MAGNESIUM-2.6
___ 04:05PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
___ 04:05PM ___ PTT-30.7 ___
___ 04:05PM WBC-4.1 RBC-4.17* HGB-13.6 HCT-41.1 MCV-99*
MCH-32.5* MCHC-33.0 RDW-14.0
___ 04:05PM PLT COUNT-148*
___ 04:05PM ___ 07:50PM BLOOD CK-MB-5 cTropnT-0.25*
___ 04:10AM BLOOD CK-MB-5 cTropnT-0.25*
___ 12:10PM BLOOD CK-MB-5 cTropnT-0.23*
MICRO
BCx ___ x 2 - negative
___ 11:15 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH. OF TWO COLONIAL MORPHOLOGIES.
IMAGING
CT HEAD w/o contrast
Left basal ganglia intraparenchymal hemorrhage with
intraventricular extension. There is surrounding mass effect
with 3-mm
rightward shift of the normal midline structures. The basal
cisterns are
patent. Prominence of the right temporal horn suggests early
entrapment.
CXR ___. Catheter seen coursing from the left axillary region,
crossing the midline chest, with tip projecting over the right
lung apex. Given the non-anatomic course of this catheter, it
could be external to the patient, but clinical correlation is
advised.
2. Standard positioning of the endotracheal tube and orogastric
tube.
3. Mild to moderate pulmonary edema and small left pleural
effusion. Bibasilar airspace opacities could reflect
superimposed aspiration or infection.
EEG ___ - ___
This is an abnormal continuous ICU EEG because of continuous
focal slowing, absent alpha rhythm, and attenuation of faster
frequencies over the left hemisphere. These findings are
indicative of focal cerebral dysfunction, likely structural in
origin, in the left hemisphere. This correlates with her known
intracerebral hemorrhage on the left. Background activity over
the right is also slow with a slow posterior dominant rhythm,
indicating more diffuse cerebral dysfunction, which is
etiologically nonspecific. No electrographic seizures or
epileptiform discharges are present.
CXR ___
Previous mild pulmonary edema has improved. Heart size top
normal, unchanged. No pleural effusion. Lungs clear of any
focal abnormality.
ET tube, right subclavian line, and upper enteric drainage tube
in standard placements respectively.
CT head ___
Left basal ganglia hemorrhage with intraventricular extension.
No significant interval change compared to the previous CT
examination.
CT head ___
Unchanged appearances of the left basal ganglia hemorrhage, mass
effect and intraventricular extension. Slight increase in
surrounding edema related to evolution.
CT head ___. Unchanged appearance of the left basal ganglia hemorrhage,
mass effect, and intraventricular extension.
2. Stable cerebral edema within the region surrounding the
hemorrhage.
RUE US ___
Findings concerning for central DVT in the right brachiocephalic
vein or SVC. This could be further characterized with MRV or
CTV of the chest.
CT Venogram of the chest ___. Unremarkable CT venography of the central veins without
focal filling defect worrisome for thrombus.
2. Prominent left base atelectasis and mild right base
atelectasis.
3. Left thyroid nodule which can be further evaluated with
ultrasound if indicated.
DISCHARGE LABS ****
___ 10:46AM BLOOD WBC-2.5*# RBC-3.19* Hgb-10.2* Hct-30.7*
MCV-96 MCH-31.9 MCHC-33.1 RDW-14.3 Plt ___
___ 01:00AM BLOOD ___ PTT-44.8* ___
___ 10:46AM BLOOD Glucose-132* UreaN-47* Creat-4.0*# Na-136
K-3.9 Cl-97 HCO3-22 AnGap-21*
___ 10:46AM BLOOD Calcium-9.0 Phos-6.8* Mg-2.4
___ 04:36AM BLOOD D-Dimer-2364*
Brief Hospital Course:
Ms. ___ was admitted to the neurology ICU on ___ as a
transfer from ___, with altered mental status
requiring intubation from a L basal ganglia/thalamic hemorrhage,
likely ___ hypertension, which expanded significantly upon
transfer but remained stable in while admitted to ___, with
the exception of ___ edema. She was initiated on
CVVH with a hypertonic saline bath for sodium 150 and serum ohm
300-310 for prevention of cerebral edema. She was placed on a
nicardipine gtt to maintain sbp <140, she received a one-time
dose of ddavp on admission for platelet dysfunction in uremia,
and all heparin products were held. Neurosurgery was consulted
upon her arrival, and followed with her, no intervention was
deemed necessary. She was initially lethargic, responsive only
to voice and following minimal commands, with leftward eye
deviation and right hemiparesis. On ___, she began to become
more responsive and agitated, she self-extubated and pulled her
NGT.
Cardiac enzymes were drawn several times for EKG findings of
lateral TWI, they remained flat at 0.2 (which may be her
baseline ___ renal disease). She was maintained on SSI for her
diabetes.
As she remained stable on room air she was transferred to the
floor for further management. She continued to receive ___
dialysis and was followed by ___ Diabetes. PEG tube was
placed on ___. As there were no clinical seizure events, Keppra
was discontinued. After keppra was DCed, the patient's mental
status improved somewhat and she was more awake and alert than
prior, and intermittently followed commands.
There was concern for R upper extremity swelling, and DVT U/S
suggested possible central thrombosis. CT venogram ruled out
thrombosis and anticoagulation was not needed.
Her mental status slowly improved and she began to open eyes to
voice, and could intermittently follow some appendicular
commands on the L. She continued to have a R gaze palsy and
right facial droop. The right side remained paretic.
# HTN: the patient's goal SBP was < 140 given bleed. She was
started on PO labetalol, and also got dialysis. She recieved IV
hydral as need for elevated BP. Could consider restarting home
nifedipime ER 60 mg daily as this medication was held during
admission
# ESRD on HD: the patient was continued on ___ dialysis, and
lytes monitored at dialysis
# ENDO: DM1, on standing insulin and ISS. ___ diabetes team
followed the patient in house and will continue to follow as an
outpatient.
# GI: Due to altered mental status and need to deliver nutrition
to allow the patient to participate in rehab and recovery. S/p
PEG placement ___, tube feeds were advanced slowly and the
patient tolerated them well. Tube feeds should be low K and low
Phos (as recommended by nutrition and renal) for ESRD.
- at rehab, the patient should be assessed by speech and swallow
when she is improved enough to trial PO intake again
# Low WBC intermittently: unclear etiology, not persistently low
- monitor CBC once per week
# ID: the patient was continued on doxycycline supressive
therapy after recent infeciton (MSSA septic knee in ___, for
now this is planned to continue indefinently given her hardware
in place
# Thrush: the patient was started on nystatin in house
- DC nystatin when thrush resolved
# Throid nodule seen on CT scan incidentally
- outpatinet follow up with PCP ___
# Psych: the patient's home psych meds were held given acute
stroke (lexapro, bupropion, flurazapam). If planning to restart
soon, would start with lexapro first, since bupriopion can lower
seizure threshold.
# Code - Full, confirmed
# Contact: ___ ___
TRANSITIONAL ISSUES:
- Follow up L thyroid nodule with PCP, consider thyroid
ultrasound as outpatient if clinically indicated
- Diabetic management: patients blood sugars were erratic
throughout her stay, and the patient was followed by diabetes
endocrine consult. Continue regular finger sticks and will
likely need adjustments to her lantus and/or short acting
insulins. The patient will follow up with ___ clinic
after discharge
- continue to monitor BP, goal SBP < 140, add further blood
pressure medications as needed. Could consider restarting home
nifedipime ER 60 mg daily as this medication was held during
admission
- outpatient Stroke follow up
- will consider outpatient MRI/MRA about 2 months after time of
discharge, to be determined at time of outpatient neurology
follow up
- continue MWF dialysis, monitor electrolytes at dialysis,
follow up any renal recs about phos binders etc
- at rehab, the patient should be assessed by speech and swallow
when she is improved enough to trial PO intake again
- monitor CBC once per week
- DC nystatin when thrush resolved
Medications on Admission:
1. BuPROPion (Sustained Release) 200 mg PO BID
2. Calcium Acetate ___ mg PO TID W/MEALS
3. Cyanocobalamin 1000 mcg PO DAILY
4. Escitalopram Oxalate 30 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Metoclopramide 5 mg PO QIDACHS
7. NIFEdipine CR 30 mg PO DAILY
8. Pregabalin 25 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Acetaminophen 650 mg PO Q6H pain or fever
11. CefazoLIN 2 g IV QMOWE POST HD Duration: 6 Weeks
day 1 of antibiotics ___
12. CefazoLIN 3 g IV ___ POST HD Duration: 6 Weeks
day 1 of antibiotics ___
13. Calcium Carbonate 1000 mg PO DAILY
14. Clonazepam 0.5 mg PO Q 8H anxiety
15. Lantus *NF* (insulin glargine) 9 units SUBCUTANEOUS QAM
16. NovoLOG *NF* (insulin aspart) 0 ASDIR SUBCUTANEOUS QACHS
Please take per sliding scale
Discharge Medications:
1. Doxycycline Hyclate 100 mg PO Q12H
2. Docusate Sodium 100 mg PO BID
3. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
4. Glucose Gel 15 g PO PRN hypoglycemia protocol
5. Labetalol 300 mg PO TID
6. Lanthanum 1000 mg PO TID W/MEALS
7. Neomycin-Polymyxin-Bacitracin 1 Appl TP ASDIR
8. Nephrocaps 1 CAP PO DAILY
9. Nystatin Oral Suspension 5 mL PO QID
10. Senna 1 TAB PO BID:PRN constipation
11. Cyanocobalamin 1000 mcg PO DAILY
12. FoLIC Acid 1 mg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. Calcium Carbonate 1000 mg PO DAILY
15. Glargine 12 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
16. Heparin 5000 UNIT SC TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L basal ganglia bleed with extension into the left lateral
ventricle
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of ___ while ___ were here at ___
___. ___ were admitted following right-sided
weakness that resulted in a fall. On CT scan ___ were found to
have a left sided hemorrhage in the brain. Because of this, ___
required intubation and sedation. ___ were monitored on EEG and
we aggressively controlled your blood pressure and managed the
swelling in your brain. ___ received continual dialysis while in
the ICU. Once ___ were stable, ___ were transferred to the floor
and continued to be monitored clinically for seizures. As there
were no clinical events we discontinued Keppra. We placed a PEG
tube for long term feeding and medication administration.
Because there was some swelling in your right arm, we did an
ultrasound to look for clots and then a CT venogram, which did
not find any blood clots. During your stay on the floor ___
were continued on ___ hemodialysis and ___ Diabetes managed
your diabetes medication.
It is important that ___ take all medications as prescribed, and
keep all follow up appointments.
Followup Instructions:
___
|
10652506-DS-17
| 10,652,506 | 26,893,049 |
DS
| 17 |
2184-03-14 00:00:00
|
2184-03-14 14:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
___
Attending: ___
Chief Complaint:
This is a ___ year old man who was transfered from OSH with upper
extremity weakness and MRI showing C spine cord signal change
after a fall down stairs.
Major Surgical or Invasive Procedure:
___ C3-7 posterior laminectomy and fusion
History of Present Illness:
This is a ___ year old man who had been drinking early the day of
admit when he fell down the stairs. He was taken to OSH where
exam showed minimal
strength in UE's and ___. CT C spine showed no fx, MRI T/L
spine
showed degenerative changes but did capture C5-C6 stenosis and
cord signal change. He has no dedicated C spine MRI. He was in a
collar and transfered to ___ for further care.
Past Medical History:
- ASD repair at ___ yrs old at ___, then followed
every few years by Dr. ___
- ___ -- followed by Dr. ___ at ___
___
(after Dr. ___ in ___ or ___
- Seizures since ___ yrs old previously on Tegretol currently on
Depakote, followed by Dr. ___
- S/p L nephrectomy
- IVC filter
- EtOH abuse
- Rotator cuff tear
- Hernia repair
Social History:
___
Family History:
NC
Physical Exam:
On Admission:
BP: 101/71 HR: 54 R 10 O2Sats 98
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: Reactive EOMs Full
Neck: C Collar in place
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q AT ___ G
R 3 5 2 3 3 3 0 4 4 5
L 3 5 3 3 3 3 0 4 4 5
Sensation: Decreased sensation from T4 down.
Reflexes: B T Pa Ac
Right 0 0 2 0
Left 0 0 2 0
Toes mute
No rectal tone
At ___ His is a cervical collar. His wound is clean
and dry with staples in place. Motor strength: R Tr 3, Gr 3 D 4+
B 5-, L tr 2, Gr 3 D 4+ B 5+
4+ IP's, full distal. OD ___ OS ___ He was anisocoric with Left
pupil ___ and right pupil ___. He was awake, alert and oriented
x 3.
Pertinent Results:
Trauma scan ___
Mildly enlarged heart. No evidence of intrathoracic trauma
CT Torso ___
1. No evidence of intra-abdominal or intrathoracic injury.
2. No evidence of acute fracture.
3. Delayed excretion of the right kidney; left kidney is
surgically absent; IV hydration is recommended
MR CERVICAL SPINE W/O CONTRAST ___
1. Abnormal signal intensity involving C3 to C6 vertebral bodies
concerning for bone marrow edema/contusions with prevertebral
soft tissue edema.
2. Increased spinal cord signal from C4 to C6 levels as
described above may represent spinal cord edema/contusion or
prior myelopathic changes.
3. Anterior longitudinal ligament is not well seen at C6-C7
levels.
Possibility of ALL injury cannot be entirely excluded at this
level.
4. Increased signal also seen in the posterior paraspinal soft
tissues and in the interspinous spaces extending from C2 to C7
levels concerning for
interspinous ligament injury.
EEG ___
A single EKG channel shows a generally regular rhythm
with an average rate of 35 bpm.
IMPRESSION: This is an abnormal awake and drowsy portable EEG
because
of occasional right frontotemporal epileptiform discharges
indicative of
a potential epileptogenic focus in this region. There is one
marked
event with arousal-related myoclonic jerk most likely
representing a
hypnic jerk. Background otherwise shows a normal 9 Hz posterior
dominant rhythm. Note is made of continuous bradycardia
throughout the
recording.
CXR ___
Heart size is enlarged but stable. Median sternotomy wires are
unremarkable.
Lungs are clear with no appreciable pleural effusion or
pneumothorax
demonstrated. Minimal right basal opacity most likely reflects
area of
atelectasis, better appreciated on the CT torso from ___.
Carotid dopplers ___
Right ICA no stenosis.
Left ICA <40% stenosis.
LENS ___
DVT with small focal nonocclusive clot seen in the right
popliteal vein. This is the only site of disease
Brief Hospital Course:
This is a ___ y/o man with history of heavy ETOH consumption
presents s/p fall down stairs after losing his balance. He was
taken to an OSH where c-spine imaging revealed stenosis and he
was then transferred to ___ for further neurosurgical
evaluation. He was admitted to neurosurgery in the ICU for
monitoring for DTs. MRI c-spine revealed stenosis at C4-6 with
T2 signal changes. He remains in a c-collar. On ___, his exam
revealed weakness in his bilateral triceps and IPs. He is
antigravity distally in his lowers and proximally in his uppers.
He was transferred out of the ICU and upon bed transfer he was
noted to be dusky and non responsive. FSBS was stable / his VS
were stable except for his persistent bradycardia. There was a
second brief episode that was questionable for sz activity as
well. His heart rate was as low as 24. He was transferred back
to the TSICU.
Cardiology consult was called the following am: They felt that
there was a negligible risk of endocarditis and that antibiotic
prophylaxis was not recommended.
EP consult was done for bradycardia. They felt that Given that
he had a good chronotropic response to the 150's on stress echo
in ___, he will likely be able to mount a response to the
physiologic stressors during the operation
planned for ___. A pacer was not necessary.
EEG was done to eval for seizure activity in light of seizure
history from age ___, the last one in ___. He can not fully
describe the events, He has LOC and her might have a generalized
convulsion. EEG was done and this showed some occasional right
frontotemporal epileptiform discharges indicative of a potential
epileptogenic focus in this region. Depakote was continued.
Level was 90 on ___.
Nephrology was contacted due to his history of left nephrectomy,
decreased clearing at right kidney during torso scan and
elevated BUN/creatinine. He was being hydrated. Morphine was
changed to oxycodone per the pharmacy due to clearance rate. Pm
labs on ___ showed a drop in Creat from 1.5 to 1.2 and drop in
Bun from 39 to 35 and K was 4.4. Urine studies were sent due to
high UO. Nephrology recommended to stop IVF and to get a renal
ultrasound as an outpatient. He was cleared medically for the OR
and he went for C3-7 posterior laminectomies and fusion on ___.
He tolerated the procedure very well with no complications. Post
operatively he was taken to the PACU for further care. His post
op exam remained stable. On ___ his lower extremity strength
did improve as did his deltoid and biceps strength. His Foley
was removed but he was unable to void on his own and had over 1L
on bladder scan and the catheter was replaced.
On ___ he had LENIS and this showed R popliteal non occlusive
DVT. No treatment was started as it was non occlusive and the
plan is to repeat these studies in one week.
He was medically stable on ___ and telemetry was discontinued.
He was found to be anisocoric but has no other neurologic
change.
Medications on Admission:
Theophylline, Depakote, Neurontin
Discharge Medications:
1. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
2. insulin regular human 100 unit/mL Solution Sig: Two (2) units
Injection ASDIR (AS DIRECTED): see sliding scale.
3. methocarbamol 500 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day): hold for lethargy.
4. divalproex ___ mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QAM (once a day (in the
morning)).
5. divalproex ___ mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO QPM (once a day (in the
evening)).
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain or fever: max 4g/24 hrs.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. theophylline 200 mg Tablet Extended Release 12 hr Sig: One
(1) Tablet Extended Release 12 hr PO BID (2 times a day) as
needed for bradycardia.
12. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
13. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q3H (every 3
hours) as needed for pain: hold rr < 12
.
14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
15. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
cervical stenosis
cervical myelopathy
Spinal cord injury
Hyponatremia
Azotemia
Profound hypotension
Urinary retention
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:
Do not smoke.
Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery.
If you have steri-strips in place, you must keep them dry for
72 hours. Do not pull them off. They will fall off on their own
or be taken off in the office. You may trim the edges if they
begin to curl.
No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
Limit your use of stairs to ___ times per day.
Have a friend or family member check your incision daily for
signs of infection.
If you are required to wear one, wear your cervical collar or
back brace as instructed.
You may shower briefly without the collar or back brace;
unless you have been instructed otherwise.
Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. unless directed by your
doctor.
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.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
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.
Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
Fever greater than or equal to 101° F.
Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Followup Instructions:
___
|
10652583-DS-16
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| 16 |
2124-09-23 00:00:00
|
2124-09-23 16:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
SBO
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with history significant for ventral
epigastric/umbilical hernia repair presents with 3 days of
abdominal pain with nausea, vomitting, anorexia. Patient
reports abdominal discomfort initially but experienced colicky
___ pain around navel. Drinking liquids, teas and juice, would
induce nausea and vomiting. Has not been able to eat in the
last 3 days. Emesis appear brown; denies hematemesis. Endorses
flatus ___ times a day) and normal bowel movements once a day.
Stool is formed and brown. The last time he had emesis and BM
was this morning. He presents to ED for unremitting abdominal
pain, N/V.
Past Medical History:
PMH:
Hyperlipidemia
HTN
Coronary artery disease
Prostate cancer
PSH:
Ventral epigastric with mesh, umbilical, left scrotal, right
inguinal hernia repair ___, by Dr. ___
Cataract repair (___)
Prostate ca, s/p brachytherapy ___
CABG x2 (___)
Social History:
___
Family History:
NC
Physical Exam:
On admission:
Vitals: T 97.8 HR 68 BP 103/58 RR16 Sats95% Pain: 0
Gen: elderly man, with distended abdomen, in no acute distress.
AOx3.
HEENT: Mucus membranes moist
CV: RRR, nl S1, S2, no MRG. Old, healed vertical sternotomy
scar.
Pulm: Clear anteriorly. Inspiratory crackles bilaterally at the
bases. No wheezes or rhonchi.
Abdomen: Normal bowel sounds. Distended. Tympanitic on
auscultation. Diffuse tenderness to, worse near umbilicus.
Palpable mass on navel. No guarding or rebound tenderness.
Negative ___ sign. Old 6cm vertical median scar through
umbilicus, healed. Palpable mass at umbilicus.
Extremities: ___, DP pulses 2+, no edema.
On discharge:
AFVSS
Gen: awake, alert, NAD
HEENT: MMM
CV: RRR
Pulm: nonlabored breathing
ABD: soft, minimally distended, not tympanitic, nontender. no
guarding or rebound tenderness. 6cm vertical median scar well
healed
EXT: no ___
Pertinent Results:
___ 04:26PM ___ PTT-32.0 ___
___ 04:15PM GLUCOSE-195* UREA N-32* CREAT-2.5*#
SODIUM-138 POTASSIUM-3.8 CHLORIDE-85* TOTAL CO2-36* ANION
GAP-21*
___ 04:15PM estGFR-Using this
___ 04:15PM CALCIUM-10.1 PHOSPHATE-4.2# MAGNESIUM-3.5*
___ 04:15PM WBC-14.6* RBC-5.47 HGB-14.8 HCT-46.4 MCV-85
MCH-27.1 MCHC-32.0 RDW-13.0
___ 04:15PM NEUTS-79.5* LYMPHS-14.3* MONOS-5.7 EOS-0.2
BASOS-0.2
___ 04:15PM PLT COUNT-270
CT Abd ___:
1. Decompression of the stomach and small bowel following
nasogastric tube
placement, and air seen in the ascending and transverse colon.
The distal
small bowel is not well followed with possible transition point
noted in the
right lower quadrant. No intraperitoneal free air.
2. Left pulmonary lobe basilar patchy opacity which could
represent infection.
3. Tiny left adrenal adenoma.
AXR: ___:
Findings compatible with small bowel obstruction. No evidence
of free
intraperitoneal air.
Brief Hospital Course:
Mr. ___ was admitted to the acute care surgery service with a
small bowel obstruction and acute kidney injury. He had a KUB
taken in the ED which was suggestive a high grade SBO given
severe diffuse dilation. His creatinine was initially 2.5. He
had an NGT placed which initially put out 2 liters, and then
500cc over the next ___ hours. He was given a one liter lactated
ringers bolus for fluid resuscitation. He was initially made
NPO with IVF, NGT and a foley. He had another one liter bolus
on HD2. On HD2, he underwent a CT scan of his abdomen which
showed interval improvement s/p NGT placement. There was
decompression of his stomach and small bowel, and air was seen
in the ascending and transverse colon. He was passing flatus.
We continued to manage him conservatively. His NGT was
discontinued and his diet was steadily advanced to regular which
he tolerated without nausea or vomiting. His foley was
discontinued on HD3 and he was voiding freely. His creatinine
at this point had downtrending to 1.3. He was ambulating
without assistance. He had no pain. He can follow up with the
___ clinic as needed. He was given discharge instructions and
he understand the plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Moexipril 30 mg PO DAILY
2. Atenolol 100 mg PO DAILY
3. Amlodipine 5 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. sildenafil 50 mg oral daily prn
6. Aspirin 325 mg PO DAILY
7. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Atenolol 100 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. Moexipril 30 mg PO DAILY
7. sildenafil 50 mg oral daily prn
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with a small bowel obstruction which was
treated conservatively. You also had evidence of a temporary
injury to your kidneys, but this improved after we gave you more
fluids and your small bowel obstruction improved. You are now
safe to be discharged from the hospital. Please be sure to call
us at the number listed below for any questions or concerns.
Followup Instructions:
___
|
10652583-DS-17
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| 17 |
2127-03-26 00:00:00
|
2127-03-27 19:40:00
|
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:
Defibrillation ___
ICD Placement : ___
LHC: ___
TEE: ___
History of Present Illness:
Mr. ___ is a ___ gentleman with a PMH of CAD s/p CABG
in ___, CHF (EF 40% in ___, prostate cancer, hypertension,
and hyperlipidemia who presented to the ED after going to his
PCP's office with complaints of left-sided chest pain and
epigastric pain, concerning for ACS. On admission to the floor,
he had a monomorphic VT cardiac arrest, for which he is now
transferred to the CCU for further care.
The patient was not able to be interviewed. Per the ___
admission note, the patient had been having several days of
epigastric and left-sided abdominal discomfort that was unlike
his pain prior to his CABG. He did have a sensation of irregular
heart rate. He when to his PCP's office and was found to have an
EKG with atrial fibrillation and interior Q waves, precordial T
wave flattening. He was sent to the ED, where he again had an
EKG that showed atrial fibrillation vs. atrial flutter. He had a
chest x-ray that showed possible pneumonia, for which he
received azithromycin and ceftriaxone. After admission, he was
started on heparin drip.
A code blue was called at 5:30 AM on ___. Patient was
unresponsive with no pulse. Per the nurse, she was alerted to
see him after his telemetry alarmed for VT. CPR was initiated
after code team arrival. After defibrillator pads were placed,
the patient was found to be in a monomorphic VT rhythm. 1 shock
was delivered. He received a loading dose of 300 mg of
amiodarone bolus with a drip after. His rhythm was atrial
fibrillation after defibrillation with a palpable pulse. He had
spontaneous movement of his extremities and breathing on his own
after ROSC, but did not respond to command. He was transferred
to the CCU for further care.
Past Medical History:
- CABG in ___
- Diabetes
- Hypertension
- Dyslipidemia
- Prostate cancer
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 97.1 BP 104/74 HR 82 RR 25 O2 SAT 96% on CMV 400 x 20 PEEP
5 FiO2 100%
GENERAL: Elderly gentleman, unconscious.
HEENT: Normocephalic atraumatic. Sclera anicteric.
NECK: JVP of >15 cm.
CARDIAC: Irregularly irregular rate and rhythm. Normal S1, S2.
LUNGS: Patient is ventilated with breath sounds bilaterally.
ABDOMEN: Soft, non-distended.
EXTREMITIES: Warm, well perfused. No peripheral edema.
SKIN: No significant skin lesions or rashes.
DISCHARGE PHYSICAL EXAM:
VS: T Afebrile BP 100-130/60-70 HR 60-90s RR 18 O2 SAT 96% on RA
I/O: ___ yesterday
GENERAL: Elderly gentleman, NAD.
HEENT: Normocephalic atraumatic. Sclera anicteric.
NECK: Neck veins flat.
CARDIAC: Irregularly irregular rate and rhythm. Normal S1, S2.
LUNGS: CTAB, symmetric chest wall excursion, no increased WOB.
ABDOMEN: Soft, non-distended.
EXTREMITIES: Warm, well perfused. No peripheral edema.
SKIN: No significant skin lesions or rashes.
Pertinent Results:
ADMISSION LABS:
___ 05:15PM BLOOD WBC-7.1 RBC-5.09 Hgb-13.8 Hct-43.7 MCV-86
MCH-27.1 MCHC-31.6* RDW-16.1* RDWSD-49.1* Plt ___
___ 05:15PM BLOOD ___ PTT-36.2 ___
___ 05:15PM BLOOD Glucose-133* UreaN-27* Creat-1.2 Na-134
K-8.6* Cl-100 HCO3-26 AnGap-17
___ 05:15PM BLOOD cTropnT-<0.01 proBNP-4761*
___ 07:49PM BLOOD Lactate-2.3* K-3.9
___ 08:45PM URINE Color-Straw Appear-Clear Sp ___
___ 08:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
PERTINENT RESULTS:
___ 05:16AM BLOOD WBC-11.0* RBC-4.39* Hgb-11.9* Hct-36.8*
MCV-84 MCH-27.1 MCHC-32.3 RDW-15.9* RDWSD-48.0* Plt ___
___ 05:03AM BLOOD Glucose-152* UreaN-31* Creat-1.8* Na-136
K-3.5 Cl-100 HCO3-24 AnGap-16
___ 06:38AM BLOOD ALT-138* AST-70* LD(LDH)-270* AlkPhos-123
TotBili-0.7
___ 05:03AM BLOOD ALT-126* AST-55* AlkPhos-105 TotBili-0.8
___ 05:16AM BLOOD ALT-100* AST-37 AlkPhos-96 TotBili-1.0
___ 12:40AM BLOOD CK-MB-3 cTropnT-<0.01
___ 12:40AM BLOOD TSH-5.7*
___ 05:03AM BLOOD T4-7.4 Free T4-1.4
___ 05:16AM BLOOD PSA-20.5*
___ 01:01AM BLOOD Lactate-2.8*
___ 06:03AM BLOOD Lactate-4.5* K-3.3
___ 06:46AM BLOOD Glucose-246* Lactate-7.3* Na-136 K-3.0*
___ 08:24AM BLOOD Lactate-4.5*
___ 04:46PM BLOOD Lactate-2.4* K-3.8
___ 03:08PM BLOOD Lactate-2.1*
___ 05:26AM BLOOD Lactate-1.2
DISCHARGE LABS:
___ 04:42AM BLOOD WBC-7.6 RBC-4.09* Hgb-11.1* Hct-35.6*
MCV-87 MCH-27.1 MCHC-31.2* RDW-15.4 RDWSD-48.7* Plt ___
___ 04:42AM BLOOD ___ PTT-31.6 ___
___ 04:42AM BLOOD Glucose-102* UreaN-22* Creat-1.1 Na-137
K-4.0 Cl-98 HCO3-28 AnGap-15
___ 04:42AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.9
MICROBIOLOGY:
___ 5:15 pm BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING/PROCEDURES:
CXR PA and LATERAL (___)
FINDINGS:
Patient is status post median sternotomy and CABG. Heart size
is moderately
enlarged, unchanged. The aorta is tortuous. The mediastinal
contours are
otherwise similar. Enlargement of the right hilum is unchanged,
compatible
with mild enlargement of the right pulmonary artery. Pulmonary
vasculature is
not engorged. Patchy right basilar opacity is concerning for an
area of
infection with a small right pleural effusion. No pneumothorax
is present.
Severe degenerative changes are noted within the thoracic spine.
LHC (___)
Coronary Anatomy
Dominance: Right
* Left Main Coronary Artery
The LMCA is free of significant stenosis.
* Left Anterior Descending
The LAD is occluded proximally..
* Circumflex
The Circumflex is occluded proxiimally.
* Right Coronary Artery
The RCA is occluded proximally. There is a collaterals from the
LCX via a proximal atrial branch.
SVG to OM2 is a large vessel and is patent. There is ___
eccentric proximal stenosis.
LIMA has take-off from the vertebral and is not able to be
engaged selectively. Non-selective angio shows
is a large vessel with stenosis
TTE (___)
Mild spontaneous echo contrast is seen in the body of the left
atrium. Moderate to severe spontaneous echo contrast is present
in the left atrial appendage. The left atrial appendage emptying
velocity is depressed (<0.2m/s). A left atrial appendage
thrombus cannot be excluded. LV systolic function appears
depressed. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) are mildly thickened. The
mitral valve leaflets are not well seen.
IMPRESSION: Severe spontaneous echo contrast in the left atrial
appendage with decreased emptying velocity. Cannot exclude the
possibility of left atrial appendage thrombus due to difficulty
visualizing the entire appendage.
The images were reviewed with Dr. ___ at the time they were
obtained. Dr. ___ was notified of the findings by telephone on
___ at 8:45.
CXR (___)
FINDINGS:
The patient has been extubated. Interval insertion of left
pectoral
transvenous pacemaker with tip terminating in the right
ventricle. No
pneumothorax. The sternotomy wires and surgical clips are
unchanged.
Right lower lobe atelectasis is persistent. The lungs are
otherwise clear.
No pleural effusion. The cardiomediastinal silhouette is
unchanged.
IMPRESSION:
Interval insertion of left pectoral transvenous pacemaker with
tip terminating
in the right ventricle. Overall improved aeration of the lungs
with mild
right lower lobe atelectasis.
Brief Hospital Course:
Mr. ___ is a ___ gentleman with a PMH of CAD s/p CABG
in ___, CHF (EF 40% in ___, prostate cancer, hypertension,
and hyperlipidemia who presented to the ED after going to his
PCP's office with complaints of left-sided chest pain and
epigastric pain, concerning for ACS. Also found to have new
Afib. On the floor he was found to be in volume overload as well
as to have a newly diagnosed atrial fibrillation. Shortly after
being admitted to the cardiology floor, he developed a
monomorphic ventricular tachycardia (rate of ~280ms); he was
pulseless during this episode but achieved ROSC after 1
defibrillation and minimal chest compressions (back into atrial
fibrillation). He was intubated during the code and required
brief period of vasopressor support. He was transferred to the
CCU, intubated and sedated.
# VT arrest.
Patient received 1 shock, minimal chest compressions and 300 mg
amiodarone. Patient arrived on the CCU intubated and sedated.
Required brief pressor support but was weaned off pressors and
extubated shortly after arrival. Cardiac catheterization on ___
showed known proximal occlusion of LAD, LCx and RCA ___
collaterals and a patent saphenous vein graft. VT was deemed to
be likely scar mediated from patient's prior MI and known
inferior hypokinesis. A PPM was placed by our EP team on ___
without incident and patient remained stable for the rest of his
stay.
# Atrial Fibrillation.
New onset, noticed first in the outpatient setting, without
clear etiology. Patient could have had worsening HF that lead to
the symptoms. Given report of chest pain, patient may have had a
recent ischemic event that lead to further reduced EF. Patient
also with some EKGs concerning for a flutter pattern. A heparin
drip was resumed after patient was deemed to not be a high bleed
risk and he was eventually bridged to apixaban. TSH was normal.
He was started on metoprolol tartrate which was titrated to 75
mg Q6 with some success in rate control with resting ventricular
rates in the ___ range. He was started on digoxin as well
and bridged from heparin to apixaban for anticoagulation. A TEE
and DCCV was scheduled but DCCV was aborted after a TEE with
some visual disturbance; clot in the left atrial appendage could
not be ruled out on TEE. Patient remained stable and patient was
discharged home with plan for ___ after 4 weeks of
anticoagulation.
# Volume Overload | Acute Systolic Heart Failure
Patient appeared fluid overloaded on presentation to the CCU,
likely reflecting new CHF diagnosis
- Preload: Patient was gently diuresed
- Afterload: Patient was started on lisinopril on discharge
- Pump: Metoprolol as above
# Pneumonia. Pt with CXR concerning for infection on
presentation. White count peaked at 11. Patient afebrile
throughout stay. Patient was given a 5 day course of ceftriaxone
given his critical state.
# ___. Presented with creatinine of 1.0, spiked to 1.8 on
___. Possibly prerenal from cardiogenic shock. Ace
inhibitor was held and creatinine improved to baseline.
ADMISSION WEIGHT: 88.7
DISCHARGE WEIGHT: 74.9
DISCHARGE CREATININE: 1.1
TRANSITIONAL ISSUES
- Patient is to keep arm in sling for 1 week after PPM placement
(date of procedure ___.
- Will need stitches removed at time of follow-up.
- Patient started on lisinopril 2.5 mg here. He will need
follow-up labs in 1 week to check potassium and creatinine
- was discharged with 1 month supply apixaban. If patient is
unable to aquire more apixaban, it is reasonable to bridge to
warfarin as an outpatient after ___. He will need 4 weeks of
anticoagulation before ___ and 3 weeks after.
- he was started on metoprolol succinate 150 mg BID for rate
control
- was started on digoxin 0.125 mg daily. would require digoxin
level measurement with follow
- His aspirin was changed from 325 mg daily to 81 mg daily.
- He was given atorvastatin 80 mg in the hospital and he was
discharged with 40 mg daily (changed from his home dose of 20 mg
daily).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Hydrochlorothiazide 25 mg PO DAILY
5. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
6. Atenolol 100 mg PO DAILY
7. Moexipril 30 mg PO DAILY
8. Sildenafil 50 mg PO ASDIR
9. Centrum Men (mv,Ca,min-iron-FA-lycopene) 8 mg iron- 200
mcg-600 mcg oral DAILY
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
2. Digoxin 0.125 mg PO DAILY
RX *digoxin 125 mcg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
3. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
4. Metoprolol Succinate XL 150 mg PO BID
Please take once in the morning and once at night,
RX *metoprolol succinate 100 mg 1.5 tablet(s) by mouth twice a
day Disp #*90 Tablet Refills:*0
5. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
6. Atorvastatin 80 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
7. Centrum Men (mv,Ca,min-iron-FA-lycopene) 8 mg iron- 200
mcg-600 mcg oral DAILY
8. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
9. Sildenafil 50 mg PO ASDIR
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
S/P VT arrest
Atrial Fibrillation
Congestive Heart Failure
SECONDARY DIAGNOSIS
___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you here at ___.
Why did I come to the hospital?
- You presented to us from your outpatient doctor with chest
pain and epigastric pain. You were found to have extra fluid in
your lungs and also a new rhythm called atrial fibrillation.
- While being treated on the cardiology service you went into a
dangerous rhythm (monomorphic ventricular tachycardia).
What was done for me while I was in the hospital?
- CPR was performed and a shock was delivered to your heart to
bring you out of the dangerous rhythm
- You were treated for this rhythm with a pacemaker to prevent
further episodes
- Medication was given to control your heart rate.
- Please keep your left arm in the sling for 1 week. Do not
engage in any heavy lifting or raise the arm above 90 degrees
- In your follow up apt, please have any stitiches removed
It was a pleasure taking care of you at the ___. We wish you
all the best.
Your ___ team
Followup Instructions:
___
|
10652583-DS-21
| 10,652,583 | 24,239,654 |
DS
| 21 |
2128-12-19 00:00:00
|
2128-12-19 20:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
digoxin
Attending: ___.
Chief Complaint:
Shortness of breath, leg swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old man with a history of metastatic
prostate cancer, CAD w/ h/o CABG in ___ and ischemic
cardiomyopathy with EF 20%, VT s/p ICD placement, atrial
fibrillation (not currently on anticoagulation), T2DM, who
presents with new onset chest pain. He had multiple episodes of
chest pain while at home the night before his admission. It
lasted for ___ minutes at a time, was pressure and left sided,
and did not radiate. This was also associated with dyspnea,
which has been worsening for about 2 weeks. The morning of
admission, he had additional episodes of chest pain, worse with
ambulation, and did NOT have relief from SL nitro x3. He took a
full aspirin at home.
Initially, he presented to ___ (went to urology today
and they capped his left nephrostomy tube). Labs there revealed
BNP of 13532 (14228 on ___, and before that was 9695 on
___ at ___. CK-MB was 3.4 (normal) and Trop-T was
0.026 at 1400. Hgb 9.3 (baseline), and UA revealed ___ WBC w/
500 leuks, negative nits, +protein, -ketones and glucose.
His last outpatient cardiology visit was with Dr. ___ on
___ when he was hypervolemic and they re-started torsemide
20 mg. For afib anticoagulation: rivaroxaban was held due to ___
and expense, and was stopped in his previous admission when he
developed a hematoma ___ percutaneous nephrostomy tube
placement. Warfarin was considered but held off due to patient
preference, and because of the possibility of procedures in the
near future for his prostate cancer as he had just had bilateral
nephrostomy tubes placed for obstructive uropathy.
Past Medical History:
CAD s/p CABG in ___
Ischemic CMP with EF of 20%
Hx of VT s/p ICD
Afib on Xarelto (held for last 4 days)
Diabetes
Prostate Ca s/p brachytherapy and ADT, lost to f/u over last ___
years
HTN
HLD
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 97.8PO 120 / 78 L Sitting 79 18 98 RA
GENERAL: NAD, pleasant, cachectic man appearing stated age.
Appears very weak and frail when moving from a sitting to laying
position.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, JVP visible just above the clavicle at 45
degrees, ~9 cm
HEART: Irregular rhythm w/ regular rate, S1/S2, no murmurs,
gallops, or rubs. No chest wall TTP.
LUNGS: Decreased right base breath sounds. No wheezes, rales,
rhonchi, breathing comfortably without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly. Left nephrostomy tube
capped. Right nephrostomy tube draining golden urine.
EXTREMITIES: no cyanosis, clubbing. 2+ pitting edema to the
knees.
PULSES: 1+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
========================
___ 0607 Temp: 97.8 PO BP: 114/62 R Lying HR: 91 RR: 20 O2
sat: 99% O2 delivery: ra Dyspnea: 0 RASS: 0 Pain Score: ___
GENERAL: NAD, pleasant, cachectic
HEENT: AT/NC, EOMI, PERRL
NECK: supple, no LAD, JVP 2-3cm above clavicle, no significant
distension appreciated
HEART: Irregular rhythm w/ regular rate, HR ___, S1/S2, no
murmurs
LUNGS: No crackles noted. No rales, rhonchi. Breathing
comfortably
ABDOMEN: nondistended, nontender in all quadrants
Left nephrostomy tube capped. Right nephrostomy tube draining
EXTREMITIES: no cyanosis, clubbing. Minimal edema, significantly
improved pedal edema
PULSES: 1+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities
SKIN: warm and well perfused
Pertinent Results:
ADMISSION LABS:
===============
Trop 0.03
CK-MB 2
Chem 7: Na 141 K 4.7 Cl 103 CO2 22 AG 16 BUN 31 Cr 1.5
___ 13.4 PTT 30.5 INR 1.2
PERTINENT LABS:
===============
___ 09:53PM BLOOD cTropnT-0.03*
___ 09:53PM BLOOD CK-MB-2
___ 06:10AM BLOOD CK-MB-2 cTropnT-0.02*
DISCHARGE LABS:
===============
___ 07:35AM BLOOD WBC-7.9 RBC-3.29* Hgb-8.7* Hct-28.6*
MCV-87 MCH-26.4 MCHC-30.4* RDW-21.5* RDWSD-68.0* Plt ___
___ 07:35AM BLOOD Plt ___
STUDIES/IMAGING:
===============
CXR ___
Compared to chest radiographs since ___ most recently ___
and one ___.
Now mild pulmonary edema has improved substantially. Moderate
right pleural effusion not appreciably changed. Moderate
cardiomegaly also stable. No pneumothorax. Transvenous right
ventricular pacer defibrillator lead is on course from the left
pectoral generator unchanged.
TTE ___
IMPRESSION: Good image quality. Large filamentous mass attached
to the right atrial lead c/w fibrin strand, thrombus, or
vegetation. Mild symmetric left ventricular hypertrophy with
mild cavity dilation and severe global systolic dysfunction with
regional variation c/w ischemic cardiomyopathy. Moderate
tricuspid regurgitation. Mild to moderate mitral regurgitation.
Pulmonary artery diastolic hypertension.
Severe pulmonary artery systolic hypertension.
Brief Hospital Course:
Mr. ___ is a ___ metastatic prostate cancer, CAD w/
h/o CABG in ___ and ischemic cardiomyopathy with EF 20%, VT s/p
ICD placement, atrial fibrillation (not currently on
anticoagulation), T2DM who presents with chest pressure.
ACUTE ISSUES:
================================
# DECOMPENSATED HEART FAILURE WITH REDUCED EF:
Patient presented with acute on chronic decompensated systolic
heart failure as evident by worsening edema, distended JVP, and
worsening DOE. His BNP was elevated at 13,000 with negative
cardiac enzymes and EKG without new changes. His heart failure
is likely worsening due to natural progression of disease, no
reported medication noncompliance and no concern for worsening
ischemia. Repeat ECHO with reduced EF of 23%, stable from prior.
He was diuresed on IV Lasix gtt and transitioned to PO torsemide
40mg. He was continued on his home metop succ 25mg. He was
resumed on afterload reducing agents consisting of hydralazine
10mg TID and Imdur 30mg on discharge. Follow up has been
arranged with his outpatient cardiologist. Weight at discharge:
67.6 kg (149.03 lb).
# Hx of VT s/p ICD placement:
EP interrogated his ICD on ___ and noted function was normal
with acceptable lead measurements and battery status. He did
have intermittent episodes of NSVT lasting ___ seconds while
in-house without any hemodynamic instability.
# METASTATIC PROSTATE CANCER:
# BILATERAL PCN:
Continued home bicalutamide. Seen by ___ on ___ with right PCN
capped. No issues. Plan to keep both PCNs capped with ___
follow-up next month as previously scheduled.
# R. Knee pain:
Developed right knee pain after walking day prior. + Warmth and
tenderness on exam but no effusion or erythema. Plain film
demonstrated no acute pathology. Pain improved with Tylenol.
# Goals of Care:
We initiated discussions regarding severity of his disease as
well as goals of care and code status. Palliative care provided
support. Continue these discussions as outpatient. Patient was
full code at discharge. Additionally, patient refusing discharge
to rehab and also refusing ___. Patient with full capacity.
TRANSITIONAL ISSUES:
===============================
Discharge weight: 67.6 kg (149.03 lb)
Medications:
New: Isosorbide mononitrate, hydralazine
Changed: Increased torsemide from 20mg daily to 40mg daily
[ ] Capped R PCN on ___. Patient continued to have good urine
output without evidence of obstruction at discharge. He has ___
appointment on ___
[ ] Monitor volume status and titrate diuretics as clinically
indicated.
[ ] Monitor BP on new afterload agents; titrate as clinically
indicated.
[ ] Monitor right knee pain
[ ] Continue goals of care discussions
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. bicalutamide 50 mg oral DAILY
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Torsemide 20 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Aspirin 81 mg PO DAILY
7. GlipiZIDE XL 2.5 mg PO DAILY
Discharge Medications:
1. HydrALAZINE 10 mg PO Q8H
RX *hydralazine 10 mg 1 tablet(s) by mouth Every 8 hours Disp
#*90 Tablet Refills:*0
2. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
3. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth Daily Disp #*60 Tablet
Refills:*0
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. bicalutamide 50 mg oral DAILY
7. GlipiZIDE XL 2.5 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on chronic systolic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear ___,
Thank you for coming to ___!
Why were you admitted?
- You were admitted for worsening shortness of breath and leg
swelling in the setting of chest pain
What happened while you were in the hospital?
- We did an echo (ultrasound) of your heart, which showed that
your heart function was stable.
- We gave you some medications to help with removing excess
fluid from your body.
- We did labs to evaluate your chest pain, and it did not show
any acute heart attack.
- We transitioned you to oral diuretic which you were stable on
before discharge.
- We capped your right nephrostomy tube.
What should you do when you go home?
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs in one day or 5 lbs in 3 days
- If you have any concerns regarding shortness of breath, please
talk to your cardiologist immediately
- Please also follow up with your Interventional Radiology
appointment on ___ for nephrostomy tube (kidney tubes)
exchange. You will need to call your doctor sooner if you
develop pain in your abdomen, fever, chills, or are unable to
urinate.
- Your discharge weight is 67.6 kg (149.03 lb).
- Please contact your doctor or go to the ED immediately if you
develop worsening knee pain with associated swelling, redness,
or fever.
It was a pleasure taking care of you! We wish you all the best.
- Your ___ Team
Followup Instructions:
___
|
10652693-DS-11
| 10,652,693 | 29,461,184 |
DS
| 11 |
2123-10-07 00:00:00
|
2123-10-07 14:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
confusion - now resolved
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms ___ is a ___ year old woman with a PMH of melanoma and
multiple likely embolic strokes who is presenting as a transfer
from ___ for evaluation after a third
episode of confusion. History was taken from patient, son, and
outside hospital records. The first episode was in ___, at that time she was home in the afternoon and became
instantly light headed and felt off balance and was confused.
It lasted about 20 minutes. She was taken to an OSH where she
believes a NCHCT was unrevealing and she was sent home on her
home aspirin. She did well for the next year until ___
At that time she was found to be "not acting right" disoriented
complaining of right upper extremity numbness. She could not
walk and an ambulance was called where she returned to baseline
over about 2 hours. She was admitted to the hospital and had a
slight bump in cardiac enzymes to a trop of 0.77, echo was done
and per report no evidence of PFO on bubble study, but extensive
mitral annular calcification which results in restriction of
leaflet motion narrowing of the mitral orifice. No evidence of
prolapse and mild mitral regurgitation. EF 72%. Trop trended
down and was 0.42 on day of discharge (___). MRI
demonstrated scattered punctuated strokes in the cerebellar
hemispheres, and there was no significant stenosis or occlusion
of the major neck vessels. This was discussed with the stroke
fellow at ___ who thought it was appropriate to continue with
aspirin and could add statin (started lipitor) and would be
appropriate to have a TEE relatively soon. She followed up with
a Neurologist in ___ On ___ - abmulatory ECG report -
NSR and Sinus tachycarida, on ___ - Transesophageal echo -
aortic sclerosis without significant stenosis/2+mitral
regurgitation/concentric left ventricular hypertrophy with
hyperdynamic lv function, no thromboembolic source evident, on
___ - CTA head/neck - no emobilic occlusion or severe
stenosis
is identified - 3mm posteroinferolaterally directed right
anterior choroidal artery aneurysm no dissection/ stenosis. On
___ - US duplex carotid arteries- no hemodynamically
significant stenosis is noted in the internal/common carotids/
anterograde flow is noted in the cervical vertebral arteries
bilaterally.
She continued to do well until yesterday evening (___),
she was at her grandson's ___ party at her son's house. They
were having dessert when she looked at a birthday card and said
"what is this for" they found her disoriented and confused she
stated her arms were heavy. Her son brought a video on his
iphone of the event where she appears to have a symmetric face
but is clearly asking questions of what is going on. This
lasted
about an hour and she was brought to ___.
Given the complexity and the increase in frequency of the events
she was transferred to ___ for further evaluation.
Of note she 65lbs of weightloss and night sweats over the past
year "without trying." She denies prior blood clots or
miscarriages or any clotting problems. She does state that
sometimes she finds that her "left eye" droops. Sometimes he
she
has "triple vision" of objects at night and see's halos. She
has known cataracts that she needs to have corrected, no clear
diplopia. She has a bit of current sinus congestions today but
no illness.
On neuro ROS, the pt denies current headache, loss of vision,
blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness.
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:
-HTN
-obesity
-smoker
-melanoma - removed from right wrist showed a second incision -
she had a lymph node biopsy. She sees Dr. ___ for
___
-hysterectomy secondary to cervical cancer - still has ovaries
-tonsillectomy
-some nonmelanoma skin cancers? removed from other arm
Social History:
___
Family History:
mother deceased secondary to breast cancer. father
deceased secondary to suicide. brother has diabetes
Physical Exam:
Physical Exam:
Vitals: T:97.2 P:78 R:16 BP:130/88 SaO2:100% on RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities:warm and well perfused
Skin: no rashes or lesions noted.
.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall ___ at 5 minutes. The pt. had
good
knowledge of current events. There was no evidence of apraxia
or
neglect. Calculation was intact (answers seven quarters in
$1.75)
.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
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
**has bad knee arthritis and pain and did not want formal
testing
.
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 * 1
R 2 2 2 * 1
Plantar response was flexor bilaterally.
**has bad knee arthritis and pain and did not want formal
testing
-Coordination: No intention tremor, mild clumsiness on RAM left
greater than right.
-Gait: Good initiation. wide-based secondary to habbitus.
Romberg absent.
DISCHARGE EXAM:
Afebrile, vital signs stable.
General: Patient is well-appearing obese female appearing her
stated age, well nourished, well groomed, in NAD
Head/Eyes/Ears: Skull is atraumatic and normal appearing;
conjunctiva are clear/pink, sclera anicteric; no sinus
tenderness; pink oral mucosa with moist mucus membranes, no oral
lesions, has dentures
Neck: Supple, thyroid palpable without gross enlargement or
nodules, unable to assess JVP due to body habitus, no bruits
were auscultated
Lymph Nodes: no cervical, auricular, or supraclavicular LAD
Cardiovascular: distant heart sounds due to body habitus, normal
S1 and S2 with physiologic splitting, no murmurs, rubs or
gallops
Pulmonary: CTAB, no rh/r/wh
Abdominal: obese, BS present, soft, NT/ND abdomen without
masses, no CVA tenderness
Skin: Skin warm and without rash, pigmented lesions, petechiae,
or ecchymoses
Extremities: WWP without clubbing, cyanosis, or edema. Good
range of motion in all joints and spine, no evidence of swelling
and deformity. Bilateral knee pain reported with ROM.
NEUROLOGIC EXAMINATION:
Mental Status:
Gen: Patient is alert and interactive relaxed, and cooperative.
Patient has a normal affect and insight into her state.
Orientation: Patient is alert and oriented to person, place, and
time (month, day, year).
Attention: Months backwards without difficulty.
Language: Fluent speech without paraphasic errors; naming intact
to high and low frequency items, follows simple and complex
commands without left-right confusion.
Memory: Registers ___ words and recalls ___ at 5 minutes.
Cranial Nerves:
I - not assessed since no recent change in taste/smell
II, III - visual acuity, visual fields full to confrontation,
pupils
4>2 mm bilaterally to light and accommodation
III, IV, VI - EOM intact, no ptosis, no nystagmus, no diplopia
reported
V - sensation intact to light touch and temp in all 3 divisions,
strength intact by jaw clench
VII - facial strength intact and symmetric without droop
IX, X - voice normal, palate elevates midline
XI - SCM and trapezius strength ___ bilaterally
XII - tongue protrudes midline without atrophy or fasiculations
Motor: Normal bulk, and tone. No tremor, rigiditiy, or
bradykinesia. No pronator drift. Finger tapping normal.
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: Light touch and proprioception intact. Temperature
intact. No evidence of exinction.
Reflexes:
Bi C6 Tri C7 Bra C6 Pat L4 ___ S1 Toes
R 2 2 2 2 unable to assess
Down
L 2 2 2 2 unable to assess
Down
Coordination: finger-nose-finger intact, finger tap, fast and
fine movements normal, no tremor or ataxia
Pertinent Results:
___ 04:00AM BLOOD WBC-8.2 RBC-3.95* Hgb-11.7* Hct-35.7*
MCV-90 MCH-29.6 MCHC-32.7 RDW-14.4 Plt ___
___ 04:00AM BLOOD Plt ___
___ 04:00AM BLOOD Glucose-96 UreaN-17 Creat-0.6 Na-138
K-4.4 Cl-105 HCO3-27 AnGap-10
___ 04:30PM BLOOD CK-MB-7
___ 04:30PM BLOOD cTropnT-0.13*
___ 11:52PM BLOOD CK-MB-5 cTropnT-0.14*
___ 10:55AM BLOOD CK-MB-4 cTropnT-0.10*
___ 04:00AM BLOOD Calcium-9.7 Phos-3.9 Mg-1.9
Brief Hospital Course:
# Neuro:
MRI brain was unrevealing for any new infarct. Old findings
appeared stable when compared to outside MRI imaging. CT torso
was performed to rule out occult malignancy causing TIAs, and
this was unremarkable as well. We decided against performing an
extended hypercoagulable work up as she had had an extensive
work up already which was unrevealing for thrombosis or embolic
disease. We continued her home ASA but held her
antihypertensives for 2 doses until we had the MRI confirming no
new stroke. She received an EEG prior to discharge; the
preliminary read is overall normal but the final read from the
Epileptologist was pending at the time of discharge. Given her
symptoms but negative imaging findings, we discussed with the
patient upon discharge that we felt stroke/TIA was unlikely (at
least in this most recent episode), and the more likely
possibilities at this point in time were either complex partial
seizure or complex migraine variant. We discharged her home on
all of her home medications with the addition of Verapamil to
treat complex migraine variant. She will follow up with Dr.
___ in Stroke ___ in one month.
# Cardiovascular:
Her blood pressure was stable throughout her admission. Troponin
was 0.13 (1600 ___ on admission, then trended to 0.14 (2400
___, and finally 0.1 (0800 ___. She denied chest pain or
other symptoms of myocardial ischemia throughout her admission,
and her EKG in the ED was unremarkable. Regardless, cardiology
was consulted to help us determine if she could be having silent
myocardial ischemia. They felt that this was unlikely and did
not recommend any changes to our plan. We started her
antihypertensive medications prior to discharge once her MRI
showed no new stroke.
# Pulmonary:
CXR was non-focal, and she remained stable from a respiratory
standpoint throughout her admission
# Renal:
Electrolytes were stable, as were BUN and Cr, throughout her
admission.
# Infectious disease:
There were no fevers or other signs or symptoms of infecion
during this admission.
# FEN/GI:
She ate well during this admission. She was given IV fluids
overnight for hydration but also drank well without need for
boluses.
# Prophylaxis:
DVT: pneumoboots were placed during this admission
Medications on Admission:
-Lipitor 10 mg daily
-Aspirin 325 mg daily
-lisinopril 15 mg daily
-HCTZ 12.5 mg daily
-MVI
-Vitamin D
-Calcium
Discharge Medications:
1. Verapamil SR 120 mg PO HS
RX *verapamil 120 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*2
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. Calcium Carbonate 500 mg PO BID
5. Hydrochlorothiazide 12.5 mg PO DAILY
6. Lisinopril 15 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Complex migraine variant versus complex partial seizure
resulting in confusional episodes.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the Neurology Service for concern over a
new stroke. We do not think you had a new stroke, and are
considering either complex partial seizures or migraine variants
as possibilities to explain your symptoms. We are starting you
on a medication called Verapamil to help prevent these symptoms.
You should continue all of your other home medications.
Please follow up with Dr. ___ in the ___ Clinic at ___
___, ___ Building, ___ floor, on ___ at 2pm. If you need further directions, parking
instructions, rescheduling, or other questions, please call the
Stroke Clinic at ___. Please call us as well if you
have new concerning symptoms, or any questions about this
admission. For other new symptoms or concerns please contact
your primary physician.
Followup Instructions:
___
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|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ MVC vs parked car, 30mph, unrestrained, +EtOH, txf OSH w/ R
7th rib fx and small PTX, L nasal fx, ?tiny R retrobulbar
hematoma
Past Medical History:
HTN, heavy smoker, EtOH use disorder
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission Physical Exam:
GEN: A&O, NAD
Neuro: CN ___ intact, ophthalmologic exam nl
HEENT: No nasal septum hematoma, boggy mucosa
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
Discharge Physical Exam:
VS: 97.4, 68, 117/67, 18, 99%ra
Gen: A&O x3
HEENT: right eye ecchymosis, conjunctiva injected
CV: HRR
Pulm: TTP over left side. LS w/ faint expiratory wheeze
Abd: soft NT/ND
Ext: no edema
Pertinent Results:
CXR ___
Right deep sulcus sign is compatible with right-sided
pneumothorax seen on
outside CT chest performed earlier on same day.
R ANKLE XR ___
Unremarkable examination of the right ankle.
CXR ___
Small right pneumothorax detectable on concurrent chest CT is
not evident on the conventional radiograph pain, which does show
mildly displaced fracture antral lateral aspect right seventh
rib. Right pleural effusion is small. Cardiomediastinal and
hilar silhouettes normal. Lungs clear.
CT CHEST ___
Small right hydro pneumo/hemo pneumothorax. The pneumothorax
component shows mild interval decrease in size.
Subsegmental opacification in the posterior basal aspect of the
right lower lobe most likely represents retained secretions and
atelectasis secondary to splinting of the right hemidiaphragm,
in the differential diagnosis consider aspiration.
CXR ___
Heart size is normal. Mediastinum is normal. Lungs are clear.
Minimal
amount of left pleural effusion/pleural thickening is unchanged.
Known small
right apical pneumothorax is not clearly seen on the chest
radiograph as was
noted previously. Left lung is clear.
Brief Hospital Course:
___ was admitted for observation, pain control and
pulmonary toilet. She noted that she has a history of alcohol
withdrawal, and was thus placed on CIWA. A tertiary survey
performed on ___ revealed no additional injuries. Her
pneumothorax was monitored with serial chest X-rays, and was not
visible on the last CXR taken ___. Plastics was consulted
regarding her nasal fracture, and recommended nonoperative
management. Ophthalmology was also consulted regarding the
retrobulbar hematoma, and recommended no acute intervention.
During her hospitalization she did not note any visual symptoms.
On discharge she was afebrile, hemodynamically stable, and
ambulating. She was discharged with instructions to follow up in
___ clinic in ___ weeks
Medications on Admission:
lisinopril 10 mg qd
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
3. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine HCl-menthol [Endoxcin] 4 %-1 % apply to right rib
chest wall every twelve (12) hours Disp #*14 Patch Refills:*0
4. Nicotine Patch 21 mg TD DAILY
RX *nicotine 21 mg/24 hour 1 patch to arm daily Disp #*14 Patch
Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth Q3H Disp #*50 Tablet
Refills:*0
6. Senna 8.6 mg PO BID
7. Lisinopril 10 mg PO DAILY
8. PARoxetine 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
[] Minimally displaced fracture of the lateral aspect of the
right seventh rib.
[] Small right pneumothorax
[] Right ___ hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ after a motor vehicle collision that
occurred while you were driving intoxicated. You fractured a rib
and had a small injury to your lung, and a right ___
hematoma. Plastic Surgery was consulted for the eye hematoma. On
exam, there was no other injury and no intervention warranted.
You have had X-Rays that show the lung injury is improving. You
are now medically clear to be discharged home to continue your
recovery. Please note the following discharge instructions:
* Your injury caused one rib fractures which can cause severe
pain and subsequently cause you to take shallow breaths because
of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
Followup Instructions:
___
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2122-03-03 09:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___ Laparoscopic appendectomy
History of Present Illness:
___ year old female with history of RLQ/LLQ abdominal pain,
associated
with nausea/wretching, no chest pain, shortness of breath,
fever/chills, change in bowel or bladder habits. The pain is
focal, non-radiating, moderate/severe, worse with activity, no
significan relieving factors.
ROS:
Past Medical History:
GYN hx: LMP ___. Has not ever seen a Gynecologist. No hx of
STI or abnormal Pap. Sexually active with one male partner. Uses
the ___. Hx of ovarian cyst as described above.
OB Hx: GO
Social History:
___
Family History:
noncontributory
Physical Exam:
Physical Exam: ___: upon admission:
Vitals: afebrile, vitals stable
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: Regular
PULM: unlabored
ABD: Soft, nondistended, + RLQ tenderness, focal + rebound, +
guarding, + rosvigs, negative psoas, negative obturator no
palpable masses.
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 11:55AM BLOOD WBC-13.2* RBC-4.62 Hgb-12.3 Hct-38.6
MCV-84 MCH-26.7* MCHC-32.0 RDW-13.7 Plt ___
___ 11:55AM BLOOD Neuts-89.0* Lymphs-7.3* Monos-2.8 Eos-0.7
Baso-0.2
___ 11:55AM BLOOD ___ PTT-28.1 ___
___ 11:55AM BLOOD Glucose-107* UreaN-7 Creat-0.8 Na-139
K-3.8 Cl-103 HCO3-24 AnGap-16
___: Doppler abdomen and pelvis:
1. Possible distal appendicitis with trace right lower quadrant
free fluid.
Preliminary Report2. No evidence of ovarian torsion.
___: pelvic US:
Preliminary Report1. Possible distal appendicitis with trace
right lower quadrant free fluid.
Preliminary Report2. No evidence of ovarian torsion.
___: cat scan of abdomen and pelvis:
Acute appendicitis with small to moderate amount of intermediate
density pelvic free fluid. No drainable fluid collection or
free air.
Brief Hospital Course:
The patient was admitted to the hospital with abdominal pain.
Upon admission, the patient was made NPO, given intravenous
fluids and underwent imaging. Cat scan imaging showed acute
appendicitis with a small to moderate amount of pelvic free
fluid. The patient was taken to the operating room where she
underwent a laparoscopic appendectomy. The operative course was
stable with minimal blood loss. The patient was extubated after
the procedure and monitored in the recovery room where vital
signs remained stable. The post-operative course was stable.
After recovery from anesthesia, the patient resumed a regular
diet. Her pain was controlled with oral analgesia. Her vital
signs remained stable and she was afebrile. The patient was
discharged home in stable condition. A follow-up appointment
was made with the acute care service.
Medications on Admission:
none
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. 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
3. Senna 8.6 mg PO BID:PRN constipation
4. Acetaminophen 650 mg PO Q6H
Discharge Disposition:
Home
Discharge Diagnosis:
acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
___ were admitted to the hospital with lower abdominal pain. ___
underwent a cat scan of the abdomen which showed acute
appendicitis. ___ were taken to the operating room where ___
had your appendix removed. ___ recovering from the surgery and
___ are preparing for discharge home with the following
instructions:
___ were admitted to the hospital with acute appendicitis. ___
were taken to the operating room and had your appendix removed
laparoscopically. ___ tolerated the procedure well and are now
being discharged home with the following instructions:
Please follow up at the appointment in clinic listed below. We
also generally recommend that patients follow up with their
primary care provider after having surgery. We have scheduled an
appointment for ___ listed below.
ACTIVITY:
Do not drive until ___ have stopped taking pain medicine and
feel ___ could respond in an emergency.
___ may climb stairs.
___ may go outside, but avoid traveling long distances until ___
see your surgeon at your next visit.
Don't lift more than ___ lbs for ___ 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.
___ may start some light exercise when ___ feel comfortable.
___ will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when ___
can resume tub baths or swimming.
HOW ___ MAY FEEL:
___ may feel weak or "washed out" a couple weeks. ___ might want
to nap often. Simple tasks may exhaust ___ may have a sore throat because of a tube that was in your
throat during surgery.
___ could have a poor appetite for a couple days. 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 ___ may shower and remove the gauzes over your
incisions. Under these dressings ___ 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.
___ 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 ___ were told
otherwise.
___ 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.
___ may shower. As noted above, ask your doctor when ___ may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, ___ may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. ___ can get both of these
medicines without a prescription.
If ___ 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 ___ find the pain is
getting worse instead of better, please contact your surgeon.
___ 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. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if ___ take it before your
pain gets too severe.
Talk with your surgeon about how long ___ 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 ___ are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when ___ cough
or when ___ are doing your deep breathing exercises.
If ___ 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 ___ were on before the operation just as
___ did before, unless ___ have been told differently.
If ___ have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if ___ 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:
___
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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:
Failure to thrive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old M with CAD, CKD, and glaucoma sent in by family and
___ due to overall poor functioning at home. Pt is ___ only
speaking with difficulty hearing, unable to provide history via
phone interpreter. Per family, he has been complaining of
dizziness and has appeared to be disoriented. He lives alone and
has fired many home agencies so he has no home care. Per PMD
notes, he has refused placement in the past despite the fact
that it was felt to be the best for him. Pt gets meals at adult
day care and when family brings some in for him but unable to
cook. Per family, he has not been eating much. He has been
getting medications pre-poured by a ___ which comes twice per
week, but there has been concern for how well he has been
complying. Aside from a complaint of dizziness and frequent
falls, he has not complained of any localizng symptoms. No
fevers or chills.
In the ED, he was afebrile with stable vitals. Labs were notable
for normal CBC, Cr at baseline of 1.5 with metabolic acidosis
with high anion gap (has been noted on many prior labs). Lactate
was checked and was as high as 3.2 but decreased to 1.8 with
hydration. He had u/a which was unremarkable, CXR which showed
no infiltrate. CT of head and torso were performed which
revealed only dilated ventricles and an inguinal hernia without
complications. He was admitted for further care and disposition.
Past Medical History:
# H/o CAD (MI in ___ with Q-waves in I/aVL), followed closely
by cardiology, last seen by Dr. ___ in ___, ETT-MIBI
with fixed defects in ___.
# Chronic renal insufficiency - baseline creatinine ~1.5
# Hypertension
# Glaucoma
# Hyperlipidemia
# BPH
# GERD
Social History:
___
Family History:
negative for CA
Physical Exam:
Admission Exam:
Vitals 97.6 134/80 76 18 100%RA
Gen: elderly man in no distress
HEENT: moist mm, clear OP, no cervical LAD
CV: rrr, no r/m/g
Pulm: faint bibasilar crackles
Abd: soft, nontender, nondistended
Ext: no edema; L arm with evidence of remote burn trauma
Neuro: alert, not oriented to place, asking his daughter to be
called
Discharge Exam:
98.5 124/90 84 18 100%RA
Pain ___
No distress, elderly, ___ speaking, very difficult to
redirect, tangential with pressured speech, perseverating on his
blood pressure (which is fine) and his kidneys which dont work
(Cr has been stable). Legally blind
MMM
RRR, no MRG
CTAB, comfortable
soft, nontender, nondistended
no edema; L arm with evidence of remote burn trauma
alert, moves all extremities, very hard of hearing, blind
Pertinent Results:
___ 11:15AM BLOOD WBC-6.4 RBC-4.32* Hgb-13.7* Hct-40.4
MCV-94 MCH-31.7 MCHC-33.9# RDW-15.2 Plt ___
___ 11:15AM BLOOD Neuts-70.1* ___ Monos-6.0 Eos-3.5
Baso-0.5
___ 11:15AM BLOOD ___ PTT-32.1 ___
___ 11:15AM BLOOD Glucose-102* UreaN-23* Creat-1.6* Na-139
K-4.4 Cl-104 HCO3-18* AnGap-21*
___ 09:15AM BLOOD Glucose-89 UreaN-20 Creat-1.4* Na-140
K-3.7 Cl-109* HCO3-21* AnGap-14
___ 11:15AM BLOOD ALT-9 AST-22 AlkPhos-87 TotBili-0.5
___ 11:15AM BLOOD ALT-9 AST-22 AlkPhos-87 TotBili-0.5
___ 11:15AM BLOOD Lipase-23
___ 05:45PM BLOOD cTropnT-<0.01
___ 09:15AM BLOOD Phos-2.0*
___ 09:15AM BLOOD VitB12-343
___ 09:15AM BLOOD TSH-3.7
___ 07:07PM BLOOD Lactate-1.8
CXR: Interstitial pulmonary edema, probable underlying
emphysema.
CT Head: No acute intracranial hemorrhage. Ventriculomegaly, not
significantly changed. Please correlate for normal pressure
hydrocephalus.
CTAP: 1. Right inguinal hernia containing non-obstructed bowel
loops. 2. Left upper pole indeterminate exophytic lesion. This
can be further assessed with non-emergent ultrasound.
Brief Hospital Course:
___ with CAD, CKD III, HTN, who presents with failure to thrive
found to have mild dehydration which resolved with IVFs, ___ and
family indicated patient needs placement.
# Failure to Thrive: He reported feeling unwell for the past at
least 6 months but could not localize symptmos further. He
denies all review of systems. Initial labs showed mild lactate
elevated and chemistry showing mild dehydration which resolved
with IVFs.
# Deconditioninig: After discussion with his daughter and
granddaughter, there were no acute medical concerns. Rather,
their main concern is that he is not safe to return home. He
worked with ___ and they recommended rehab. Initially, the
patient was resistant to rehab or placement or increased
services at home. However, after discussion with the daughter
the patient was willing to attend rehab for further evaluation
and treatment of physical strength and other medical conditions.
# CAD: Chronic, stable.Continued aspirin and atorvastatin.
# Hypertension: Chronic, stable, continued home medications.
# CKD stage III: Chronic, stable admitted at baseline Cr
1.4-1.6. Continued home regimen.
# Glaucoma. Continued home eyedrops.
No changes were made to his medications during the
hospitalization.
Transitional issues:
- Placement - either nursing facility, assisted living facility
or significantly increased home services were recommended.
- Left upper pole indeterminate exophytic lesion. This can be
further assessed with non-emergent ultrasound. PCP notified of
these results.
- Code - full
- Contact - daughter ___ ___, granddaughter ___
___ (HCP)
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Allopurinol ___ mg PO DAILY
2. Amlodipine 7.5 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Dexilant (dexlansoprazole) 30 mg oral daily
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
6. Lisinopril 5 mg PO DAILY
7. Lorazepam 0.5 mg PO BID:PRN anxiety
8. Mirtazapine 22.5 mg PO HS
9. oxybutynin chloride 10 mg oral daily
10. Polyethylene Glycol 17 g PO DAILY
11. Ranitidine 150 mg PO DAILY
12. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
13. Acetaminophen 325-650 mg PO Q6H:PRN pain
14. Aspirin 81 mg PO DAILY
15. Vitamin D3 (cholecalciferol (vitamin D3)) 2,000 unit oral
daily
16. Docusate Sodium 100 mg PO BID
17. Senna 8.6 mg PO BID
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Allopurinol ___ mg PO DAILY
3. Amlodipine 7.5 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
8. Lisinopril 5 mg PO DAILY
9. Mirtazapine 22.5 mg PO HS
10. Ranitidine 150 mg PO DAILY
11. Senna 8.6 mg PO BID
12. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
13. Vitamin D3 (cholecalciferol (vitamin D3)) 2,000 unit oral
daily
14. Polyethylene Glycol 17 g PO DAILY
15. oxybutynin chloride 10 mg oral daily
16. Lorazepam 0.5 mg PO BID:PRN anxiety
17. Dexilant (dexlansoprazole) 30 mg oral daily
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Failure to thrive
Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Mr ___,
It was a pleasure treating you during this hospitalization. You
were admitted from home with dehydration and weakness. After IV
fluids you felt much better and there were no significant active
medical issues to address. However, it was determined you
required continued physical therapy before you could be safetly
discharged home. You agreed to be transferred to another
facility to work on your medical issues including weakness.
Followup Instructions:
___
|
10653013-DS-20
| 10,653,013 | 25,408,801 |
DS
| 20 |
2160-02-24 00:00:00
|
2160-02-24 21:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cephalosporins / Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with a h/o recurrent pericarditis
and undifferentiated episodic tachycardia who presents with
chest pain, shortness of breath, and ___ lbs weight gain.
He was initially diagnosed with viral pericarditis in ___
___ after presenting with pleuritic chest pain and an ECG
showing diffuse STE. He was started on colchicine and NSAIDs and
despite this therapy had a recurrence of his symptoms and
represented to ___ (___). At the time of representation
he was not on any medication and was restarted on
colchicine/ibuprofen and sent home. He was again hospitalized
___ to ___ at ___ for recurrent
tachycardia and chest pain. At that time, it was thought that he
experienced another bout of pericarditis. He was treated with
colchicine and Motrin. His EKGs, chest x-ray and TTE per report
were within normal limits. The patient was initiated on
Lopressor 12.5 mg b.i.d for his tachycardia. However, his
beta-blocker therapy resulted in decrease in bradycardia and his
was stopped by his PCP. He presented to the ED ___ for an
episode of palpitation with heart rate to the 150s. At that
time, he had a normal EKG and a negative chest x-ray.
He presented to his PCP with intermittent chest pain ___ and was
started on ibuprofen 800mg TID and referred to cardiology, who
he saw him ___. At that time he was thought not to have active
pericarditis or PE, ibuprofen was discontinued and indomethacin
25mg TID x14 days was started with plan for followup echo.
In the ED initial vitals were 100.0 147 149/76 18 100% RA. WBC
10.5 down from 13.9 ___. CXR with no cardiomegaly, pleural
effusions, pulmonary edema.
On review of systems, he denies any prior history of stroke,
TIA,
deep venous thrombosis, pulmonary embolism, bleeding at the time
of surgery or other episodes, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. He denies recent fevers,
chills or rigors. He denies exertional buttock or calf pain. All
of the other review of systems were negative.
Cardiac review of systems is notable for absence paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, syncope or
presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, -Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
-Recurrent pericarditis
-Episodic Tachycardia: ___ of Hearts ___ episodic sinus
tachycardia to the 130s to 150s associated with palpitations
3. OTHER PAST MEDICAL HISTORY:
None
Social History:
___
Family History:
Mother has hyperthyroidism. Grandparents had hypertension and
hyperlipidemia. Grandmother was hyperthyroid as well.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: t 98.8 BP 140/94 HR 112 RR 20 O2 100%RA
General: well appearing, no distress
HEENT: malar rash, OP clear
Neck: JVP not elevated
CV: Reg rhythm, tachycardic, normal s1/s2, no murmurs/rubs,
gallops, no rubs while leanign forward
Lungs: CTA bilaterally, no wheezes
Abdomen: Soft, nontender
Ext: No edema, no rash
Skin: diffuse rough-textured rash along shoulders
DISCHARGE PHYSICAL EXAM:
VS: 98.1 115/65 81 20 100%RA
General: well appearing, no distress
HEENT: rash, OP clear
Neck: JVP not elevated
CV: Reg rhythm, tachycardic, normal s1/s2, no murmurs/rubs,
gallops
Lungs: CTA bilaterally, no wheezes
Abdomen: Soft, nontender
Ext: No edema, no rash
Skin: diffuse rough-textured rash along shoulders
Pertinent Results:
ADMISSION LABS:
___ 02:45PM BLOOD WBC-10.5 RBC-5.46 Hgb-16.4 Hct-46.9
MCV-86 MCH-30.0 MCHC-34.9 RDW-12.6 Plt ___
___ 02:45PM BLOOD Neuts-72.9* ___ Monos-3.4 Eos-0.2
Baso-1.1
___ 02:45PM BLOOD Plt ___
___ 02:45PM BLOOD Glucose-105* UreaN-11 Creat-1.1 Na-141
K-3.5 Cl-104 HCO3-24 AnGap-17
___ 02:45PM BLOOD Calcium-9.9 Phos-2.0*# Mg-2.1
___ 02:45PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 02:45PM BLOOD D-Dimer-221
DISCHARGE LABS:
___ 06:32AM BLOOD WBC-6.4 RBC-4.38* Hgb-13.7* Hct-37.6*
MCV-86 MCH-31.3 MCHC-36.4* RDW-12.5 Plt ___
___ 06:32AM BLOOD ESR-2
___ 06:32AM BLOOD Glucose-92 UreaN-7 Creat-0.8 Na-139 K-4.0
Cl-105 HCO3-28 AnGap-10
___ 06:32AM BLOOD Calcium-9.0 Phos-3.7# Mg-2.1
___ 06:32AM BLOOD CRP-2.2
REPORTS:
___ CardiovascularECHO
Findings
This study was compared to the prior study of ___.
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). TDI E/e' < 8,
suggesting normal PCWP (<12mmHg). Doppler parameters are most
consistent with normal LV diastolic function. No resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels. Normal descending aorta diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild MVP.
Normal mitral valve supporting structures. ___ of the mitral
chordae (normal variant). No resting LVOT gradient. No MS.
___ VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal tricuspid valve supporting structures. No TS.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR. Normal main PA. No Doppler evidence for
PDA
PERICARDIUM: Trivial/physiologic pericardial effusion.
Pericardium appears thickened.
Conclusions
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 65%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Doppler parameters
are most consistent with normal left ventricular diastolic
function. Right ventricular chamber size and free wall motion
are normal. The diameters of aorta at the sinus, ascending and
arch levels are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is borderline/mild
bileaflet mitral valve prolapse. There is a trivial/physiologic
pericardial effusion. The pericardium appears thickened.
Compared with the prior study (images reviewed) of ___
borderline mitral valve prolapse is now seen.
___ Imaging CHEST (PA & LAT)
FINDINGS: The cardiac, mediastinal and hilar contours are
normal. Lungs are clear and the pulmonary vasculature is
normal. No pleural effusion or pneumothorax is seen. No acute
osseous abnormalities detected. IMPRESSION: No acute
cardiopulmonary abnormality.
Brief Hospital Course:
CHEST PAIN: The patient had had multiple admission for chest
pain consistent with pericarditis over the last year. At the
time of admission, the only therapy he was on was indomethacin.
He presented to ___ ED on ___ with chest pain and
shortness of breath. There, he was administered morphine with
improvement in his chest pain. An EKG was negative for
conduction delay and ST/T changes. He was seen by Cardiology
(Dr. ___, who recommended that the patient be admitted and
restarted on colchicine (and continued on his home indomethacin)
for a concern of pericarditis. During this hospitalization, the
patient's EKG remained without conduction abnormalities or
ischemic changes. Telemetry showed occasional sinus tachycardia
but was negative for arrhythmia. The patient had a repeat
transthoracic echocardiogram on ___ that was normal (EF 65%,
normal cavity sizes/pressures, normal systolic and diastolic
function) other than some borderline/mild bileaflet mitral valve
prolapse. The Rheumatology team was consulted for a possible
autoimmune etiology for his recurrent pericarditis. They
recommended that the patient be seen by Rheumatology as an
outpatient for further work-up of causes of recurrent
pericarditis such as lupus, rheumatoid arthritis, mixed
connective tissue disease, adult onset stills, scleroderma, and
Sjorgens as well as Familial mediterranean fever and Tumor
necrosis factor receptor-1 associated periodic syndrome (TRAPS).
The patient remained stable in the hospital, and was discharged
on daily colchicine and indomethacin. At the time of discharge,
he was scheduled to see Cardiology and Rheumatology as an
outpatient.
TRANSITIONAL ISSUES:
- No pending results
- The patient remained full code during this hospitalization
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Indomethacin 25 mg PO TID
Discharge Medications:
1. Indomethacin 25 mg PO TID
2. Colchicine 0.6 mg PO DAILY
RX *colchicine [Colcrys] 0.6 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was pleasure to take care of you during this hospitalization.
You were admitted to ___ for chest pain that was concerning
for pericarditis (inflammation of the sac around your heart).
You were treated with oral medications for this (colchicine and
indomethacin). Monitoring of your heart did not show any
inflammation or damage. The Rheumatology team saw you for this,
and they recommended that you continue the oral medications
above and that you follow-up with them as an outpatient.
You remained stable throughout this hospitalization, and are now
safe to go home. You are being discharged on oral medications
to treat possible pericarditis. You have follow-up for this
hospitalization scheduled with general medicine, Cardiology, and
Rheumatology.
Please take your medications as prescribed and follow-up with
your doctors.
Followup Instructions:
___
|
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| 10,653,013 | 24,543,475 |
DS
| 21 |
2160-06-13 00:00:00
|
2160-06-13 19:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cephalosporins / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
chest pain, palpitations
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old male with history of recurrent pericarditis and
sinus ___ transfered from ___.
Sharp, ___ chest pain localized to the left anterior chest
started at 3pm day of admission. Patient was not pleuritic in
nature and was not positional, and not exertional. No radiation.
Patient denies shortness of breath, dizziness, syncope, nausea,
diaphoresis. This pain is somewhat similar to his previous
pericarditis pain, though the confirmed case was pleuritic in
nature, his pain has never ___ positional.
His chest pain started in ___ with tachycardia and chest pain
and was diagnosed with pericarditis. Per report, he had diffuse
ST elevations at that time. At that time, he was started on
NSAIDs and Colchicine. Since then he has been seen by both
cardiology and rheumatology and has been worked up extensively
including autoimmune workup and so far all work up has been
negative. His NSAIDS has been discontinued and he is only
maintained on the Colchicine.
Palpitations started at 8pm. Patient has history of sinus
tahcycardia, and usually does not feel palpitations until his
heart rate is over 150. Denies fevers, chills, poor PO intake,
cough, diarrhea, urinary symptoms, bleeding or brusing. At this
point any activity usually triggers tahcycardia to 150s. He was
seen by EP on ___. His EKGs, CXR and TTE at that time were
within normal limits. The patient was initiated on Lopressor
12.5mg BID for his tachycardia, though this was later d/c'ed for
hypotension. He was seen in Cardiology Clinic on ___, at
which time he was referred to ___ for further
workup. He was seen in the ED ___ with tachycardia and chest
pain and started on prednisone 40mg x 5 days. Tachycardia at
that time resolved with pain control and IV fluids.
At ___, due to concern for possible SVT he recieved 6mg
and 12 adenosine hr 170, then received 45mg iv dilt, on dilt gtt
10mg/hr and transfered to our ED.
In the ED intial vitals were: 98.8 129 144/72 18 99% RA. Labs
significant for WBC of 14.6. Normal chem 7. Normal trop and
negative ___. Patient was given 2L NS, Ketorolac 30mg IV and
transfered to the floor. Vitals upon transfer 98.1, 120, 149/98,
20, 100% RA. On the floor he feels his pain is much better after
the ketorolac, no ___. No longer feeling palpitations.
Review of Systems:
(-) night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, abdominal
pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, -Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
-Recurrent pericarditis
-Episodic Tachycardia: ___ of Hearts ___ episodic sinus
tachycardia to the 130s to 150s associated with palpitations
3. OTHER PAST MEDICAL HISTORY:
None
Social History:
___
Family History:
Mother and maternal grandmother have hypothyroidism.
Grandparents have hypertension, hyperlipidemia. Paternal
grandmother has diabetes. Uncle has skin cancer. Maternal
grandfather died from lung cancer. An uncle has ulcerative
colitis. There is no family history of fever syndromes, renal
failure requiring hemodialysis, FMF, rheumatoid arthritis,
lupus. The family is of ___ and ___ descent. No
FH of early CAD or early cardiac death.
Physical Exam:
PHYSICAL EXAM:
Vitals- 98.1, 120, 149/98, 20, 100% RA. pulsus paradoxus <
10mmHg
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
CHEST: no TTP over anterior chest
Abdomen- soft, ___, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- ___ intact, motor function grossly normal
Pertinent Results:
___ 10:55PM BLOOD ___
___ Plt ___
___ 10:55PM BLOOD ___
___
___ 10:55PM BLOOD ___ ___
___ 10:55PM BLOOD ___
___ 10:55PM BLOOD ___
___
___ 10:55PM BLOOD cTropnT-<0.01 ___
___ 10:55PM BLOOD ___
___ 11:35PM BLOOD ___
___ 07:00AM BLOOD ___
___ 10:55PM BLOOD ___
___ 11:04PM BLOOD ___
___ 07:00AM BLOOD ___
___ Plt ___
___ 07:00AM BLOOD ___
___
___ 11:25PM URINE ___ Sp ___
___ 11:25PM URINE ___
___
Microbiology: none
Admission EKG: sinus tachycardia to 125. normal axis and
intervals. No ST elevaton elevation.
Imaging:
CXR ___:
Frontal and lateral views of the chest were obtained. The heart
size and cardiomediastinal contours are normal. The lungs are
clear. No focal consolidation, pleural effusion, or
pneumothorax.
IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
___ yo male with recurrent pericarditis and sinus tachycarida
here with palpitations and chest pain.
# Chest pain. While the patient has a history of pericarditis,
this presentation is not typical. Neither history, exam nor EKG
fully support this diangosis. His pain is not pleuritic in
nature, is not positional, there is no rub and EKG is without
diffuse ST elevations. This is not ischemic in nature with
normal EKG other than tachycardia and negative trop. No evidence
of pulmonary involvement with normal CXR and negative ___.
Chest wall pain is unlikely given lack of ___,
while some autoimmune disease can cause anterior chest pain, but
again very unlikely with currently normal CRP. Given patient's
history of pericarditis and general improvement after NSAIDs or
prednisone with treatment, will treat as pericarditis for now.
He received an extra dose of colchicine, ketorolac in the ED,
and ibuprofen on the floor. His pain resolved. Discharged on
indomethacin for 3 days in addition to daily colchicine.
# Tachycardia: Currently in NSR. Tele strips from ___ are
difficult to interpret as some rates are over 170 but they
overall appears to be sinus. Likely related to pain and
hypovolemia as rate slowing down after pain control and
hydration. Given known history of sinus tachycardia, normal
voltage EKG, normal CXR, and normal pulus, unlikely to be due to
tamponade. Patient has already been tried on ___ and
did not tolerate them well. He received IVF for possible
dehydration, although lytes were normal. HR ___ once on the
floor. Given prior intolerance of beta blockers, we did not
continue diltiazem started at ___, but rather discharged
with metoprolol tartrate to use PRN palpitations. TSH normal.
# Leukocytosis. No evidence of acute infection. CXR and UA
normal. Likely stress induced vs inflammatory. Normalized in
the morning.
# Elevated BP. Likely due to pain. Normalized in the morning.
# Code: Full (discussed with patient)
___ Issues:
- 3 day course indomethacin
- continue colchicine
- ___ with Rheumatology for etiology of pericarditis
- discuss Cardiology ___ (Dr ___ with PCP
- metoprolol tartrate 12.5mg for symptomatic palpitations
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Colchicine 0.6 mg PO DAILY
Discharge Medications:
1. Colchicine 0.6 mg PO DAILY
2. Metoprolol Tartrate 12.5 mg PO BID:PRN palpitations
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*15 Tablet Refills:*0
3. Indomethacin 25 mg PO TID Duration: 3 Days
RX *indomethacin 25 mg 1 capsule(s) by mouth three times a day
Disp #*9 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
palpitations and sinus tachycardia ___ pericarditis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you at ___
___. You first went to ___ after an
episode of chest pain and palpitations, probably due to your
recurrent pericarditis. Your heart rate was in the ___
range, treated with adenosine and diltiazem to slow the heart
rate. You were transferred to our emergency department, when
you received IV NSAID for pain relief and as an
___. Your heart rate remained < 100 while you
were at ___.
Please take indomethacin for 3 days for continued
___ effect. We will also provide low dose
metoprolol to use when you have palpitations to slow your heart
rate. If you find that using this pill does not stop the
palpitations, call your PCP or come to the emergency room.
Please also ___ with your PCP and with your Rheumatologist
to find a cause of your symptoms.
Followup Instructions:
___
|
10653013-DS-25
| 10,653,013 | 21,892,218 |
DS
| 25 |
2161-01-13 00:00:00
|
2161-01-13 17:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cephalosporins / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/pericarditis presents with RLQ pain. He reports that the
pain is similar to when he was admitted to the hospital 3 days
ago. At that time he had a CT scan that was negative for
appendicitis but showed ascending and transverse colitis. He was
discharged on ___ with improved pain, not having had any BMs.
Reports that pain increased the following day and he presented
to his PCP yesterday for follow up who advised him to present to
ED to be evaluated by GI.
In ED GI and surgery consulted. Pain controlled.
On arrival to the floor pt reports RLQ abd pain, nausea, no
emesis, diarrhea or constipation. Reports last BM yesterday.
+Anorexia with poor PO intake, but pain not changed with eating.
Also with fever to 101 at home yesterday.
.
ROS: +as above, otherwise 10 point ROS reviewed and negative
Past Medical History:
Pericarditis
Palpitations
Seborrheic dermatitis
Hip tendinopathy
Social History:
___
Family History:
Mother and maternal grandmother have hypothyroidism.
Grandparents have hypertension, hyperlipidemia. Paternal
grandmother has diabetes. Uncle has skin cancer. Maternal
grandfather died from lung cancer. An uncle has ulcerative
colitis. There is no family history of fever syndromes, renal
failure requiring hemodialysis, FMF, rheumatoid arthritis,
lupus. The family is of ___ and ___ descent. No
FH of early CAD or early cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Afeb VSS
PAIN:6
General: nad
Lungs: clear
CV: rrr no m/r/g
Abdomen: hypoactive BS, soft, nd, tender RLQ
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands
.
DISCHARGE PHYSICAL EXAM:
VS: AVSS
Pain: ___
Gen: NAD, pleasant, ambulatory
HEENT: anicteric, MMM
Abd: soft, ND, NABS, + TTP on deep palpation of RLQ.
Ext: no edema
Skin: no rash
Neuro: AAOX3, fluent speech
Pertinent Results:
ADMISSION LABS:
===================
___ 05:15PM BLOOD WBC-10.4# RBC-4.79 Hgb-14.7 Hct-43.9
MCV-92 MCH-30.7 MCHC-33.5 RDW-13.1 Plt ___
___ 05:15PM BLOOD Glucose-99 UreaN-10 Creat-0.9 Na-143
K-3.7 Cl-105 HCO3-30 AnGap-12
___ 05:15PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 06:15PM BLOOD Lactate-1.5
.
PERTINENT LABS:
==================
___ 07:00AM BLOOD WBC-5.4 RBC-4.47* Hgb-13.7* Hct-40.1
MCV-90 MCH-30.6 MCHC-34.1 RDW-13.1 Plt ___
___ 05:15PM BLOOD ESR-2
___ 05:15PM BLOOD CRP-1.3
___ 05:15PM BLOOD ___
___ 05:15PM BLOOD C3-124 C4-17
.
MICROBIOLOGY:
=================
___ Yersinia serologies: PENDING
___ CMV IgG, IgM: NEGATIVE
___ Blood culture x 1: NGTD, final PENDING
.
IMAGING:
===========
___ Appendix US
IMPRESSION:
No definite visualization of appendix
.
___ KUB
IMPRESSION:
Unremarkable bowel gas pattern.
.
___ MRE
IMPRESSION: Extremely limited exam because the patient was
unable to continue due to claustrophobia. The small and large
bowel, however, appear unremarkable on the images provided.
.
PREVIOUS IMAGING:
====================
___ CT Abd/Pelvis
IMPRESSION: Thickening of the distal ascending and transverse
colon consistent with colitis.
.
Brief Hospital Course:
___ w/ PMH pericarditis presents with persistent RLQ pain
.
# RLQ Abdominal Pain / #Colitis: Previous w/u negative for GU
etiologies. Only finding on previous w/u was colitis seen on CT
scan. He underwent ultrasound in the ED to r/o appendicitis but
unfortunately the appendix was not well visualized. He was seen
by Surgery Consult, who felt that his clinical picture was not
c/w acute surgical abdomen, so he was admitted to medicine for
further w/u and management. He was placed on bowel rest, IV
fluids and supportive care. KUB did not show any obstruction or
perforation. He was seen by GI and an MRE was recommended.
Unfortunately, he was unable to tolerate the full study due to
claustrophobia despite premedication, but the limited study was
unremarkable. His autoimmune work-up was repeated, but ESR,
CRP, C3, C4 were all WNL and his ___ was negative. CMV
serologies (negative) and Yersinia serologies (PENDING) were
sent per GI recommendations. His pain and nausea were
controlled by PO medications and he was able to tolerate a full
liquid meal. GI recommended an empiric course of Cipro/Flagyl x
2 weeks, with close outpatient GI f/u and colonoscopy, which has
been scheduled. GI also recommended considering stopping his
indomethacin if all w/u for his abdominal pain is unrevealing,
as NSAID's can cause abdominal pain.
.
# Pericarditis: stable. No CP, SOB or rub on exam. Continued
home medications. As mentioned above, if his abdominal pain
remains persistent and without clear etiology, would consider
stopping his Indomethacin for possible NSAID-induced abdominal
pain.
.
TRANSITIONAL ISSUES:
1. complete course of empiric Cipro/Flagyl for infectious
colitis
2. f/u with GI in outpatient setting, likely will have
colonoscopy +/- EGD
3. PENDING STUDIES AT TIME OF DISCHARGE
### ___ Yersinia serologies: PENDING
### ___ Blood culture x 1: NGTD, final PENDING
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Colchicine 0.6 mg PO BID
2. Indomethacin 50 mg PO TID
3. Omeprazole 20 mg PO DAILY
4. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain
Discharge Medications:
1. Colchicine 0.6 mg PO BID
2. Indomethacin 50 mg PO TID
3. Omeprazole 20 mg PO DAILY
4. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN Pain
RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth
every 6 hours Disp #*112 Tablet Refills:*0
5. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice daily Disp
#*60 Capsule Refills:*0
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily
Disp #*60 Capsule Refills:*0
7. Bisacodyl 10 mg PO DAILY:PRN Constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
8. Ciprofloxacin HCl 500 mg PO Q12H Duration: 12 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every 12 hours
Disp #*24 Tablet Refills:*0
9. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every 8 hours Disp
#*36 Tablet Refills:*0
10. Promethazine 25 mg PO Q6H:PRN nausea
RX *promethazine 25 mg 1 tab by mouth every 6 hours Disp #*56
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal Pain of unknown etiology
Colitis
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 your persistent RLQ
abdominal pain. We have been unable to find an etiology for
your symptoms. You were seen by the GI doctors and they
recommend an empiric course of antibiotics with Cipro and
Flagyl. You will seem them in follow-up and likely undergo a
colonoscopy.
.
Please take your medications as listed.
.
Please see your physicians as listed.
.
Followup Instructions:
___
|
10653013-DS-26
| 10,653,013 | 24,303,414 |
DS
| 26 |
2161-05-09 00:00:00
|
2161-05-11 20:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cephalosporins / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with hx of recurrent pericarditis and
perimyocarditis who presents with chest pain. The patient
reports the onset of palptiations over the weekend. He presented
to ___ on ___ for evaluation. Had an EKG checked
which was wnl and discharged home. ___ he developed left
sided chest pain, which he felt was typical of his pericarditis
pain. ___ non radiating, and non-positional, not associated w/
n/v diaphoresis, or shortness of breath. He also took his temp
which was 100.1, took tylenol and came in to be evaluated.
Of note his indomethacin was discontnued in ___ in the setting
of colitis, w/ concern for NSAID induced abdominal pain. His
colchine was recently decreased to daily, per his cardiologist
in ___ sine he's been chest pain free for over 1 month.
In the ___ initial vitals were: 100.0 144 159/77 10 100%
- Labs were significant for normal white count, chem, lactate of
2.4, trop neg x1
-imaging: CXR was unremarkable, bedside ultrasound with trace
effusion
- Patient was given Ketorolac 30 mg IV x 1, and 1L NS
Vitals prior to transfer were: 99.3 93 127/63 14 100% RA
On the floor, the patient contineus to endorse left sided chest
pain, reports no improvement from toradol in the ___. He denies
any recent travel, cought, uri sx, leg pain, or hx of clots
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
Pericarditis
Palpitations
Seborrheic dermatitis
Hip tendinopathy
Social History:
___
Family History:
Mother and maternal grandmother have hypothyroidism.
Grandparents have hypertension, hyperlipidemia. Paternal
grandmother has diabetes. Uncle has skin cancer. Maternal
grandfather died from lung cancer. An uncle has ulcerative
colitis. There is no family history of fever syndromes, renal
failure requiring hemodialysis, FMF, rheumatoid arthritis,
lupus. The family is of ___ and ___ descent. No
FH of early CAD or early cardiac death.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
Vitals - T98.9 BP 142/80P 93 RR 19 100% RA
GENERAL: NAD non -toxic appearing
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 friction rub
LUNG: CTAB, no wheezes, rales,
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
PHYSICAL EXAM ON DISCHARGE:
Vitals - T 97.7 BP 126/68 (126-142/68-80) HR 57 (57-93) RR 18 O2
100%RA
GENERAL: well-appearing, NAD
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 friction rub
LUNG: CTAB, no wheezes, rales, rhonchi
ABDOMEN: nondistended, +BS, tender to palpation in LUQ and LLQ,
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:
LABS:
___ 12:15AM BLOOD WBC-10.2# RBC-5.18 Hgb-15.4 Hct-45.4
MCV-88 MCH-29.7 MCHC-33.9 RDW-14.1 Plt ___
___ 12:15AM BLOOD ___ PTT-31.2 ___
___ 12:15AM BLOOD Glucose-103* UreaN-14 Creat-1.1 Na-141
K-3.6 Cl-100 HCO3-24 AnGap-21*
___ 12:15AM BLOOD CK(CPK)-222
___ 12:15AM BLOOD CK-MB-3
___ 12:15AM BLOOD cTropnT-<0.01
___ 05:10AM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:10AM BLOOD Calcium-9.5 Phos-4.1 Mg-2.1
___ 12:15AM BLOOD CRP-0.6
___ 05:10AM BLOOD CRP-0.6
___ 12:22AM BLOOD Lactate-2.4*
___ 05:10AM BLOOD SED RATE-Test 2
EKG: EKG: sinus tach, rate of 112, J point elevation in V3-v4,
normal intervals
IMAGING:
___ CXR: No acute intrathoracic abnormality.
Brief Hospital Course:
___ year old male hx of pericarditis/myocarditis admitted with
chest pain
# Chest pain- Patient's symptoms were c/w prior episodes of
pericarditis. There was no trop leak, or ekg changes. He was
seen by his outpatient cardiologist and it was felt that he was
having a mild flare of pericarditis. He may be expericing
recurrent sx in the setting of down titration of colchine and
off NSAIDs. Troponins were negative x 2. Increased colchine to
BID and started indomethacin 50 mg TID for 1 week with taper to
25mg TID following week and then taper to 25mg BID for third
week. He was monitored on tele without events. He will be seen
by Dr. ___ in follow up.
# Anxiety - continued sertaline
***Transitional Issues***
- increased colchine to BID
- started indomethacin 50 mg TID for 1 week with taper to 25mg
TID following week and then taper to 25mg BID for third week
- omeprazole was restarted while patient will be on high dose
NSAIDs
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Colchicine 0.6 mg PO DAILY
2. Sertraline 25 mg PO DAILY
Discharge Medications:
1. Colchicine 0.6 mg PO BID
2. Sertraline 25 mg PO DAILY
3. Indomethacin 50 mg PO TID
RX *indomethacin 25 mg 2 capsule(s) by mouth three times daily
for 1 week, then 1 capsule three times daily for 1 week, then 1
capsule twice daily for 1 week Disp #*77 Capsule Refills:*0
4. Acetaminophen 1000 mg PO Q6H:PRN pain
5. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pericarditis flare
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to take care of you at ___. You were
admitted with chest pain which felt similiar to your prior
episodes of pericarditis. You were seen by your Cardiologist,
Dr. ___ it was felt that this was a mild flare of your
pericarditis. Your cholchicine was increased to twice daily. You
were started on indomethacin 50mg three times daily for 7 days,
then decreased to 25mg three times daily for 7 days, and then
25mg twice daily for 7 days. You also had abdominal pain and
diarrhea which is likely related to the medication. Please
follow up with your PCP as well as Dr. ___ as scheduled.
Sincerely,
Your ___ medical team
Followup Instructions:
___
|
10653374-DS-15
| 10,653,374 | 25,452,298 |
DS
| 15 |
2164-12-04 00:00:00
|
2164-12-04 21:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / lisinopril /
Tetanus Vaccines and Toxoid
Attending: ___.
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
EGD (___)
History of Present Illness:
___ is a ___ year old male with prostate cancer s/p
prostatectomy and pulmonary embolism who presents from home with
hematemesis.
The patient was recently seen at ___ ED on ___ for 6 days of
progressive right inguinal pain and penile edema. He was seen by
urology who felt that his symptoms were due to lymphedema from
enlarging inguinal lymph nodes. He ws discharged with outpatient
follow up.
5 days ago, the patient noticed the gradual onset of melena. It
was not associated with any abdominal pain, nausea, vomiting,
palpitations or lightheadedness. He then developed progressive
___
and scrotal/penile edema above and presented to the ED. Then, 1
day prior to admission, he noticed the gradual onset of nausea,
associated with multiple episodes of large volume, non-bloody,
non-bilious vomit that consistent mostly of undigested food.
Then, on the day of admission, the patient had an episode of
large volume that was streaked with bright red blood for which
he
presented to the ED.
In the ED, the initial vital signs were:
T 97.4 HR 80 BP 131/78 R 16 SpO2 995
Laboratory data was notable for:
Normal Chem 7
INR 1.6
Plt 294
Hgb 10.5 (10.9 most recently)
The patient received:
___ 20:36 IV Pantoprazole 40 mg
___ 22:06 PO/NG Pregabalin 100 mg
___ 22:06 PO/NG Acetaminophen 1000 mg
Imaging demonstrated:
___ 20:09 Chest (Pa & Lat)
IMPRESSION:
No definite acute cardiopulmonary process, no pneumomediastinum.
Evidence of osseous metastatic disease.
ECG:
Sinus arrhythmia Rate 80. Normal axis and intervals
Upon arrival to 12R, the patient feels tired. He denies headache
or vision changes. No chest pain or dyspnea. No diarrhea or
dysuria.
He last took rivaroxaban this morning but threw it up.
ROS: 10 point review of systems discussed with patient and
negative unless noted above
PAST ONCOLOGIC HISTORY:
- Prostate ___ ___ side
___ perineural invasion,left negative,
s/p radical ___ sides,neg nodes,neg
sem vesicles,neg EP extension,T2bNo.PSA nadir of 0.20 ___. PSA
increasing to 0.60 in ___.
- XRT/hormonal ___ ___. PSA ___.
Bone scan in ___ uptake in the right post 11th rib
-___ Goserelin 10.8mg sc q 3 months
-___ casodex ___ QD for rise in PSA.
-___ on casodex ___ qd with PSA 1.8.
-___ on casodex ___ qd with PSA 2.1.
-___ on casodex ___ qd with PSA 1.8.
-___ casodex to attempt withdrawal response.
-___ Zoladex and ___ for radiographic progression in
bones and nodes.
-___ Leupron and ___ + effexor for hot flshes
-___ on Leupron, but give ___
-___ on ___ alone
- ___ Progression of disease on imaging, as well as
incidental
PE. PSA 63. Started Casodex. Patient refused Lupron.
- ___: started enzalutamide and ___
- ___: Started Taxotere, 20% ___ ___ to anticipated
tolerance, low baseline ANC.
- ___: Started xytiga/prednisone.
- ___: Admitted to ___ for pain, imaging showed DJD
+/- diffuse bony metastatic disease. Received 10 fractions of
radiation to L2-S2. Treatment was interrupted as he had to go to
___ for a funeral.
- ___: Seen for consideration of Radium-223. Stopped
abiraterone/prednisone in preparation for radium.
- ___: Started radium
- ___: Radium #2
- ___: Radium #3
- ___: Radium #4
- ___: Radium #5
- ___: Lupron 22.5mg with Dr. ___
Past Medical History:
Prostate Cancer, as above
Hypercholesterolemia
Ocular hypertension
Rhinitis, allergic
___ adenoma
Hematuria
GERD (gastroesophageal reflux disease)
Gynecomastia
Elevated blood sugar
Hiatal hernia
PE (pulmonary thromboembolism)
Class II obesity
History of ___ esophagus
Hx of episcleritis
Allergic conjunctivitis of both eyes
Cancer of prostate
Social History:
___
Family History:
Prostate Cancer maternal side (uncles)
___ cancer (maternal uncles, ___)
HLD - brother
___ cancer - brother
No family hx of clotting d/o or blood clots.
Physical Exam:
ADMISSION:
==========
GENERAL: Sitting comfortably in bed, tired, NAD
HEENT: Clear OP without lesions. Moist membranes
EYES: PERRL, anicteric
NECK: supple
RESP: CTAB, no wheezing, rhonchi or crackles
___: Regular, no MRG
GI: soft, non-tender, no rebound or guarding
EXT: pitting edema, R>L. Significant scrotal and pedal edema
SKIN: dry, no rashes
NEURO: alert, fluent speech, flat affect. CN II-XII intact
ACCESS: PIV x2
DISCHARGE:
==========
Vitals: 98.4, BP: 139/80, HR: 78, RR: 18, O2: 99% RA
EYES: PERRL, anicteric sclerae, EOMI
ENT: OP clear
CV: RRR, nl S1, S2, no M/R/G, no JVD
RESP: CTAB, no crackles, wheezes, or rhonchi
GI: + BS, soft, NT, ND, no rebound/guarding
GU: No suprapubic fullness or tenderness to palpation
SKIN: No rashes or ulcerations noted
MSK: Lower ext warm, trace pitting edema, R>L and lower right
calf pain on palpation
NEURO: AOx3, CN II-XII intact, ___ strength in all extremities,
sensation grossly intact throughout
Pertinent Results:
ADMISSION:
==========
___ 05:23PM BLOOD WBC-6.0 RBC-3.37* Hgb-10.5* Hct-31.1*
MCV-92 MCH-31.2 MCHC-33.8 RDW-12.7 RDWSD-42.5 Plt ___
___ 05:23PM BLOOD ___ PTT-39.7* ___
___ 05:23PM BLOOD Glucose-99 UreaN-10 Creat-1.0 Na-143
K-4.0 Cl-104 HCO3-26 AnGap-13
___ 05:35AM BLOOD Calcium-8.7 Phos-2.6* Mg-1.9
Discharge labs:
___ 07:10AM BLOOD WBC-3.9* RBC-3.35* Hgb-10.5* Hct-32.3*
MCV-96 MCH-31.3 MCHC-32.5 RDW-12.9 RDWSD-44.7 Plt ___
___ 05:23PM BLOOD Neuts-79.1* Lymphs-10.8* Monos-6.8
Eos-2.3 Baso-0.3 Im ___ AbsNeut-4.75 AbsLymp-0.65*
AbsMono-0.41 AbsEos-0.14 AbsBaso-0.02
___ 07:10AM BLOOD Plt ___
___ 07:10AM BLOOD ___ PTT-46.4* ___
___ 07:10AM BLOOD Glucose-75 UreaN-8 Creat-1.0 Na-146 K-4.1
Cl-108 HCO3-24 AnGap-14
___ 05:35AM BLOOD ALT-16 AST-28 AlkPhos-103 TotBili-0.2
___ 07:10AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.0
UA (___): tr prot, 4 RBCs, otherwise neg
UCx (___):
___ 6:43 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
========
EGD (___):
-Irregular Z line at GE junction
- Erosions in the distal esophagus
-Erythema in the stomach compatible with gastritis (biopsied)
EKG (___):
NSR at 80 bpm, LAD, PR 173, QRS 92, QTC 446, TWI III
CXR (___):
No definite acute cardiopulmonary process, no pneumomediastinum.
Evidence of osseous metastatic disease.
___
Final Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation
was performed
on the right lower extremity veins.
COMPARISON: Right lower extremity ultrasound dated ___.
FINDINGS:
There is normal compressibility, color flow, and spectral
doppler of the right
common femoral, femoral, and popliteal veins. Normal color flow
and
compressibility are demonstrated in the posterior tibial and
peroneal veins.
Echogenic material along the peripheral venous lumen of the
right distal
femoral vein may represent sequelae of chronic clot.
Venous flow is noted to be slow throughout the right lower
extremity.
There is normal respiratory variation in the common femoral
veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
1. No evidence of acute deep venous thrombosis in the right
lower extremity.
Interrogated veins of the right lower extremity are compressible
with normal
flow.
2. Possible tiny nonocclusive chronic thrombus in the distal
right femoral
vein.
3. Slow flow throughout the interrogated right lower extremity
veins.
Prior:
------
CT A/P w/cont (___):
Evidence of progression of metastatic disease with increase in
osseous metastatic disease, new liver lesions, new lesion in the
prostate resection bed along the posterolateral right lateral
wall causing mild malignant obstruction of the right ureters.
Worsening lymphadenopathy along the retroperitoneal chain, right
pelvic sidewall and bilateral inguinal station.
NCHCT (___):
No acute intracranial process.
Brief Hospital Course:
___ with hx ___ and metastatic prostate cancer
complicated by pulmonary embolism ___, on Xarelto) p/w melena
and hematemesis after a 1-day history of nausea and vomiting
found to have EGD findings consistent with gastritis. He was
discharged with Protonix BID to be continued for 8 weeks and
follow-up with outpatient GI.
For his metastatic prostate cancer, recent imaging, however, is
c/f progression of metastatic disease (osseous, liver, prostate
bed, worsening LAD). In discussion with outpatient oncologist,
concerning for possible second malignancy given discrepancy
between imaging and PSA. Will require repeat biopsy, which was
offered to the patient this admission. He declined inpatient
biopsy, preferring to have the procedure arranged as an
outpatient.
Patient was also noted to have right calf pain and ___ ultrasound
was notable for possible tiny nonocclusive chronic thrombus in
the distal right femoral vein. Echogenic material along the
peripheral venous lumen of the right distal
femoral vein may represent sequelae of chronic clot. He will
continue on Xarelto and discussed follow-up with repeat
ultrasound in ___ weeks after discharge.
#NAUSEA AND VOMITING
#HEMATEMESIS:
#NORMOCYTIC ANEMIA:
P/w hematemesis and melena after a 1d history of vomiting with a
mild anemia (10.9 on admission from b/l ___. Home Xarelto
was held, and he was started on an IV PPI. He was seen by
gastroenterology and underwent an EGD on ___, which showed
erosions in the distal esophagus and erythema of the stomach c/w
gastritis (biopsied), without active bleeding. Etiology unclear
in absence of NSAID use or significant EtOH use. There was no
e/o ___ tear by EGD or CXR. His diet and Xarelto were
resumed after the procedure, which he tolerated well without
further e/o bleeding. Hgb remained stable, 10.5 at discharge. He
will be discharged on protonix 40mg PO BID, which he should
continue for 8 weeks. Outpatient GI f/u was arranged.
#METASTATIC PROSTATE CANCER:
#CANCER-RELATED PAIN:
Co-followed by Dr. ___ and Drs. ___ (___) for
metastatic prostate cancer. Receiving radium and Lupron (last
___, with impressive recent decline in his PSA. Recent
imaging, however, is c/f progression of metastatic disease
(osseous, liver, prostate bed, worsening LAD). In discussion
with outpatient oncologist, concerning for possible second
malignancy given discrepancy between imaging and PSA. Will
require repeat biopsy, which was offered to the patient this
admission. He declined inpatient biopsy, preferring to have the
procedure arranged as an outpatient. This information was
communicated to his outpatient oncology team, who will arrange
for urgent biopsy. His chronic cancer-related pain was managed
with his home medications (oxycontin, oxycodomne PRN, lyrica,
tylenol, and diazepam QHS PRN).
#HISTORY OF PE:
Bilateral segmental/subsegmental PEs ___, for which he takes
Xarelto. As above, Xarelto was held on admission in the setting
of GI bleeding, resumed prior to discharge.
#RLE DVT:
Patient was also noted to have right calf pain and ___ ultrasound
was notable for possible tiny nonocclusive chronic thrombus in
the distal right femoral vein. Echogenic material along the
peripheral venous lumen of the right distal
femoral vein may represent sequelae of chronic clot. He will
continue on Xarelto and discussed follow-up with repeat
ultrasound in ___ weeks after discharge.
___ EDEMA and SCROTAL EDEMA:
Evaluated by urology in ED ___, with underlying etiology
thought to be from lymphedema which is c/w his prior imaging.
Further work-up of his progressive malignancy as above. RLE U/S
with possible tiny nonexclusive chronic thrombus, follow-up with
___ weeks for repeat ultrasound to reassess.
# UTI PPX:
Continued home macrobid ppx, restarted on discharge.
** TRANSITIONAL **
[ ] f/u gastric biopsy, pending at discharge
[ ] PPI BID x 8 weeks
[ ] f/u with oncology for biopsy of enlarging presumed
metastatic lesions
[ ] f/u for repeat RLE ultrasound in ___ weeks to reassess
possible tiny nonexclusive chronic thrombus
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxyCODONE SR (OxyCONTIN) 20 mg PO Q12H
2. Rivaroxaban 20 mg PO DAILY
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
4. Oxybutynin XL (*NF*) 15 mg Other DAILY
5. Nitrofurantoin (Macrodantin) 50 mg PO DAILY
6. Pregabalin 200 mg PO BID
7. Diazepam 5 mg PO QHS:PRN back pain
8. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
Discharge Medications:
1. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*120 Tablet Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
3. Diazepam 5 mg PO QHS:PRN back pain
4. Nitrofurantoin (Macrodantin) 50 mg PO DAILY
5. Oxybutynin XL (*NF*) 15 mg Other DAILY
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
7. OxyCODONE SR (OxyCONTIN) 20 mg PO Q12H
8. Pregabalin 200 mg PO BID
9. Rivaroxaban 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Gastritis
Esophageal erosions
Upper GI bleeding
Metastatic prostate cancer
Cancer related pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with vomiting blood. You were
seen by the gastroenterology team and underwent an endoscopy,
which showed some erosions in your esophagus and some
inflammation in your stomach. There was no evidence of active
bleeding. You were restarted on a diet and your home Xarelto
was resumed, with no further episodes. You should start a
medicine called Protonix, which you will need for at least 8
weeks. Please monitor closely for recurrence of bleeding.
In addition, your cancer doctors recommended that ___ undergo a
biopsy of your growing tumors to ensure that you are on the
proper chemotherapy. You opted to have this procedure done as
an outpatient rather than remaining in the hospital to receive
it. Please be sure to follow-up with your oncology team to
ensure that this happens in a timely fashion.
You also had evidence of likely prior DVT in your right leg, you
will need a lower extremity venous ultrasound of your right leg
in ___ weeks for follow-up.
With best wishes,
___ medicine
Followup Instructions:
___
|
10653374-DS-17
| 10,653,374 | 25,172,959 |
DS
| 17 |
2165-04-14 00:00:00
|
2165-04-14 14:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Tetanus Vaccines
and Toxoid / lisinopril
Attending: ___.
Major Surgical or Invasive Procedure:
Right PCN Tube Exchange
Right Hip Palliative Radiation Therapy
attach
Pertinent Results:
ADMISSION
___ 11:28PM BLOOD WBC-15.2* RBC-2.93* Hgb-8.3* Hct-26.2*
MCV-89 MCH-28.3 MCHC-31.7* RDW-15.8* RDWSD-51.1* Plt ___
___ 11:28PM BLOOD ___ PTT-39.9* ___
___ 11:28PM BLOOD Glucose-111* UreaN-25* Creat-2.5* Na-129*
K-4.7 Cl-95* HCO3-19* AnGap-15
___ 08:27AM BLOOD Albumin-3.0* Calcium-8.3* Phos-3.2 Mg-1.7
___ 4:03 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS FAECALIS. >100,000 CFU/mL.
Fosfomycin AND LINEZOLID Susceptibility testing
requested per
___ (___)- ___. Fosfomycin = SENSITIVE.
Fosfomycin AND LINEZOLID test result performed by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECALIS
|
AMPICILLIN------------ <=2 S
LINEZOLID------------- S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ ___BD & PELVIS W/O CONTRAST Study Date of ___ 8:01 AM
IMPRESSION:
1. New, simple fluid in the perinephric space, possibly due to a
ruptured
renal cyst or diverticulum, and focal consolidation at the left
lung, possibly reactive. Findings may explain left sided flank
pain. No explanation for right flank pain.
2. Interval placement of second percutaneous nephrostomy tube in
the upper
moiety of the duplex right kidney. Unchanged percutaneous
nephrostomy tube in the lower moiety. Stable mild
hydronephrosis of the left kidney. No evidence of
nephrolithiasis.
3. Interval increase in the size of known liver metastases,
inguinal
lymphadenopathy, and right pelvic sidewall mass. Stable
retroperitoneal
lymphadenopathy and wide-spread osseous metastases.
DISCHARGE
___ 06:08AM BLOOD WBC-9.4 RBC-2.68* Hgb-7.4* Hct-23.7*
MCV-88 MCH-27.6 MCHC-31.2* RDW-16.0* RDWSD-52.1* Plt ___
___ 06:08AM BLOOD Glucose-92 UreaN-20 Creat-1.9* Na-130*
K-4.7 Cl-93* HCO3-22 AnGap-15
DISCHARGE PHYSICAL EXAM
========================
___ 1229 Temp: 99.2 PO BP: 103/69 HR: 108 RR: 18 O2 sat:
95% O2 delivery: RA
GENERAL: Chronically-ill appearing man, laying in bed
HEENT: NC/AT, MMM
PULM: No increased work of breathing
ABD: Soft, nontender, nondistended, active bowel sounds, 2 PCNs
in place, draining clear yellow urine
EXT: Bilateral legs edematous with 2+ pitting edema
SKIN: Warm, well-perfused, no rashes
NEURO: Alert, oriented, moving all four extremities
spontaneously.
Brief Hospital Course:
Mr ___ is a ___ year old man with history ___ 7
prostate cancer with mets to bone, lymph nodes, and liver, most
recently s/p C1D1 carbaitaxel ___, pulmonary embolism on
apixaban, with recent admission for malignant hydronephrosis s/p
2 R-sided PCNs, who presented with fever and confusion, found to
have Enterococcus UTI from ___ PCN bag, improved with drain
exchange and antibiotics, now s/p palliative XRT for R hip bone
met. He has significant pain from lymphedema and was seen by
vascular medicine consult service who recommended aggressive
wrapping, lymphedema physical therapy, and evaluation for the
possibility of venous stenting if within patient's goals of
care.
TRANSITIONAL ISSUES:
=========================
[] Linezolid ___ mg PO/NG BID LAST DAY ___.
[] Please continue to optimize pain regimen with patient's goals
of care in mind (preference for mild sleepiness over being in
pain)
[] No further chemotherapy currently planned for patient.
[] Pt is likely to benefit from hospice services. Please
continue to discuss.
[] Follow up repeat chemistry panel to evaluate renal function
if within goals of care.
[] if within goals of care, consider repeat lower extremity
Duplex US. If this were to demonstrate progression of venous
compression, then CTV and possible venous stenting could be
considered
LYMPHEDEMA CARE:
[] continue compression bandaging of his legs
[] continue leg and scrotal elevation
[] Pt has been referred to lymphedema ___ ___ 2) for
intensive physiotherapy (manual lymphatic drainage) and
arranging for intermittent pneumatic compression (IPC)
[] if within goals of care, consider repeat lower extremity
Duplex US. If this were to demonstrate progression of venous
compression, then CTV and possible venous stenting could be
considered
========================
ACTIVE ISSUES:
================
# ___ 7 prostate cancer with metastases to bone, lymph
nodes, liver
# R hip bone metastases
# Cancer related pain
# Goals of Care
Unfortunately his prostate cancer has progressed despite
multiple modes of chemotherapy. He no longer has any treatment
options available to him. Hospice was considered during this
hospitalization but the patient and his wife elected to continue
with their ___ care which they feel is adequate at home after
discharge from rehab. He was evaluated physical therapy who
believes he has rehab potential prior to discharge home. He
received 1 dose of palliative radiation therapy on ___ to the
right hip for severe pain. In addition his oral pain regimen
was titrated. A discussion with the patient regarding goals of
care revealed that the patient would prefer mild somnolence to
pain. As result of this he is on oxycodone 20 mg 3 times daily
with oxycodone 5 mg as needed. On discharge his pain is
adequately controlled with this regimen.
# Lymphedema
# Lower extremity edema
Mr. ___ has chronic lymphedema. He was briefly treated
torsemide without effect.
Medicine was consulted as it causes the patient significant
pain. They recommended aggressive wrapping which the patient at
times declined. Patient may also benefit from lymphedema
physical therapy as an outpatient. Additionally as possible
that he could have a venous outflow tract obstruction from his
pelvic mass. Evaluation for this would involve ultrasound,
potentially followed by CTV to evaluate for central target, and
potentially vascular stent if amenable. However we discussed
with the patient and his wife they preferred to continue to
think about this is an option and wanted to be discharged
instead. He should continue Ace wrapping his bilateral lower
extremities and he will see lymphedema ___ as an outpatient.
# Complicated Enterococcus UTI
Secondary to obstruction of ___ PCN, now s/p exchange with. He
was initially treated with broad-spectrum antibiotics and
narrowed to the linezolid. He will continue oral linezolid for
14-day course which ends on ___.
# ___ on CKD
Obstructive secondary to obstruction of ___ PCN, now s/p
exchange with improved renal function, although had not returned
to baseline.
CHRONIC ISSUES:
================
# Pulmonary embolism: Continued home Apixaban
# Anemia of antineoplastic therapy and renal disease: Stable.
No need for transfusions
CODE STATUS: DNR/DNI confirmed
CONTACT: ___, Relationship: wife ___, Phone
number: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Multivitamins 1 TAB PO DAILY
3. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
5. OxyCODONE SR (OxyCONTIN) 20 mg PO Q12H
6. Pantoprazole 40 mg PO Q12H
7. Pregabalin 200 mg PO BID
8. Vitamin D 1000 UNIT PO DAILY
9. Apixaban 2.5 mg PO BID
10. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
11. Polyethylene Glycol 17 g PO DAILY
12. LORazepam 0.5 mg PO Q6H:PRN nausea/vomiting/anxiety
13. Senna 17.2 mg PO BID
Discharge Medications:
1. Lidocaine 5% Patch 1 PTCH TD QPM back pain
2. Linezolid ___ mg PO BID Duration: 10 Days
3. OxyCODONE SR (OxyCONTIN) 20 mg PO TID
RX *oxycodone [OxyContin] 20 mg 1 tablet(s) by mouth three times
a day Disp #*21 Tablet Refills:*0
4. Pregabalin 75 mg PO BID
RX *pregabalin [Lyrica] 75 mg 1 capsule(s) by mouth once a day
Disp #*7 Capsule Refills:*0
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
6. Apixaban 2.5 mg PO BID
7. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
8. LORazepam 0.5 mg PO Q6H:PRN nausea/vomiting/anxiety
RX *lorazepam 0.5 mg 0.5 (One half) mg by mouth every six (6)
hours Disp #*20 Tablet Refills:*0
9. Multivitamins 1 TAB PO DAILY
10. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First
Line
11. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*42 Capsule Refills:*0
12. Pantoprazole 40 mg PO Q12H
13. Polyethylene Glycol 17 g PO DAILY
Hold for loose stools
14. Senna 17.2 mg PO BID
15. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
=========================
# ___ 7 prostate cancer with mets to bone, lymph nodes,
liver
# R hip bone mets
# Lymphedema
# Complicated Enterococcus UTI
SECONDARY DIAGNOSES
==========================
# ___
# Hyponatremia
# H/o PE
# Anemia of antineoplastic therapy and renal disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted for an infection of your kidneys related to
one of the tubes that was draining them
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were treated with antibiotics for your infection
- The infected tube that was draining your kidney was exchanged
- You received radiation therapy for your right hip to attempt
to decrease the pain that you were having from your cancer
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and come in to see your
oncologist whenever you have anything that you would like to
discuss.
- Please continue to wrap and elevate your legs
- Please see lymphedema physical therapy for manual lymphatic
drainage as it may help with your leg pain. We have arranged an
appointment for you.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10653395-DS-18
| 10,653,395 | 25,696,779 |
DS
| 18 |
2188-08-21 00:00:00
|
2188-08-24 20:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
___ Transesophageal Echo
___ ___ placement
History of Present Illness:
Mr. ___ is a ___ with myasthenia ___ (ocular
manifestations) who is presenting with a subacute and
progressive onset of lower back pain over the last month that
began after gardening. The pain was aching in nature without
radiation and without response to nabumetone. It actually has
improved modestly over the last month. Hurts the worst with
movement and transferring, there is no pain at rest or with
laying down. He's had no neurologic symptoms including weakness,
numbness, paresthesias, or spasms of the extremities and denies
bowel or bladder continence problems. He eventually underwent an
outpatient MRI (first noncon on ___, then with contrast ___,
which revealed disc disease L3-5, and enhancement around L1-L2
concerning for infection/discitis. He was subsequently referred
to the ED by his PCP for evaluation.
In the ED his initial vitals were 99.4 64 160/99 18 98% RA. His
blood was cultured. Spine consulted and declined immediate
surgical management. He was admitted for ___ biopsy.
On arrival to the floor, he has ___ back pain and is
comfortable. He has been managing with NSAIDs and APAP at home
with decent results. He denies fevers though had some shaking
chills in the ED today that responded to blankets. He denies any
recent rashes, skin trauma, GI or GU distress.
His wife mentions that he had a similar clinical syndrome of
back pain years ago that occurred in the context of prostatitis.
He has no different urinary symptoms aside from basleine
frequency. No dysuria or hematuria.
On ROS, mentions occasional diplopia from his myasthenia. denies
fevers, chest pain, chest pressure, shortness of breath,
nanusea, vomiting, diarrhea, weakness, fatigue.
Past Medical History:
-myasthenia ___
-atrial fibrillation (not on coumadin)
-BPH s/p TURP ___
-peripheral neuropathy
-erectile dysfunction
-colonic adenoma
-benign positional vertigo
-osteopenia
-mitral and aortic regurge
-pulmonary nodules
-basal cell carcinoma of face
Social History:
___
Family History:
mother with ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
============================
Vitals: T98.6 BP160/89 HR81 RR18 Sat96RA
General: well appearing
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: regular rate with occasional premature beats but not
irregularly irregular. No murmers.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rashes
Neuro: CN2-12 intact bilaterally, no ptosis, strength ___ in the
UE and ___. Plantars downgoing bilaterally. Patellar DTR 1+
bilaterally, biceps 1+ bilaterally. Sensation intact throughout.
Back: minimal tenderness over the lumbar spine on aggressive
palpation directly over the vertebrae.
DISCHARGE PHYSICAL EXAM:
==============================
Vitals: Tc99.2 130/69-165/86 55-68 18 99%RA
General: well appearing, NAD
HEENT: Sclera anicteric, MMM
Lungs: CTAB, no wheezes, rales, rhonchi
CV: regular rate with occasional premature. II/VI SEM heard at
the apex.
Abdomen: soft, NT/ND, NABS, no rebound tenderness or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rashes
Pertinent Results:
ADMISSION LABS:
=====================
MICRO:
=============
___ BLOOD CULTURE:
___ 4:50 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS EPIDERMIDIS. FINAL SENSITIVITIES.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ___ MORPHOLOGY.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS EPIDERMIDIS
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ 1 S
IMAGING:
================
___ TTE:Mildly thickened mitral leaflets with small focal
mobile echodensity as described above somewhat atypical for a
vegetation. The absence of pathologic mitral regurgitation
suggests this is a fibrin strand rather than a vegetation. Mild
symmetric left ventricular hypertrophy with normal regional and
low normal global systolic function. Mild pulmonary artery
hypertension. Dilated ascending aorta.
If clinically indicated, a TEE is suggested to better define the
mitral valve morphology.
DISCHARGE LABS:
==================
___ 05:38AM BLOOD WBC-6.1 RBC-4.24* Hgb-12.2* Hct-36.3*
MCV-86 MCH-28.7 MCHC-33.5 RDW-13.6 Plt ___
___ 05:38AM BLOOD Glucose-109* UreaN-16 Creat-0.8 Na-138
K-4.5 Cl-102 HCO3-29 AnGap-12
Brief Hospital Course:
Mr. ___ is a ___ with myasthenia ___ who was admitted
with low back pain and MRI evidence of infectious discitis found
to have staph epidermidis bacteremia presumably from a urinary
tract infection that was complicated by mitral valve
endocarditis.
.
ACTIVE ISSUES:
===================
# ENDOCARDITIS: Patient presented ___ blood cultures positive
for staph epidermidis ___ most likely secondary to urinary
source and was started on vancomycin empirically while
speciation at the time was pending. Infectious disease was
consulted given his high grade staph epidermidis bacteremia. He
had a TTE performed on ___ that could not rule out endocarditis.
He therefore underwent, TEE that showed vegetation on posterior
mitral valve most likely secondary to staph epidermidis
bacteremia from urinary source. A PICC line was placed once his
blood cultures had cleared. Based on sensitivities, he was
continued on vancomycin for ___ week course to be determined in
OPAT follow up.
.
# LOWER BACK PAIN CONCERNING FOR DISCITIS: Approximately 4 weeks
prior to admission patient developed acute onset of back pain
after gardening thought initially to be musculoskeletal in
nature by outpatient providers. He then had a MRI suggestive of
discitis. Back pain was most concerning for the possibility of
infection suggested by diffuse enhancement of the L1-2 vertebral
bodies and evidence of disc inflammation with soft tissue
irritation seen on MRI. ESR 53, CRP 35. Source of infection was
thought to be secondary to urinary tract infection as both blood
cultures and urine cultures were positive for staph epi. Given
the bacteremia and endocarditis (see above) it was determined to
forego ___ guided biopsy of the enhancing L1-L2 lesion given that
treatment duration would not be altered as above.
.
# STAPH EPI UTI: Patient in the past has grown S. epi in ___ as per ___ records initially treated with cipro then
switched to doxycycline for total of 7 days in the setting of
having been instrumented for a TURP procedure for his BPH. On
admission, he had a positive UA and he was empirically started
on vancomycin and ceftriaxone. Urine culture initially grew
mixed flora, but on further discussion with the micro lab, it
did grow Staph epi >100,000 cfu sensitive to vancomycin. His
ceftriaxone was discontinued once urine cultures were finalized.
Duration of vancomycin treatment will be determined by OPAT
follow up.
.
# HEMATURIA: At baseline patient passes ___ blood clots per week
with no visual evidence of hematuria between passing clots. Saw
urology in ___ on ___ and was planning for cystoscopy
later this year. Urology consulted and believes that this
intermittent hematuria is likely secondary to enlarged prostate
and straining with urination, as well as irritation from his
urinary tract infection. He required continuous irrigation for a
day and his foley was moved the day after it was placed. He only
then had clots with straining for BMs. Cytology was sent in the
setting of his hematuria and was positive for atypical cells.
This was communicated with the patient and he was instructed to
follow up with his ___ urologist.
.
CHRONIC ISSUES:
=====================
# MYASTHENIA ___: confined to the eyes, currently without
diplopia. He was continued on his home pyridostigmine.
.
# ATRIAL FIBRILLATION: currently not in A fib. CHADS2 of 2
(HTN/age) suggesting benefit from warfarin. He was continued on
metoprolol.
.
# BPH: continue tamsulosin
.
TRANSITIONAL ISSUES:
========================
# Cytology grew atypical cells, the patient was contacted and
instructed to call his urologist.
# Will require extended course of vancomycin for
endocarditis/osteomyelitis exact length to be determined by OPAT
follow up.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pyridostigmine Bromide 60 mg PO Q8H
2. meTOPROLOL succinate *NF* 50 mg Oral daily
hold for sBP<100, HR<55
3. Tamsulosin 0.4 mg PO HS
4. Cyanocobalamin 1000 mcg IM/SC MONTHLY
5. Sildenafil 50 mg PO PRN before sex
Discharge Medications:
1. Vancomycin 1250 mg IV Q 12H
RX *vancomycin 750 mg 1250 mg IV every twelve (12) hours Disp
#*75 Milligram Refills:*0
2. Outpatient Lab Work
Please draw Weekly CBC with Diff, Chem7, ESR/CRP, LFTs,
Vancomycin trough and fax results to ___ disease RN at
___
3. meTOPROLOL succinate *NF* 50 mg Oral daily
4. Sildenafil 50 mg PO PRN before sex
5. Cyanocobalamin 1000 mcg IM/SC MONTHLY
6. Pyridostigmine Bromide 60 mg PO Q8H
7. Tamsulosin 0.4 mg PO HS
8. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day
Disp #*30 Tablet Refills:*0
9. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*10 Capsule Refills:*0
10. Ibuprofen 600 mg PO Q8H:PRN pain
constipation
RX *ibuprofen 600 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
11. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*10 Tablet Refills:*0
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 Packet by mouth
daily Disp #*10 Packet Refills:*0
13. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 cap by mouth twice a day Disp
#*30 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY: Endocarditis, Urinary Tract Infection, Staph
Bacteremia, Hematuria, Epistaxis
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 here at ___
___!
You came to the hospital because you had an MRI that showed
there was some inflammation most likely from infection around
one of the disks in the back causing you pain.
While you were here, you were also found to have a urinary tract
infection. The infection in your urine was caused by a bacteria
caused by a Staph bacteria that you have grown in the past. The
bacteria in your urine was the same as the bacteria in your
blood.
Since this bacteria is very sticky, we did a transthoracic
echocardiogram (ultrasound of your heart) that was difficult to
tell if there was bacteria on your valve. You therefore had a
transesophageal echocardiogram (ultrasound looking at your heart
through your food pipe) that showed there was bacteria stuck to
your heart.
The infectious disease doctors were ___ and we have
treated you with antibiotics called Vancomycin which you will
need for ___ weeks. The infectious disease doctors ___
for how long.
You had some blood in your urine. You were seen by the
urologists who think that the blood most likely is coming from
your prostate and the irritation from the urinary tract
infection made you have more blood.
The night before you were being discharged, you had a bloody
nose. Your nose bleed had resolved after applying pressure for
an hour. You should see your ENT about this.
The following changes were made to your medications:
--START Vancomycin 1250mg twice a day
FOR YOU PAIN:
--take tylenol (acetaminophen) 1000mg three times a day for the
next week and then take it as needed
--If the pain is really bad you can take ibuprofen or take
oxycodone.
--If you do take oxycodone, you should not drive as it can make
you sleepy. Additionally, you should take stool softeners
(colace/senna) as this medication will make you constipated
Followup Instructions:
___
|
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| 18 |
2172-06-26 00:00:00
|
2172-06-26 17:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
musculo-skeletal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old male with history of Marfan syndrome s/p MV repair
and ASD closure in ___ who presented earlier in ___ to ___
ED with 7 days of left-sided
chest pain. Underwent chest CT that ruled out an aortic
dissection but revealed an ascending aortic aneurysm measuring
4.6 cm involving the aortic root. He had a similar episode of
chest pain in ___ which showed aortic root on CT to be 3.5cm
but echo showed the root to measure 4.4cm. In addition, the
aorta measured 4.3cm when he underwent MV repair and ASD closure
in ___. He was evaluated by Dr. ___ yesterday with a plan
for surgery in the near future. This morning he woke w/LUQ pain
rated ___, no radiation, no associated
nausea/vomiting/diarrhea/constipation, no fevers/chills, no
dysuria. He presented to ED tonight for further evaluation. On
CTA his aortic root now measures 4.9cm increased in size from
4.6cm earlier this month. He reports that he always has mid
chest discomfort and today has been no different.
Past Medical History:
Marfans
MV repair/ASD closure ___ (___)
Social History:
___
Family History:
three first degree relatives who have died from ruptured aortic
aneursyms
Physical Exam:
Pulse:61 Resp: 12 O2 sat:100% on RA
B/P Right: Left:110/56
General:marfanoid appearance, no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM x[]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] No Murmur [x] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x], pain with palpation to L lower ribs, reproducible with
palpation, extending around to his back
Extremities: Warm [x], well-perfused [x] No Edema [x] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
DP Right:2+ Left:2+
___ Right:2+ Left:2+
Radial Right:2+ Left:2+
well healed sternal incision and chest tube sites, sternum
stable
Pertinent Results:
___ 04:40PM GLUCOSE-83 UREA N-12 CREAT-0.8 SODIUM-143
POTASSIUM-4.3 CHLORIDE-109* TOTAL CO2-27 ANION GAP-11
___ 04:40PM WBC-6.9 RBC-4.80 HGB-14.1 HCT-43.0 MCV-90
MCH-29.3 MCHC-32.7 RDW-13.8
___ 04:40PM NEUTS-49.2* ___ MONOS-4.7 EOS-6.9*
BASOS-1.5
___ 04:40PM PLT COUNT-242
___ ECHOCARDIOGRAPHY REPORT
___ ___ MRN: ___ Portable TTE
(Complete) Done ___ at 2:18:49 ___ FINAL
Referring Physician ___
___ of Cardiothoracic Surg
___ Status: Inpatient DOB: ___
Age (years): ___ M Hgt (in): 74
BP (mm Hg): 109/70 Wgt (lb): 160
HR (bpm): 52 BSA (m2): 1.98 m2
Indication: Preoperative aortic root and acending aorta
replacement. S/P Mitral valve repair # 36mm ring ___.
Left ventricular function.
ICD-9 Codes: 414.8, 424.1, 424.0, 424.2
___ Information
Date/Time: ___ at 14:18 ___ MD: ___.
___, MD
___ Type: Portable TTE (Complete) Sonographer: ___,
___
Doppler: Full Doppler and color Doppler ___ Location: ___ 6
Contrast: None Tech Quality: Adequate
Tape #: ___-0:00 Machine: E9-2
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.4 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.8 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.4 m/s
Left Atrium - Peak Pulm Vein D: 0.3 m/s
Right Atrium - Four Chamber Length: 5.0 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.1 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 67% >= 55%
Aorta - Sinus Level: *4.4 cm <= 3.6 cm
Aorta - Ascending: *5.3 cm <= 3.4 cm
Aorta - Arch: 2.4 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.2 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 0.8 m/sec <= 2.0 m/sec
Mitral Valve - Mean Gradient: 2 mm Hg
Mitral Valve - Pressure Half Time: 79 ms
Mitral Valve - E Wave: 0.9 m/sec
Mitral Valve - A Wave: 0.9 m/sec
Mitral Valve - E/A ratio: 1.00
Mitral Valve - E Wave deceleration time: *285 ms 140-250 ms
TR Gradient (+ RA = PASP): *<= 203 mm Hg <= 25 mm Hg
Pulmonic Valve - Peak Velocity: 0.7 m/sec <= 1.5 m/sec
Findings
This study was compared to the prior study of ___.
LEFT ATRIUM: Normal LA and RA cavity sizes.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<=2.1cm)
with <50% decrease with sniff (estimated RA pressure ___
mmHg).
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
regional/global systolic function (biplane LVEF>55%). No resting
LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildy dilated aortic root. Moderately dilated ascending
aorta Normal aortic arch diameter. Normal descending aorta
diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.
MITRAL VALVE: Mitral valve annuloplasty ring. Well-seated mitral
annular ring with normal gradient. No MR.
___ VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is ___ mmHg. Normal left
ventricular wall thickness, cavity size, and regional/global
systolic function (biplane LVEF = 67 %). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level with sinus effacement. The
ascending aorta is moderately dilated. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis. Trace aortic regurgitation is seen. A mitral
valve annuloplasty ring is present. The mitral annular ring
appears well seated with normal gradient. No mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Dilated aortic root and ascending aorta. Normal
biventricular cavity sizes with preserved regional and global
biventricular systolic function.
Compared with the prior study (images reviewed) of ___,
the ascending aorta is now moderately dilated. The other
findings are similar.
Brief Hospital Course:
Mr. ___ was admitted with a CT reading of an ascending
aortic aneurysm that increased from 4.6cm to 4.9cm over several
weeks and a complaint of flank pain. His flank pain appeared to
be musculo-skeletal in that it was reproducable with pressure
applied to his flank. Dr. ___ his CT scans and felt
that the aneurysm was not appreciably increased. An echo was
performed which revealed an ascending aorta measuring 5.3 (4.4
at the sinus level) and a well seating, normally functioning
mitral valve. These results were related to Dr. ___
felt Mr. ___ could be discharged home to return to clinic
in a week and a half. It was stressed to the ___ and his
brother that he must obtain dental clearance as soon as possible
in preparation for surgery. He will return to see Dr. ___ on
___ at 3:30 ___ with his dental clearance.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
Discharge Medications:
1. Atenolol 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
aortic root aneurysm
Discharge Condition:
good
Discharge Instructions:
Call ___ with chest or back pain.
Continue to take your medications as prescribed.
Avoid lifting heavy weight.
Followup Instructions:
___
|
10653756-DS-21
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DS
| 21 |
2172-08-20 00:00:00
|
2172-08-20 16:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left arm pain/weakness
Major Surgical or Invasive Procedure:
Valve-sparing aortic root replacement
with a 32 mm Valsalva Dacron graft and ascending aortic
replacement with a 24 mm Gelweave tube graft.
History of Present Illness:
This is a ___ year old male w/marfan syndrome and redo
sternotomy/Valve sparing aortic root repair (32mm & 24mm
gelweave
double graft) on ___ who was discharged to home yesterday
presents today w/complaints of 3days L-arm pain. negative ___
and CXR yesterday. He had mild similiar pain prior to the
surgery
but has been much worse since. He has persitent poor
appetite/nausea ___ pain. He has no appetite and he cannot move
his arm ___ pain. Sensation and strength are intact. The pain
starts at his right ear and radiates down across his back to his
left arm. Patient had not taken oxycodone since 9 AM this AM.
CXR done shows no significant change. There is left-sided
persistent pleural effusion and opacification of the left lung
base as well as patchy right basilar opacification, all
suggesting atelectasis. The cardiac, mediastinal and hilar
contours appear stable.
CTA done shows focal absence of opacification in the distal and
radial artery of the left upper extremity may be due to
thrombus.
There is reconstitution of flow distal to this, likely from
retrograde flow through the palmar arch. The subclavian,
axillary, brachial, and ulnar arteries are patent without
evidence of stenosis or dissection. Hematoma surrounding the
ascending aorta may be postoperative in nature. No active
extravasation. The visualized aorta is normal in caliber. There
is no evidence of dissection or thrombus.
Patient is currently complaining of ___ pain, left arm,
radiating to left shoulder and right neck. He states pain is
"sharp and stabbing" and feels "muscular". Pain relieved with
Motrin.
VS:
T 98.2 BP 121/79 ST 104 R 18 100% RA
PE:
Neuro: AAOx 3 in NAD
___: RRR
Lungs: CTA
Sternal incision C/D/I, without sternal click
No ___ edema, 2+ radial pulses bilaterally
Past Medical History:
Ascending aortic aneurysm
Gastroesophageal Reflux Disease
Lactose intolerance
Marfan's syndrome
Past Surgical History
-MV repair and ASD closure (___) by Dr. ___ aortic root replacement
with a 32 mm Valsalva Dacron graft and ascending aortic
replacement with a 24 mm Gelweave tube graft.
Social History:
___
Family History:
Father, brother and sister with ___. Father died at
age ___, brother died at age ___, and sister died at age ___.
Physical Exam:
VS:
T 98.2 BP 121/79 ST 104 R 18 100% RA
PE:
Neuro: AAOx 3 in NAD
___: RRR
Lungs: CTA
Sternal incision C/D/I, without sternal click
No ___ edema, 2+ radial pulses bilaterally
Pertinent Results:
___ 06:35AM BLOOD WBC-5.7 RBC-3.44* Hgb-10.3* Hct-30.6*
MCV-89 MCH-30.0 MCHC-33.7 RDW-15.0 Plt ___
___ 06:35AM BLOOD Plt ___
___ 03:15PM BLOOD ___ PTT-29.3 ___
___ 06:35AM BLOOD Glucose-104* UreaN-8 Creat-0.6 Na-139
K-4.0 Cl-100 HCO3-27 AnGap-16
___ CXR
There has been no significant change. There is left-sided
persistent pleural
effusion and opacification of the left lung base as well as
patchy right
basilar opacification, all suggesting atelectasis. The cardiac,
mediastinal
and hilar contours appear stable.
IMPRESSION:
Stable appearance of the chest.
CTA upper extremity ___
Hematoma surrounding the ascending aorta may be postoperative in
nature. No
active extravasation. The visualized aorta is normal in caliber.
There is no
evidence of dissection or thrombus.
On this study, ascending aorta is not completely included.
Correlate with
upper extremity/thorax CTA obtained concurrently for further
detail.
NOTIFICATION: These findings were discussed with Dr. ___
by Dr. ___
at 19:10 of on ___ by telephone at time of
discovery.
The study and the report were reviewed by the staff radiologist.
CTA Neck ___
Hematoma surrounding the ascending aorta may be postoperative in
nature. No
active extravasation. The visualized aorta is normal in caliber.
There is no
evidence of dissection or thrombus.
On this study, ascending aorta is not completely included.
Correlate with
upper extremity/thorax CTA obtained concurrently for further
detail.
Brief Hospital Course:
Patient was admitted to ___ for evaluation, he has remained
hemodynamically stable. He was seen by the vascular service and
it was determined that his radial clot was minimal and does not
require anticoagulation. He was started on neurontin and motrin
for pain control with good effect. He continued to have upper
extremity weakness and was seen by the neurology service too. It
was their impression that his continued weakness was related to
possible spasm or rotator cuff injury. His left upper extremity
is warm, well prefused, + 2 radial pulse, no edema, decreased
upper extremity strength. He is being discharged to home on
neurontin and motrin. Advised to call if pain worsens or
neuromuscular changes develop. He may need to f/u with
orthopedics if issue continues. All follow-up appt arranged. He
was discharged in stable condition.
Medications on Admission:
. Acetaminophen 650 mg PO Q4H:PRN pain/fever
maximum 4000mg/day please
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
3. Omeprazole 20 mg PO DAILY
4. Cephalexin 500 mg PO Q6H ___ phlebitis Duration: 6 Days
RX *cephalexin 500 mg 1 tablet(s) by mouth every six (6) hours
Disp #*24 Tablet Refills:*0
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
6. Senna 17.2 mg PO HS
RX *sennosides [senna] 8.6 mg 2 tablets by mouth at bedtime Disp
#*60 Tablet Refills:*0
7. Atenolol 12.5 mg PO DAILY
RX *atenolol 25 mg 0.5 (One half) tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Atenolol 12.5 mg PO DAILY
3. Gabapentin 100 mg PO TID
RX *gabapentin 100 mg 1 capsule(s) by mouth three times a day
Disp #*60 Capsule Refills:*1
4. Cephalexin 500 mg PO Q6H Duration: 5 Days
5. Ibuprofen 600 mg PO Q6H:PRN pain
take with food
RX *ibuprofen 200 mg 3 tablet(s) by mouth every six (6) hours
Disp #*60 Tablet Refills:*1
6. Omeprazole 20 mg PO DAILY
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
left arm pain/weakness
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Edema-none
extremities: Right upper ext, warm, +2 pulses, good motor
strength, sensation intact
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10653798-DS-7
| 10,653,798 | 29,265,811 |
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| 7 |
2150-06-26 00:00:00
|
2150-06-26 16:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ciprofloxacin / latex
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ who presented to the ___ ED on ___ with
epigastric, RUQ and RLQ pain which first began on ___.
He describes the pain as mild (___), in the epigastric
region. It does not radiate and has not changed in intensity
since it began. No n/v, f/c. No diarrhea, decreased bowel
movements, which he attributes to decreased appetite. No melena,
no BRBPR. Has tried to maintain good hydration, but continues to
feel dehydrated. He had a CT when he came to the ___ ED, which
was initially read as not concerning, but mild ___
stranding was noted on the final read and he was contacted to
return to ___. He has noticed cramping in his feet, worse in
the left foot, which he attributes to dehydration, but these
began over 6 months ago.
On ___ morning he had a syncopal episode. He has had only
one previously, approximately ___ years ago, of unknown cause. He
lost consciousness for a few seconds while bending over to lift
the toilet seat, and was conscious by the time he was found by
his wife, who was only a few feet away. Hit head on wood bar on
wall while falling down. He had mild confusion which improved
after a minute. He has not had any chest pain, dizziness,
shortness of breath, or palpitations.
Past Medical History:
___ esophagus
RETINAL VASCULAR OCCLUSION - BRANCH
CANCER, PROSTATE s/p radiation beam therapy in ___
CORONARY ARTERY DISEASE
HEADACHE - MIGRAINE
HYPERCHOLESTEROLEMIA
PRESBYOPIA
HEARING LOSS, SENSORINEURAL
GLAUCOMA
Social History:
___
Family History:
No first degree relatives with cancer.
Physical Exam:
Exam on admission:
VS: 97.9 97.8 138/82 80 20 98/RA
Gen: NAD
HEENT: Anicteric sclera. Slightly dry mucus membranes.
Cor: RRR, no m/r/g
Pulm: CTAB, no w/r/r
Abd: Soft. Non-distended. Mild tenderness to palpation in
epigastric region and RLQ.
Neuro: A&O to conversation. EOMI. Facial movements intact. SCM,
triceps, biceps, deltoids, quads, gastroc, tib anterior strength
intact bilaterally.
Exam on discharge:
Gen: Seated comfortably
HEENT: Anicteric sclera. Mildly dry mucus membranes.
Cor: RRR. Distant HS. No m/r/g
Pulm: CTAB, no w/r/r
Abd: +BS. Soft. Non-distended. Tender to palpation over LLQ,
hypogastric region. Rebound tenderness (local) over hypogastric
region. No epigastric tenderness.
Ext: WWP, 2+ DP bilaterally
Neuro: Alert and oriented to conversation.
Pertinent Results:
Admission labs:
Chem: ___ glu 108 Ca 9.5 Mg 2.1
LFTs: AST 20 ALT 20 AP 49 Tbili 0.4 Alb 4.5
CBC: 12.6>13.8/43.0<196
Diff: N81.6 L11.3 M5.8 E0.9 B0.4
Lipase: ___
Trop-T: <0.01
Labs on discharge:
WBC-8.8 RBC-4.71 Hgb-12.9* Hct-39.6* MCV-84 MCH-27.4 MCHC-32.6
RDW-13.5 Plt ___
ALT-20 AST-20 AlkPhos-49 TotBili-0.4
Glucose-72 UreaN-7 Creat-0.9 Na-140 K-4.1 Cl-106 HCO3-29
Calcium-8.8 Phos-2.6* Mg-2.0
Brief Hospital Course:
Mr. ___ is a ___ with a history of CAD and prostate CA s/p
radiation beam therapy. He presented to the ___ ED after a
syncopal episode on ___ and noted abdominal pain at
the time of presentation. He was discharged from the ED in
stable condition, but asked to return when the final read of an
abdominal CT scan noted ___ stranding. Lipase on
arrival to the ED on ___ was elevated to ___. He was admitted
to ___ for treatment of acute pancreatitis.
#)Acute pancreatitis: No known gallstones, no EtOH use. By
exclusion, etiology may be secondary to medication (statin). Mr.
___ was started on liberal fluids with IV D5NS for
resuscitation. He noted some lightheadedness on standing the day
following presentation, but this resolved. He was written for
acetaminophen and tramadol prn, but never requested pain
medications. No vomiting or diarrhea. He was initially kept NPO
overnight, but advanced quickly to clear fluids as tolerated on
___. He had some abdominal pain and nausea with solid foods
on ___, but tolerated cereal, toast, and fruit on ___
without discomfort. His fluids were discontinued ont ___ and he
was considered stable for discharge.
Transitional issues:
#) CAD - He was continued on his home diltiazem SR 120mg. We
recommended he stop atorvastatin, which can, in rare cases cause
pancreatitis, until speaking with his physician.
Chronic issues:
#) ___ esophagus - We continued his home omeprazole 20mg
bid and ranitidine 150mg bid
#) Glaucoma - We continued his home latanoprost drops ___
#) RVO - We continued his home brimonidine drops OS bid
Medications on Admission:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
2. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
3. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic BID (2
times a day).
6. atorvastatin 20mg daily
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
2. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
3. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic BID (2
times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
Acute pancreatitis, possibly secondary to statin
Secondary diagnoses:
CAD
hyperlipidemia
prostate ca
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ with
acute pancreatitis. Your abdominal CT scan and abdominal
ultrasound was reassuring. You received IV fluids and your diet
was gently advanced. On the day of discharge, you tolerated your
diet will and had improvement in abdominal pain.
Durring you admission, we drew a blood test called ___ that
was elevated. This test can be elevated in several conditions,
including some forms of cancer. This result is difficult to
interpret in the setting of acute pancreatitis, and you should
discuss this result with your PCP and ___.
It was a pleasure caring for you at ___.
Please stop your atorvastatin as this medication in rare cases
may cause pancreatitis. Please discuss this medication with your
PCP.
No other changes have been made to your home medications.
Please take your medications as prescribed and keep your
outpatient appointments.
Followup Instructions:
___
|
10654029-DS-19
| 10,654,029 | 23,998,479 |
DS
| 19 |
2138-02-23 00:00:00
|
2138-02-23 20:13:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
CC - RLQ Abd Pain, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ y/o woman with migraines, HLD, who presented to the
ED with myalgias, chills/fevers, diarrhea and abdominal pain.
Her symptoms began 3 days PTA with myalgias, chills and
subjective fevers. These then progressed to nausea and diarrhea
with watery stool; temp that day was 101. The following day,
while at work, the patient began experiencing severe
___ pain which then traveled to the RLQ (and remained
localized there), along with increased stool output. Given the
severity of her abdominal pain, she presented tot he ED
yesterday. She had approximately 12 stools yesterday, and noted
BRB in the stools last night.
She was observed in the ED overnight, where initial vitals were
notable for normal temp and mild tachycardia. Labs were notable
for a normal lactate, slightly elevated LFTs; imaging
demonstrated pan-colitis and though not clearly visualized, no
signs of appendicitis (CT abdomen). Patient was given 4 L IVF,
Zofran (4 mg x 1), morphine (4 mg x 1) and ketorolac (15 mg x
1). She was also given loperamide with decrease in her stool
output. This AM after a PO challenge (clears) pt noted to have
significant cramping. Stool cultures were sent and patient was
admitted to medicine for further management.
Currently, she is recovering from a migraine. She does not have
any abdominal pain currently, no nausea or vomiting. No rashes.
No recent travel history, unusual exposures, or undercooked
foods. Family members have been healthy. She does work in a
hospital (___ at ___), so there have been a few
cases of norovirus and cdiff there.
10-pt ROS otherwise negative in detail.
Past Medical History:
Migraines (on topiramate/botox injections, followed by Headache
clinic)
Seasonal affective disorder
Hyperlipidemia
Exercise induced asthma
Social History:
___
Family History:
No history of IBD.
Physical Exam:
ADMISSION EXAM:
VS: 98.1, BP 106/66, HR 80, RR 16, SaO2 100/RA
General: Fatigued-appearing woman in NAD, AO X 3
HEENT: Anicteric sclerae, MM slightly dry, OP clear
Neck: supple, no LAD
Chest: CTA-B, no w/r/r
CV: RRR s1 s2 normal, no m/g/r
Abd: soft, ND/NABS, +TTP in the RLQ with milder TTP in the
___ region, no rebound or guarding, no HSM
Ext: no c/c/e, wwp
Neuro: AO x 3, non-focal exam
Skin: warm, dry, no rashes
DISCHARGE EXAM:
Vitals: T: 98.5 P: 123/76 R: 18 O2: 100%RA
Gen: NAD, lying in bed
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear
___: RRR, no MRG, full pulses, no edema
Resp: normal effort, no accessory muscle use, lungs CTA ___-
anterior auscultation.
GI: soft, non-tender on palpation. No rebound or guarding.
Skin: No visible rash. No jaundice.
Neuro: AAOx3. No facial droop.
Psych: Full range of affect
Pertinent Results:
ADMISSION LABS:
___ 06:30PM WBC-6.3 RBC-3.76* HGB-11.7 HCT-35.4 MCV-94
MCH-31.1 MCHC-33.1 RDW-13.3 RDWSD-45.8
___ 06:30PM NEUTS-69 BANDS-0 ___ MONOS-4* EOS-0
BASOS-0 ___ MYELOS-0 AbsNeut-4.35 AbsLymp-1.70
AbsMono-0.25 AbsEos-0.00* AbsBaso-0.00*
___ 06:30PM PLT SMR-NORMAL PLT COUNT-216
___ 06:30PM ALBUMIN-4.2
___ 06:30PM LIPASE-34
___ 06:30PM ALT(SGPT)-55* AST(SGOT)-63* ALK PHOS-65 TOT
BILI-0.2
___ 06:30PM GLUCOSE-90 UREA N-14 CREAT-0.9 SODIUM-133
POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-21* ANION GAP-17
___ 06:37PM LACTATE-0.9
MICRO:
**FINAL REPORT ___
FECAL CULTURE (Final ___:
NO SALMONELLA OR SHIGELLA FOUND.
NO ENTERIC GRAM NEGATIVE RODS FOUND.
CAMPYLOBACTER CULTURE (Final ___:
Reported to and read back by ___ ___ ___ @11:30
AM.
CAMPYLOBACTER JEJUNI.
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.
.
MODERATE POLYMORPHONUCLEAR LEUKOCYTES.
FEW RBC'S.
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.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
___ CT abdomen:
1. Pancolitis, with wall thickening most severe in the cecum and
ascending
colon. Etiology may be infectious or inflammatory. No
drainable fluid
collection or extraluminal gas.
___ Appendix u/s:
IMPRESSION:
Appendix not identified.
DISCHARGE LABS:
___ 07:17AM BLOOD WBC-3.8* RBC-3.20* Hgb-10.1* Hct-30.3*
MCV-95 MCH-31.6 MCHC-33.3 RDW-13.8 RDWSD-48.1* Plt ___
___ 06:30PM BLOOD Neuts-69 Bands-0 ___ Monos-4* Eos-0
Baso-0 ___ Myelos-0 AbsNeut-4.35 AbsLymp-1.70
AbsMono-0.25 AbsEos-0.00* AbsBaso-0.00*
___ 07:08AM BLOOD Glucose-83 UreaN-3* Creat-0.7 Na-139
K-3.8 Cl-111* HCO3-21* AnGap-11
___ 07:10AM BLOOD ALT-32 AST-26
___ 07:10AM BLOOD CRP-61.5*
Brief Hospital Course:
___ y/o healthy woman presenting with fever, abdominal pain, and
diarrhea, findings on imaging demonstrating pan-colitis. Her
course is summarized by problem below.
ACTIVE:
# Pan-colitis due to Camphylobacter jejuni
The patent presented with symptoms and imaging findings most
consistent with infectious colitis. She was treated supportively
with bowel rest and IV fluids. She was started on empiric
antibiotics with cipro/flagyl prior to results of stool culture
given lack of improvement.Ultimately stool culture returned
positive for Camphylobacter jejuni (remainder of studies
negative including Norovirus and C diff) On further
questioning, the patient recalls eating undercooked chicken at a
restaurant. She was continued on high dose Cipro alone and will
complete a 5 day course. Her diarrhea resolved prior to
discharge. She continued to have poor appetite but was
tolerating some POs. Given her work as a ___, we discussed
return to work. As her diarrhea has resolved, and she is
otherwise well, I see no medical contraindication for return to
work pending clearance by her institution employee health
department. Would consider a repeat CT scan after complete
resolution of symptoms to assure pan colitis has resolved and to
rule out underlying inflammatory etiology.
CHRONIC:
# Migraines - The patient experienced migraines while
hospitalized which responded well to sumitriptan and tylenol.
# Seasonal affective d/o - continued venlafaxine
# Hyperlipidemia - held statin on admit due to elevated LFTs
likely in the setting of acute illness. Restarted on discharge.
TRANSITIONAL ISSUES:
[ ] Consider repeat CT scan 4 weeks to assess for resolution of
inflammation
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Venlafaxine 75 mg PO DAILY
2. Topiramate (Topamax) 50 mg PO QHS
3. Atorvastatin 20 mg PO QPM
Discharge Medications:
1. Topiramate (Topamax) 50 mg PO QHS
2. Venlafaxine 75 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Ciprofloxacin HCl 750 mg PO Q12H
RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth Q12hrs Disp
#*5 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pancolitis due to Camphylobacter jejuni
Migraines
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dr. ___ were admitted for management of your GI
symptoms. Your CT scan showed pan- colitis and your stool
cultures were positive for camphlobacter jejuni. You were
managed with fluids and bowel rest and antibiotics. Please
discuss your CT findings with Dr. ___. She may want to repeat
a CT scan to make sure that the abnormalities seen have
resolved. You will need to continue antibiotics for a total of 5
days.
It was a pleasure caring for you and we wish you the best!
Followup Instructions:
___
|
10654540-DS-12
| 10,654,540 | 28,269,731 |
DS
| 12 |
2130-09-01 00:00:00
|
2130-09-01 18:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Nsaids / Aspirin
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with no PMH presented for evaluation of chest
pain. He reports sudden onset of sharp L sided CP 2 days ago
which has been progressively worsening. Worse with taking a deep
breath. No SOB, cough, hemoptysis, nausea, diaphoresis or any
fevers or chills.
He had L sided calf pain which has since resolved. He flew back
from ___ about six weeks prior on ___ (5 h flight).
In the ED, - Initial vitals: 92 180/80 16. EKG was felt to be
unremarkable. Labs showed: D-Dimer: 7733, Troponin neg x2,
proBNP: 29. CTA was obtained which showed showed multifocal
pulmonary embolism involving bilateral lobar and segmental
branches.
He was started on a heparin gtt and admitted to medicine for PE.
Past Medical History:
Bilateral radial fractures s/p repair
Social History:
___
Family History:
father died of esophageal cancer, mother diagnosed with colon
cancer. No h/o cardiac disease / stroke / blood clots.
Physical Exam:
PHYSICAL EXAM:
Vitals: 98.3 PO 148 / 87 87 16 100 RA
General: alert, comfortable, pleasant
HEENT: Sclerae anicteric, MMM, oropharynx clear, PERRLA, EOMI
Neck: supple, JVP not elevated
Lungs: CTAB, no wheezes, rales, or rhonchi
CV: RRR, S1/S2, no m/r/g
GI: soft, NT/ND, BS+, no rebound tenderness or guarding, no
organomegaly
MSK: no ___, no calf tenderness or pain with dorsiflexion of
either foot, well perfused
Neuro: CN2-12 intact, no focal deficits
Skin: No rash or lesion
DISCHARGE PHYSICAL EXAM:
General: alert, comfortable, pleasant
HEENT: Sclerae anicteric, MMM, oropharynx clear, PERRLA, EOMI
Neck: supple, JVP not elevated
Lungs: CTAB, no wheezes, rales, or rhonchi
CV: RRR, S1/S2, no m/r/g
GI: soft, NT/ND, BS+, no rebound tenderness or guarding, no
organomegaly
Pertinent Results:
Labs
----
___ 12:42AM BLOOD WBC-8.3 RBC-5.24 Hgb-15.3 Hct-46.0 MCV-88
MCH-29.2 MCHC-33.3 RDW-13.5 RDWSD-43.6 Plt ___
___ 12:42AM BLOOD Neuts-55.6 ___ Monos-11.9 Eos-3.6
Baso-1.1* Im ___ AbsNeut-4.60 AbsLymp-2.29 AbsMono-0.99*
AbsEos-0.30 AbsBaso-0.09*
___ 12:42AM BLOOD Glucose-109* UreaN-18 Creat-1.0 Na-140
K-4.2 Cl-100 HCO3-27 AnGap-13
___ 04:00AM BLOOD cTropnT-<0.01
___ 12:42AM BLOOD cTropnT-<0.01
___ 12:42AM BLOOD proBNP-29
___ 12:42AM BLOOD D-Dimer-7733*
CTA ___
1. Multifocal pulmonary embolism is identified involving
bilateral lobar and segmental branches.
2. Mildly enlarged right heart may reflect mild right heart
strain. If clinically indicated, echocardiogram can provide
better evaluation.
3. Small ground-glass opacity in the left upper lobe lingula may
reflect pulmonary infarct.
Brief Hospital Course:
___ healthy gentleman who presented to the ED with acute
onset chest pain and found to have low-risk PE.
# PE
CTA showed multifocal pulmonary embolism involving bilateral
lobar and segmental branches as well as possible RV strain.
However, troponin, BNP negative, EKG similar to prior and
therefore no evidence of right heart strain. His PE was possibly
provoked in the setting of a recent flight from ___ in
___. He was started on a heparin gtt and subsequently
transitioned to apixaban.
Transitional issues
===================
[] started on apixaban for PE. He should take 10mg BID for 7
days (last dose ___ pm) and then transition to 5mg BID (first
dose ___ am).
[] it is unclear if this was provoked (he had a long flight but
it was six weeks prior); he needs at least three months of
therapy, but would consider either empiric lifelong
anticoagulation, or a full hypercoagulable workup prior to
permanent cessation of treatment.
#CODE: Full (presumed)
#COMMUNICATION: wife (___)
Medications on Admission:
No meds
Discharge Medications:
1. Apixaban 5 mg PO BID
take 2 pills twice a day until ___ am, then take 1 pill twice
a day
RX *apixaban [Eliquis] 5 mg 2 tablet(s) by mouth twice a day
Disp #*110 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary 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 a pleasure taking care of you at ___!
Why was I admitted to the hospital?
- you had chest pain and were found to have a blood clot in you
lungs
- you were started on medications to thin your blood
What should I do after discharge?
- you should continue taking the blood thinning medication
(Apixaban) for at least three months - please take 2 pills twice
a day for a total for seven days (last dose ___ pm) and then
take 1 pill twice a day (first dose ___ am)
- please follow up with your PCP as below to determine the final
length of your treatment
All the best,
Your ___ care team
Followup Instructions:
___
|
10654573-DS-21
| 10,654,573 | 21,319,891 |
DS
| 21 |
2117-06-26 00:00:00
|
2117-06-30 10:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
___:
1. Open reduction and internal fixation of a transscaphoid
perilunate dislocation with fixation of the scaphoid.
2. Open reduction of a lunate and triquetral dislocation.
3. Open reduction of a radiocarpal dislocation.
4. Acute carpal tunnel release.
5. Closed reduction of pelvic ring injury.
History of Present Illness:
___ man with a reported fall from 25 feet onto his left
side landing on rocks, probable loss of consciousness. Obvious
facial trauma, left wrist deformity, left hip pain. Vitals are
within normal limits. Alert and oriented x3.
Past Medical History:
None
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
Constitutional: Patient distress secondary to pain
HEENT: Multiple facial lacerations of the lip, left nasal
sidewalk, abrasions to face.
Oropharynx within normal limits
Chest: Cervical collar in place
Cardiovascular: Tachycardic and regular
Abdominal: Soft, nondistended, no significant tenderness,
FAST negative
Pelvic: Stable
Extr/Back: Probable before he left wrist with significant
tenderness. Left hip to palpation
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
___: No petechiae
Discharge Physical Exam:
VS: T: 99.9, HR: 90, BP: 143/71, RR: 18, O2: 100% RA
GENERAL: A+Ox3, NAD
HEENT: facial lacerations with sutures, well-approximated, no
evidence of infection
CV: RRR
PULM: CTA b/l
EXTREMITIES: LUE in splint with ace bandaging. +1 edema in LUE,
warm, well-perfused b/l with capillary refill <2 seconds.
Pertinent Results:
___ 06:35PM WBC-13.8* RBC-4.41* HGB-12.5* HCT-38.1*
MCV-86 MCH-28.3 MCHC-32.8 RDW-13.9 RDWSD-43.6
___ 06:35PM PLT COUNT-202
___ 10:53AM GLUCOSE-126* UREA N-16 CREAT-0.9 SODIUM-137
POTASSIUM-3.4 CHLORIDE-103 TOTAL CO2-24 ANION GAP-13
___ 10:53AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 10:53AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 10:53AM WBC-18.1*# RBC-4.65 HGB-13.3* HCT-40.0 MCV-86
MCH-28.6 MCHC-33.3 RDW-13.8 RDWSD-42.9
___ 10:53AM NEUTS-82.8* LYMPHS-9.6* MONOS-6.1 EOS-0.1*
BASOS-0.4 IM ___ AbsNeut-14.95*# AbsLymp-1.74 AbsMono-1.11*
AbsEos-0.02* AbsBaso-0.08
___ 10:53AM PLT COUNT-230
___ 10:53AM URINE COLOR-Yellow APPEAR-Clear SP
___
___ 10:53AM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 10:53AM URINE RBC-31* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 08:29AM GLUCOSE-127* LACTATE-1.7 NA+-139 K+-3.6
___ 08:29AM HGB-14.9 calcHCT-45
___ 08:15AM WBC-9.2 RBC-5.17 HGB-14.6 HCT-47.4 MCV-92
MCH-28.2 MCHC-30.8* RDW-13.8 RDWSD-46.3
___ 08:15AM NEUTS-49.3 ___ MONOS-5.3 EOS-1.7
BASOS-0.4 IM ___ AbsNeut-4.55 AbsLymp-3.87* AbsMono-0.49
AbsEos-0.16 AbsBaso-0.04
___ 08:15AM PLT COUNT-224
Imaging:
___: Nerve resection Pathology:
Peripheral nerve with no specific pathologic changes
___: CT Head:
1. No acute intracranial process.
2. Soft tissue swelling overlying the left frontal bone without
underlying
fracture.
___: CT C-spine:
No acute fracture or malalignment of the cervical spine.
___: CT Sinus/Mandible/Max:
1. Mildly displaced left nasal bone fracture without any other
fractures
identified.
2. Soft tissue swelling and stranding overlying the left mid
face with a 2.4 cm hematoma overlying the anterior left
zygomatic arch.
___: CT Torso:
1. Comminuted left sacral fracture. There is widening of the
right sacroiliac joint with a small focus of gas.
2. Comminuted impacted pubic symphysis fracture with 2 separate
fracture
fragments and localized hematoma inferior to the fracture and
adjacent to the bladder. The hematoma contains small areas of
active extravasation.
3. No traumatic injury to the chest or abdomen. No evidence of
free air.
___: CXR:
No acute cardiopulmonary process. No displaced rib fracture.
___: L Knee x-ray:
1. No evidence of acute fracture involving the left hip, or
left knee.
2. Comminuted, impacted pubic symphysis fracture, more
completely evaluated
on the recent CT.
3. Previously described left sacral fracture is not well seen
on this exam,
however irregular lucencies in this region may be a correlate.
4. Mixed lucent and sclerotic lesion within the proximal tibia
measuring at least 3.4-cm, incompletely evaluated on this exam.
This is of uncertain
etiology. Potential differential considerations include bone
infarct, healing nonossifying fibroma, or enchondroma. It is
also possible it represents sequela from previous injury or
treatment. If not previously characterized, then a non-urgent
MRI or prior clinical correlation is recommended for further
evaluation.
___: L Femur:
1. No evidence of acute fracture involving the left hip, or
left knee.
2. Comminuted, impacted pubic symphysis fracture, more
completely evaluated
on the recent CT.
3. Previously described left sacral fracture is not well seen
on this exam, however irregular lucencies in this region may be
a correlate.
4. Mixed lucent and sclerotic lesion within the proximal tibia
measuring at least 3.4-cm, incompletely evaluated on this exam.
This is of uncertain
etiology. Potential differential considerations include bone
infarct, healing nonossifying fibroma, or enchondroma. It is
also possible it represents sequela from previous injury or
treatment. If not previously characterized, then a non-urgent
MRI or prior clinical correlation is recommended for further
evaluation.
___: Pelvis x-ray:
Re demonstrated is a comminuted, impacted pubic symphysis
fracture, with the left pubic symphysis distracted approximately
2.6 cm above the right pubic symphysis and overlap of
approximately 1.6 cm. No additional fractures of the left hip
are identified. The previously noted left sacral fracture is
not well seen on this study.
Incidental note is made of a mixed lucent and sclerotic lesion
within the
proximal tibia, incompletely evaluated on this exam however
measuring at least 3.4-cm x 2.4-cm.
No fractures are seen involving the left knee. No focal lytic
or sclerotic
lesions are seen. No soft tissue calcification, or radiopaque
foreign bodies identified.
IMPRESSION:
1. No evidence of acute fracture involving the left hip, or
left knee.
2. Comminuted, impacted pubic symphysis fracture, more
completely evaluated on the recent CT.
3. Previously described left sacral fracture is not well seen
on this exam,however irregular lucencies in this region may be a
correlate.
4. Mixed lucent and sclerotic lesion within the proximal tibia
measuring at least 3.4-cm, incompletely evaluated on this exam.
This is of uncertain
etiology. Potential differential considerations include bone
infarct, healing nonossifying fibroma, or enchondroma. It is
also possible it represents sequela from previous injury or
treatment. If not previously characterized, then a non-urgent
MRI or prior clinical correlation is recommended for further
evaluation.
___: L Wrist x-ray:
Complete anterior and proximal dislocation of the lunate.
Displaced fracture through the scaphoid bone, with volar
dislocation of the
proximal fragment from radiocarpal joint.
No evidence of an elbow fracture.
___: L forearm x-ray:
Complete anterior and proximal dislocation of the lunate.
Displaced fracture through the scaphoid bone, with volar
dislocation of the
proximal fragment from radiocarpal joint.
No evidence of an elbow fracture.
___: L elbow x-ray:
Complete anterior and proximal dislocation of the lunate.
Displaced fracture through the scaphoid bone, with volar
dislocation of the
proximal fragment from radiocarpal joint.
No evidence of an elbow fracture.
___: Pelvis (AP, inlet, outlet) x-ray:
Comminuted, impacted pubic symphysis fracture, with the left
pubic symphysis distracted approximately 2.6 cm above the right
pubic symphysis and overlap of approximately 1.6 cm. Likely
posterior displacement of the left parasymphyseal pubic ramus.
Previously noted comminuted left sacral fracture on the CT is
not as well seen on this exam, however subtle irregular
lucencies may be a correlate. There does appear to be widening
of the right SI joint of approximately 8 mm.
___: R Wrist x-ray:
No fracture.
___: R Forearm x-ray:
No fracture.
___: L Tib/Fib x-ray:
Unchanged appearance of a mixed lucent and sclerotic lesion
within the
proximal tibia with findings most suggestive of a nonossifying
fibroma.
___: Pelvis (AP, inlet, outlet) x-ray:
Overall, interval improvement in the alignment of the pubic
symphysis,
compared to the most recent prior exam, status post closed
reduction, with
mild residual subluxation of the left pubic symphysis
approximately 5 mm
superior to the right pubic symphysis.
Mild distension of the small bowel measuring up to 5-cm is
likely secondary to ileus, as air is seen in the colon.
___: Pelvis (AP, inlet & outlet) x-ray:
Stable appearance of the pubic symphysis with mild superior and
posterior
subluxation of the left pubic symphysis relation to the right.
Discontinuity of the left sacral arcuate lines is consistent
with known sacral fracture better seen on prior CT. No new
fracture.
Brief Hospital Course:
Mr. ___ is a ___ year-old male s/p fall of 3 stories while at
work. His injuries included a comminuted left sacral fracture,
open L wrist lunate dislocation, L scaphoid fracture, facial
lacerations, and a mildly displaced left nasal bone fracture.
The patient was admitted to the Acute Care Surgery service and
the Orthopaedics and Plastic Surgery teams were consulted. The
Plastic Surgery team irrigated the patient's facial lacerations
and repaired them with sutures at the bedside. No surgical
intervention was required for his closed nasal bone fracture.
The patient was then emergently taken to the operating room for
treatment of his pelvic fracture and carpal dislocation and
fracture.
On HD1, the patient underwent ORIF of a transscaphoid perilunate
dislocation with fixation of the scaphoid, open reduction of a
lunate and triquetral dislocation, open reduction of a
radiocarpal dislocation, acute carpal tunnel release, and closed
reduction of pelvic ring injury. The patient tolerated this
procedure well (reader, please see operative note for further
details. The patient was made non-weight bearing on the LLE and
LUE and WBAT on the RLE, full-weight bearing on the RUE.
The patient was then transferred to the surgical floor for
further medical care. On POD1, the patient complained of pain in
his LUE and the Orthopaedics team loosened the LUE splint. On
POD2, the patient's foley catheter was removed and he voided
appropriately. The patient was evaluated by both Occupational
and Physical Therapy. The patient was cleared to be discharged
home with a wheelchair. On POD4, the patient had a repeat pelvic
x-ray which showed stable appearance of the pubic symphysis with
mild superior and posterior subluxation of the left pubic
symphysis relation to the right. No new fractures were
identified.
The patient was alert and oriented throughout hospitalization;
pain was managed with oral hydromorphone and acetaminophen once
transitioned to a diet. The patient remained stable from a
cardiovascular standpoint; vital signs were routinely monitored.
He remained stable from a pulmonary standpoint. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization. The patient tolerated a
regular diet, intake and output were closely monitored. The
patient's fever curves were closely watched for signs of
infection, of which there were none. The patient's blood counts
were closely watched for signs of bleeding, of which there were
none. The patient received subcutaneous lovenox and ___ dyne
boots were used during this stay and was encouraged to get up
and ambulate as early as possible. Per Orthopaedics
recommendations, the patient was discharged on a one month
supply of lovenox for prophylaxis.
At the time of discharge, the patient was doing well. He did
have a low grade temperature of 99.9, but was asymptomatic
without signs or symptoms of infection. The patient was
hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
None
Discharge Medications:
1. Wheel chair
Dx:s/p fall, L pelvic fx, L scaphoid fx
Px:Good
Duration: 13 (thirteen) months
2. Acetaminophen 1000 mg PO Q8H:PRN pain
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*30 Tablet Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN moderate to
severe pain
do NOT drink alcohol or drive while taking this medication
RX *oxycodone 5 mg ___ tablet(s) by mouth every three (3) hours
Disp #*60 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*30 Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID
please hold for loose stool
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
6. Enoxaparin Sodium 40 mg SC Q24H Duration: 30 Days
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 40 mg/0.4 mL 40 mg Q24H Disp #*30 Syringe
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
-Left pelvic ring fracture
-Transscaphoid perilunate dislocation
-Left lunate dislocation
-Left nasal bone fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital after suffering a fall. You
were found to have a left pelvic ring fracture, injuries to your
left wrist including dislocation of the left scaphoid and
lunate, a mildly displaced left nasal bone fracture, and facial
lacerations. You were admitted to the Acute Care Surgery team
for further medical care.
You were urgently taken to the operating room with the Plastic
Surgery team and Orthopaedics team. You underwent surgery to
fix your left wrist fractures by Plastics and had a closed
reduction of the pelvic ring injury by Orthopaedics. You
tolerated these procedures well. You also had sutures placed to
your nasal lacerations by the Plastics team which will be
removed at your follow-up appointment. You have worked with
Physical and Occupational Therapy and you may be full weight
bearing on your right lower extremity and right arm, non-weight
bearing on the left lower extremity, and non-weight bearing on
the left upper extremity. You may wear a sling to your left arm
for comfort. You are being prescribed Lovenox injections for
one month to help prevent blood clots.
You are now medically cleared to be discharged home with a
wheelchair and Physical Therapy services. Please note the
following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
10654660-DS-18
| 10,654,660 | 21,250,572 |
DS
| 18 |
2145-09-11 00:00:00
|
2145-09-13 11:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Facial pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ y F with new oropharyngeal mass invading R pterygopalatine
fossa mass , admitted 2 weeks ago for the above complaint and
discharged on ___ after evaluation by ENT and
neurosurgery. She underwent outpatient biopsy of the mass which
showed Diffuse Large B cell Lymphoma. Germinal center type.
Awaiting Cytogenetics.
She presents to the ER today for persistent R facial pain as a
transfer from ___.In ER. She endorses decreased PO
intake due to the pain and a little bit of increased confusion
due to not eating. Denies CP, SOB, N/V/D, fevers, night sweats
or
other systemic symptoms.
Her vitals were 98.5 104 150/68 18 100% RA , normal cbc, lft and
bmp.
Admission to ___ for pain control and expedited surgery if
deemed
necessary
On floor, she is complaining of pain. She does not feel there is
a sharp electric jolt type of pain, it is constantly present and
nothing worsens it as it is already quite severe. She is unable
to open her jaw competely from the tumor involvement. She
mentions decreased hering in her R ear.
No fevers chills. No dysphagia. She does have trouble chewing
food due to limited ROM of jaw. No chest pain or SOB. No
abdominal pain. No dysuria or change in bowel habits
REVIEW OF SYSTEMS:
GENERAL: No fever, chills, night sweats, recent weight changes.
HEENT: No sores in the mouth,intolerance to liquids or solids,
sinus tenderness, rhinorrhea, or congestion.
CARDS: No chest pain, chest pressure, exertional symptoms, or
palpitations.
PULM: No cough, shortness of breath, hemoptysis, or wheezing.
GI: No nausea, vomiting, diarrhea, constipation or abdominal
pain. No recent change in bowel habits, hematochezia, or melena.
GU: No dysuria or change in bladder habits.
MSK: No arthritis, arthralgias, myalgias, or bone pain.
DERM: Denies rashes, itching, or skin breakdown.
NEURO: + headache and R facial pain. No weakness or numbness in
extremities.
Past Medical History:
- HTN
- HLD
- hypothyroidism
- osteoarthritis R knee s/p R TKR
- depression
- anxiety
- chronic venous insufficiency
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: NAD
VITAL SIGNS: ___
HEENT: MMM, no OP lesions, Protruberance noted on R side of
face. Skin on face normal with no redness. Limited ROM at jaw.
DEcreased hearing on R side.
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis;
SKIN: No rashes or skin breakdown
NEURO: Cranial nerves II-XII are within normal limits excluding
visual acuity which was not assessed, no nystagmus; strength is
___ of the proximal and distal upper and lower extremities
DISHCARGE PHYSICAL EXAM:
General: Lying in bed, intermittently holding right cheek when
speaking but appears comfortable overall.
VS: 98.8, 120s/60s, 80s, 20, 100% RA
HEENT: Jaw ROM limited. MMM, no OP lesions. ~5x5x3 cm mass
protruding from right side of face at eye level. Overlying skin
without erythema or warmth. Small interval decrease in size.
CV: RRR, normal S1/S2, no m/r/g
PULM: CTAB no adventitious sounds
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
EXT: Significant adiposity ___ bilat. Non-pitting edema
bilaterally. No skin changes.
SKIN: No rashes or skin breakdown
NEURO: Cranial nerves II-XII intact though sensation to light
touch different character over mass. EOMI intact, no nystagmus.
___ strength UE and ___.
Pertinent Results:
Admission labs:
___ 09:00PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 09:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-10 BILIRUBIN-SM UROBILNGN-4* PH-6.0 LEUK-TR
___ 09:00PM URINE RBC-1 WBC-6* BACTERIA-FEW YEAST-NONE
EPI-10 TRANS EPI-<1
___ 09:00PM URINE MUCOUS-FEW
___ 04:37PM GLUCOSE-92 UREA N-11 CREAT-0.8 SODIUM-137
POTASSIUM-3.3 CHLORIDE-96 TOTAL CO2-25 ANION GAP-19
___ 04:37PM estGFR-Using this
___ 04:37PM ALT(SGPT)-14 AST(SGOT)-19 LD(LDH)-255* ALK
PHOS-105 TOT BILI-0.7
___ 04:37PM ALBUMIN-3.7 CALCIUM-9.8 PHOSPHATE-3.1
MAGNESIUM-1.8 URIC ACID-6.5*
___ 04:37PM WBC-9.9 RBC-4.00 HGB-12.9 HCT-37.4 MCV-94
MCH-32.3* MCHC-34.5 RDW-15.4 RDWSD-52.6*
___ 04:37PM NEUTS-61.3 ___ MONOS-12.2 EOS-1.7
BASOS-0.7 IM ___ AbsNeut-6.06 AbsLymp-2.29 AbsMono-1.21*
AbsEos-0.17 AbsBaso-0.07
___ 04:37PM PLT COUNT-426*
___ 04:37PM ___ PTT-29.1 ___
Discharge labs:
___ 06:33AM BLOOD WBC-6.5# RBC-2.87* Hgb-8.9* Hct-28.1*
MCV-98 MCH-31.0 MCHC-31.7* RDW-14.6 RDWSD-52.7* Plt ___
___ 06:33AM BLOOD Neuts-89* Bands-1 Lymphs-6* Monos-0 Eos-2
Baso-1 Atyps-1* ___ Myelos-0 AbsNeut-5.85 AbsLymp-0.46*
AbsMono-0.00* AbsEos-0.13 AbsBaso-0.07
___ 06:33AM BLOOD ___ PTT-25.4 ___
___ 06:33AM BLOOD Glucose-80 UreaN-6 Creat-0.5 Na-138 K-3.7
Cl-106 HCO3-29 AnGap-7*
___ 06:33AM BLOOD ALT-17 AST-11 LD(LDH)-176 AlkPhos-76
TotBili-0.2
___ 06:33AM BLOOD Albumin-2.6* Calcium-7.8* Phos-2.3*
Mg-2.0
CT head w/wo contrast ___:
IMPRESSION:
1. No acute intracranial process. Specifically, no intracranial
hemorrhage or
large intracranial mass.
2. Partial visualization of 7 cm mass within right masticator
space causing
moderate oropharyngeal narrowing. Please refer to same-day CT
neck for
further evaluation.
CT neck w/wo contrast ___:
IMPRESSION:
1. No interval change since ___.
2. Unchanged ill-defined mass involving right masticator space
with adjacent
osseous erosion and encasement of the right carotid canal and
right cavernous
sinus. Patent vasculature.
3. Persistent moderate mass effect along oropharynx
TTE ___:
IMPRESSION: Low normal global left ventricular systolic
function. No pathologic valvular flow.
CT abd/pelvis ___:
IMPRESSION:
1. No evidence of intra-abdominal or intrapelvic
lymphadenopathy.
2. Please refer to the dedicated CT chest report of the same
date for the
intrathoracic findings.
CT chest ___:
IMPRESSION:
No pathologically enlarged thoracic lymph nodes. No suspicious
pulmonary
nodules or masses.
Brief Hospital Course:
___ with a hx of hypothyroidism, HLD, and large right pterygoid
space malignant tumor recently diagnosed as DLBCL on biopsy,
presenting with uncontrolled facial pain.
#DLBCL: Pt discharged from ___ on ___ for outpatient workup
of mass and had biopsy on ___, which revealed germinal center
type, Kic67 ___. She presented to ___ with pain and
was transferred to ___ for treatment. Imaging shows encasement
of right external carotid and IJ, as well as bony erosion all
features of a locally aggressive malignancy which is concerning
given the proximity to the brain. Imaging does not show cranial
penetration or parenchymal involvement. R-CHOP was given ___, ended ___, and received prednisone 100 mg on days ___.
TTE showing preserved EF and no valvulopathy, HIV/hep serologies
negative. Started on filgrastim 480 mcg daily x8 days
(___), which may be extended by her outpatient oncologist
who she will see on ___. Pain control with oxycontin 50
mg q12h and oxycodone 10 mg q3h prn pain, along with gabapentin
100 mg TID. Bowel reg with senna, Colace, and miralax daily.
#Hyponatremia: Resolved. Likely caused by high ADH from pain,
opioids, and medication. Treated with IVF and Lasix, now
resolved.
#UTI: >100 CFU E. coli on urine cx. Pt with urinary urgency
despite having foley in place consistent with her typical UTI
sxs. Foley was removed and she was treated with a five day
course of ceftriaxone (___)
#Depression: Paxil can affect platelet count and can also have
withdrawal symptoms if decreased quickly. Continued paroxetine
30 mg daily
#Insomnia: Continued trazodone qhs and added on Zyprexa 2.5mg
QHS to help with nighttime delirium
INACTIVE ISSUES
# HTN: Held HCTZ since her BP was well within goal and c/f
hypreuricemia ___ TLS
# Venous insufficiency: On 20mg po Lasix daily at home, which
was held here. She received occasional PO Lasix doses to
maintain euvolemia.
# Hypothyroidism: Continued Synthroid 50mg daily
TRANSITIONAL ISSUES:
- f/u with Dr. ___ Dr. ___ on ___
- continue Neuopogen 480 mcg SC daily until ___, to be
evaluated at her outpatient appointment
- pain management with oxycontin 50 mg q12h and oxycodone 10 mg
q3h prn pain, along with gabapentin 100 mg TID
- HCTZ and furosemide held while inpatient
CODE: Full (confirmed)
COMMUNICATION: Patient
EMERGENCY CONTACT HCP: Son, ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY
2. Levothyroxine Sodium 50 mcg PO DAILY
3. PARoxetine 30 mg PO DAILY
4. Simvastatin 40 mg PO QPM
5. TraZODone 100 mg PO QHS:PRN insomnia
6. Docusate Sodium 100 mg PO BID
7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
8. Betamethasone Valerate 0.1% Cream 1 Appl TP DAILY to affected
area
9. Celecoxib 200 mg oral DAILY
10. Hydrochlorothiazide 25 mg PO DAILY
11. Acetaminophen 1000 mg PO TID
12. Senna 8.6 mg PO BID
Discharge Medications:
1. Filgrastim 480 mcg SC Q24H Duration: 7 Days
RX *filgrastim [Neupogen] 480 mcg/0.8 mL 480 mcg SC q24h Disp
#*5 Syringe Refills:*0
2. Gabapentin 100 mg PO TID
RX *gabapentin 100 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
3. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
4. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
RX *oxycodone [OxyContin] 30 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*14 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth daily Disp #*30 Packet Refills:*0
6. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Moderate
7. Acetaminophen 1000 mg PO TID
8. Docusate Sodium 100 mg PO BID
9. Levothyroxine Sodium 50 mcg PO DAILY
10. PARoxetine 30 mg PO DAILY
11. Senna 8.6 mg PO BID
12. Simvastatin 40 mg PO QPM
13. TraZODone 100 mg PO QHS:PRN insomnia
14. HELD- Furosemide 20 mg PO DAILY This medication was held.
Do not restart Furosemide until instructed to by your outpatient
oncologist
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Diffuse large B-cell lymphoma, germinal center type
Secondary:
Urinary tract infection
Hyponatremia
Hypothyroidism
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for right facial pain. As you know,
the biopsy taken from your facial mass is consistent with
lymphoma, a type of cancer. You were started on chemotherapy
during your hospital stay and will be discharged home to
continue cancer treatment.
You have follow-up appointments scheduled with Dr. ___.
___ of whom you met while you were in the hospital.
It was a pleasure meeting you and we wish you the best,
The ___ Care Team
Followup Instructions:
___
|
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