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10654660-DS-19
| 10,654,660 | 23,041,028 |
DS
| 19 |
2145-09-27 00:00:00
|
2145-09-27 16:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
S/p fall, weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old woman with a recent diagnosis of
germinal center B cell lymphoma of the face/skull base started
on
R-CHOP ___ and discharged from the hospital yesterday
When Oncology fellow called pt to check on her this AM, she
replied that she fell down yesterday and has been on floor
since.
She requested fellow not call Police, but concerned for safety
of
patient, Police was notified and eMS was dispatched to patient's
house.
In ER her VSS, workup for fall including, CTH, CT C spine and
pelvic XR were wnl for her age and failed to reveal any
fractures.
On floor, she is complaining of R facial pain since she did not
taker her ___ Oxycontin last night. She describes the event of
fall as such, her husband who isn't very strong physically
(patient's description) was helping her transition into a chair
and she felt her knees give away all of a sudden and found
herself on the floor. Prior to falling down she denied having
palpitations, sense of warmth or feeling dizzy. She denies head
traums or LOC. She denies seizure like activity.
She mentions that she was essentially bed bound during her
prior
hospitalization and did not ambulate much.
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 exam:
General: NAD
VITAL SIGNS:99.1 PO 130 / 46 111 18 98 RA
HEENT: MMM, seen covering R side of face with hot pack.
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB, no crackles or wheezes.
ABD: BS+, soft, NTND,
LIMBS: lower extremity has 3+ non pitting edema till knees. She
has weak muscular strength diffusely. Strength in ___ in upper
extremities and ___ in bilateral lower extremities. Lower
extremities- some movement against gravity, can wiggle toes
easiy, Normal sensation in all 4 extremities.
Normal DTR in bilateral lower extremities.
SKIN: reddish irritated skin around vaginal area. No open
lesions.
NEURO: as above.
Discharge exam:
VS: Tm 98.9, 130-160/50-60s, 70-90's, ___, 96-100% RA
Weight: Not correct today, will recheck
General: Obese female, lying in bed, appears comfortable
Wt: None today, has been stable
HEENT: MMM, no OP lesions.
CV: RRR, normal S1/S2, no m/r/g
PULM: CTAB no adventitious sounds
ABD: BS+, soft, mild tenderness to palpation, no masses or
hepatosplenomegaly
EXT: Significant adiposity ___ bilat. 1+ non-pitting edema to
knees.
SKIN: No rashes or skin breakdown appreciated
NEURO: Cranial nerves II-XII intact though sensation to light
touch different character over mass. EOMI intact, no nystagmus.
Strength is 4+/5 in upper extremities and lower extremities
Pertinent Results:
Admission labs:
___ 07:01PM BLOOD WBC-0.6*# RBC-2.82* Hgb-8.7* Hct-27.4*
MCV-97 MCH-30.9 MCHC-31.8* RDW-13.7 RDWSD-49.1* Plt ___
___ 07:01PM BLOOD Neuts-12* Bands-0 Lymphs-63* Monos-6
Eos-16* Baso-3* ___ Myelos-0 AbsNeut-0.07*
AbsLymp-0.38* AbsMono-0.04* AbsEos-0.10 AbsBaso-0.02
___ 07:01PM BLOOD ___ PTT-25.6 ___
___ 07:01PM BLOOD Glucose-97 UreaN-10 Creat-0.7 Na-135
K-4.3 Cl-99 HCO3-27 AnGap-13
___ 07:01PM BLOOD ALT-16 AST-21 CK(CPK)-278* AlkPhos-77
TotBili-0.5
___ 07:15AM BLOOD Calcium-7.8* Phos-2.8 Mg-1.9
Discharge labs:
___ 07:05AM BLOOD WBC-40.2*# RBC-2.86* Hgb-9.1* Hct-27.9*
MCV-98 MCH-31.8 MCHC-32.6 RDW-16.7* RDWSD-59.1* Plt ___
___ 07:05AM BLOOD Neuts-97* Bands-1 Lymphs-1* Monos-1*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-39.40*
AbsLymp-0.40* AbsMono-0.40 AbsEos-0.00* AbsBaso-0.00*
___ 07:05AM BLOOD Plt Smr-HIGH Plt ___
___ 07:05AM BLOOD ___ PTT-23.9* ___
___ 07:05AM BLOOD Glucose-63* UreaN-12 Creat-0.5 Na-140
K-3.0* Cl-102 HCO3-25 AnGap-16
___ 07:05AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.9 UricAcd-3.4
___ 07:05AM BLOOD ALT-29 AST-35 LD(LDH)-208 AlkPhos-76
TotBili-0.4
Microbiology:
___ 11:09 am STOOL CONSISTENCY: FORMED Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
___ 2:09 pm 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.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
___ 4:35 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
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.
___ 6:01 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 5:08 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
Imaging:
CTA Chest ___:
No pulmonary embolus or acute aortic abnormality. No acute
intrathoracic
process.
Pelvis XR ___:
No acute fracture or dislocation.
CT Head without contrast ___
1. No new acute intracranial process. No hemorrhage.
2. Decrease in size of the right masticator space partially
visualized mass
with osseous erosion into the right aspect of the skullbase in
the region of
the carotid canal, as above.
3. Unchanged opacification of the right mastoid air cells.
4. Unchanged chronic findings including age-appropriate global
atrophy and
moderate changes of chronic white matter microangiopathy.
CT C-spine without contrast ___
1. No cervical spine fracture or traumatic malalignment.
2. Unchanged mild C4 on C5 anterolisthesis, stable since at
least ___ likely degenerative in nature.
3. Mild to moderate multilevel cervical spine degenerative
changes. No spinal
canal narrowing. Moderate neural foraminal narrowing, as above.
Brief Hospital Course:
___ with a hx of hypothyroidism, HLD, and large right pterygoid
space malignant tumor recently diagnosed as DLBCL on biopsy,
presented with uncontrolled facial pain and was initiated on
R-CHOP. She ws discharged in early ___, but syncopized at
home and returned to the hospital for deconditioning and volume
overload.
#Leukocytosis: New ___ likely from filgristim and steroids.
Expect to decrease rapidly as chemotherapy takes effect.
#Thrombocytosis: Developed a reactive thrombocytosis without
signs of infection. A UA and UCx were sent which were negative.
Trended down with initiation of chemotherapy without events.
#Weakness and deconditioning: Patient appeared very
deconditioned on admission with diffuse muscle weakness, likely
from volume overload and medication effect. Her conditioned
improved after working with physical therapy, weaning off
opioids, and diuresis.
#Opioid withdrawal:
#Diarrhea: Patient was weaned off all opioids on ___, and on
___ started having significant watery diarrhea, abdominal pain,
and generalized malaise with tachypnea. Cdiff, noro, and stool
culturse were negative. Likely etiology is opioid withdrawal.
She was given small amounts of maintenance fluids, and lasix was
held. Was given tincture of opium once and discharged with
Loperamide PRN. No diarrhea the day of discharge.
#Tachypnea: She triggered for tachypnea and dyspnea. An EKG and
cardiac enzymes were normal. CTA did not show PE. Her symptoms
self-resolved and did not recur. It was thought to be secondary
to opioid withdrawal.
___ edema: Has chronic venous insufficiency for which she is on
lasix 20 mg PO at home. She presented with significant edema
secondary to her home lasix being held after last admission. She
was diuresed with lasix 40 mg PO with significant volume and
weight loss and improvement of her edema. She was continued on
her home Lasix 20mg at discharge.
#Thrush, oral: Treated with clotrimazole QID ___, 7 days)
#DLBCL. Germinal center type. ___ ___. Pt discharged from
___ on ___ for outpatient workup of mass. Biopsy on ___.
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 but she will likely need
CNS ppx because of proximity to brain and vessels. She met with
the team, Drs. ___, who will follow as outpt, and
R-CHOP was initiated on ___. TTE showing preserved EF and no
valvulopathy, HIV/hep serologies negative. Her pain was
controlled with gabapentin 1000 qAM, 100 qPM and 300 qHS, after
consultation with the inpatient pain service. She was weaned off
opioids and Tylenol completely. She was then given her second
cycle of CHOP on ___ and Rituximab ___ with filgrastim also on
___.
#Depression: Continued paroxetine 30 mg daily.
#Indigestion: Started Maalox ___ mL TID prn indigestion
#Insomnia: Continued trazodone QHS prn and Zyprexa 2.5mg QHS to
help with nighttime delirium
INACTIVE ISSUES
# HTN. Held HCTZ since her BP well within goal and c/f
hypreuricemia ___ TLS
# Hypothyroidism: Continue Synthroid 50mg daily
CODE: Full confirmed
EMERGENCY CONTACT HCP: ___ ___
___ issues:
[] Patient needs to get Neulastin in 7 ___ clinic on ___
[] Patient should complete 5 day course of 100mg of prednisone
daily to be completed on ___
[] Patient is being discharged on home Lasix 20mg daily. Was
diuresed in hospital, however dose was not adjusted in the
setting of diarrhea from opiate withdrawal. Should consider
further adjustment as outpatient based on symptoms
[] Patient was discharged on loperamide PRN for loose stools.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
2. Filgrastim 480 mcg SC Q24H
3. Omeprazole 20 mg PO DAILY
4. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Moderate
5. Gabapentin 100 mg PO TID
6. TraZODone 100 mg PO QHS:PRN insomnia
7. Simvastatin 40 mg PO QPM
8. Senna 8.6 mg PO BID
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. PARoxetine 30 mg PO DAILY
11. Levothyroxine Sodium 50 mcg PO DAILY
12. Docusate Sodium 100 mg PO BID
13. Acetaminophen 1000 mg PO TID
14. Furosemide 20 mg PO DAILY
Discharge Medications:
1. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO TID:PRN
indigestion, gas pain
2. LOPERamide 2 mg PO Q4H:PRN Loose stools
3. PredniSONE 100 mg PO ONCE Duration: 1 Dose
One dose for ___. Gabapentin 100 mg PO QAM
5. Gabapentin 100 mg PO DAILY
6. Gabapentin 300 mg PO QHS
7. Acetaminophen 1000 mg PO TID
8. Docusate Sodium 100 mg PO BID
9. Furosemide 20 mg PO DAILY
10. Levothyroxine Sodium 50 mcg PO DAILY
11. Omeprazole 20 mg PO DAILY
12. PARoxetine 30 mg PO DAILY
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Senna 8.6 mg PO BID
15. Simvastatin 40 mg PO QPM
16. TraZODone 100 mg PO QHS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary diagnosis:
Thrombocytosis
Diffuse large B-cell lymphoma
Volume overload
Opioid withdrawal
Secondary diagnosis:
Thrush
Indigestion
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 after a fall at home and
deconditioning. You were found to have excess fluid in your
body, so we gave you medications to remove the fluid. We also
weaned you off opioid medications, as they can make you feel
drowsy. You worked with our physical therapists and your
condition improved enough to go to a rehab facility. You were
also given you next round of chemotherapy, and will return to
clinic tomorrow for one final injection.
It was a pleasure to take care of you. We wish you all the best.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10654864-DS-14
| 10,654,864 | 24,008,571 |
DS
| 14 |
2119-08-28 00:00:00
|
2119-08-28 20:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
quinapril / amlodipine / sertraline / atorvastatin
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female with a history of CHF and EF of 30%,
hypertension, hyperlipidemia, diabetes, GERD, COPD, paroxysmal
A.
fib with AICD placement presents as transfer for flash pulm
edema.
The patient currently lives at ___. Per discussion with this facility, the
patient
developed a cough over the weekend, though was not febrile, and
had no other symptoms. Then overnight on ___, the patient
became
acutely short of breath, at which time she was transferred to
___ ER in ___. She was noted to be hypoxic
with sats in low ___. Hypertensive with bp 240/130. Put on Bipap
and Nitro drip for likely flash pulmonary edema. CXR showed
bilateral pulm edema and she was given Lasix and has diuresed
800cc. Lactate was found to be 3.5, and she was treated
empirically with Cefepime, Gent and Vanc.
- Exam notable for:
Irregular rhythm
Crackles to mid to lower lobes bilaterally
Soft nontender nondistended
Mild bilateral lower extremity edema
2+ pulses bilaterally
- Labs notable for:
Lactate:2.0
143 / 103 / 33
--------------< 151
5.2 / 26 / 1.2
Trop-T: <0.01
proBNP: 8748
___: 10.4 PTT: 25.1 INR: 1.0
12.4 > 12.0 / 37.2 < 233
- Imaging notable for:
IMPRESSION: Mild to moderate cardiomegaly, congestion with mild
interstitial pulmonary edema, small left pleural effusion.
- Consults: None
- Vitals prior to transfer:
T: 97.8 HR: 61 BP: 155/63 RR: 19 O2: 97% RA
Past Medical History:
HFrEF EF 30%
HTN
HLD
DMII
GERD
Paroxysmal AF
Social History:
___
Family History:
Pt is unsure on details of family history, unable to reach
family member. Will call again in AM to clarify.
Physical Exam:
ADMISSION EXAM:
VS: ___ 1623 BP: 158/75 L Lying HR: 69 RR: 16 O2 sat: 92%
O2
delivery: Ra FSBG: 211
GENERAL: Anxious appearing, lying in bed comfortably.
HEENT: PERRLA. Sclera anicteric.
CARDIAC: Regular rate and rhythm, fixed split S2. No murmurs, or
rubs.
LUNG: Faint crackles heard bilaterally at bases. otherwise clear
in all lung fields.
ABD: Normal bowel sounds, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly
EXT: Warm, well perfused, 1+ edema to mid tibia bilaterally
PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses
NEURO: Anxious. Alert and oriented x 3 once pt was more calm
after transfer to floor.
DISCHARGE EXAM:
Vitals: ___ 2322 Temp: 99.0 PO BP: 147/70 HR: 66 RR: 20 O2
sat: 90% O2 delivery: Ra
General: Lying comfortably in bed, no acute distress
Neck: JVP at 8cm
Heart: RRR, no murmurs appreciated
Lungs: Faint end expiratory wheezes, no crackles
Abdomen: soft, NTND, no organomegaly
Extremities: no peripheral edema
Pertinent Results:
ADMISSION LABS
___ 01:43PM BLOOD WBC-12.4* RBC-3.80* Hgb-12.0 Hct-37.2
MCV-98 MCH-31.6 MCHC-32.3 RDW-12.2 RDWSD-43.7 Plt ___
___ 01:43PM BLOOD ___ PTT-25.1 ___
___ 01:43PM BLOOD Glucose-151* UreaN-33* Creat-1.2* Na-143
K-5.2 Cl-103 HCO3-26 AnGap-14
___ 01:43PM BLOOD cTropnT-<0.01 proBNP-___*
___ 01:43PM BLOOD ALT-21 AST-37 AlkPhos-87 TotBili-0.4
___ 04:30AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.0
DISCHARGE LABS
___ 04:40AM BLOOD WBC-8.0 RBC-3.27* Hgb-10.1* Hct-32.0*
MCV-98 MCH-30.9 MCHC-31.6* RDW-12.0 RDWSD-43.5 Plt ___
___ 04:30AM BLOOD Glucose-141* UreaN-29* Creat-1.1 Na-141
K-3.5 Cl-98 HCO3-27 AnGap-16
___ 04:30AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.0
CXR PA & LAT
Mild to moderate cardiomegaly, congestion with mild interstitial
pulmonary
edema, small left pleural effusion.
TRANSTHORACIC ECHO
The left atrial volume index is mildly increased. There is no
evidence for an atrial septal defect by 2D/color Doppler. There
is normal left ventricular wall thickness with a normal cavity
size. There is mildmoderate
left ventricular regional systolic dysfunction with severe
hypokinesis of the inferior and inferolateral walls (see
schematic) and preserved/normal contractility of the remaining
segments. Quantitative biplane left ventricular ejection
fraction is 44 %. Left ventricular cardiac index is depressed
(less than 2.0 L/min/m2). There is no resting left ventricular
outflow tract gradient. Normal right ventricular cavity size
with normal free wall motion. There is abnormal septal motion
c/w conduction
abnormality/paced rhythm. The aortic sinus diameter is normal
for gender with normal ascending aorta diameter for gender. The
aortic arch diameter is normal. The aortic valve leaflets (3)
are mildly thickened. There is no aortic valve stenosis. There
is no aortic regurgitation. The mitral leaflets appear
structurally normal with no mitral valve prolapse. There is
trivial mitral regurgitation. The tricuspid valve leaflets
appear structurally normal. There is mild to moderate [___]
tricuspid regurgitation. There is moderate pulmonary artery
systolic hypertension. There is a trivial pericardial effusion.
IMPRESSION: Adequate image quality. Mild regional left
ventricular systolic dysfunction most consistent with single
vessel coronary artery disease (PDA distribution). Moderate
pulmonary artery
systolic hypertension.
MICRO
___ 1:17 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
The patient is a ___ with chronic systolic CHF (EF 30%),
hypertension, hyperlipidemia, diabetes, GERD, COPD, paroxysmal
A. fib with PPM who was admitted with respiratory distress. Her
chest X-ray showed pulmonary edema, and she was found to be
hypertensive with BPs in the 200s/100s. Her symptoms and
oxygenation improved with positive pressure ventilation,
diuresis and afterload reduction.
#Acute on chronic systolic CHF
#Flash pulmonary edema: Acute on chronic heart failure with
reduced ejection fraction likely secondary to severe
hypertension. As the outside hospital ED, the patient was placed
on Bipap and received a nitro gtt. She was diuresed with 40mg IV
lasix, and her symptoms improved. She was transferred to the
___ ED, and upon arrival to the floor she was greatly improved
on an room air. She had a repeat TTE which showed an EF of 44%
and posterior wall hypokinesis. She was restarted on her home
lasix 40mg PO daily. She remained hypertensive, and her imdur
and losartan were both increased. On ___, she had an episode
of hypotension which was likely secondary to her increased dose
of Imdur. Ultimately she was discharged with the
antihypertensive regimen of losartan 50 (from 25) qhs, Imdur 30
daily, and Lasix 40 daily. Her Metoprolol was consolidated to
100mg PO succinate daily.
#Leukocytosis: The patient had a mild leukocytosis on admission
without any localizing infectious symptoms, and with a negative
CXR and UA. She was not started on antibiotics, and her
leukocytosis improved. On discharge, WBC normalized to 8.0.
#HTN: Unclear cause of acute worsening of HTN. known to have
severe anxiety which can be contributing. Most likely some
element of shortness of breath which lead to increased anxiety
and worsening HTN resulting in acute afterload increase and
resultant worsening of flash edema. Afterload regimen discussed
above.
#Paroxysmal AF: The patient was in atrial fibrillation on
presentation. For rate control, she her Metoprolol was
consolidated to succinate 100mg PO daily as above. She was also
continued on Amiodarone 200mg PO daily. She is not
anticoagulated despite a CHADS2Vasc of 6. This was discussed
with her primary cardiologist who deferred decision to PCP. We
asked PCP but unfortunately did not get response. We recommend
continued discussions as outpatient moving forward. Please note
that her Aspirin dose was decreased to 81 mg (from 325) as she
has no indication for full dose aspirin.
#HLD: Continued home simvastatin 40 mg PO/NG QPM
#DMII: U-100 (insulin degludec) 10 units subcutaneous QAM at
home. HISS while in house.
#GERD: Continue ranitidine
Transitional Issues:
[]Aspirin decreased to 81 mg daily; Losartan doubled to 50
daily; Metoprolol consolidated to 100 mg succinate daily
[]Patient became hypotensive when Imdur was doubled to 60;
discharged on home dose of 30 daily
[]Consider continuing anticoagulation discussions with patient
and family based on risk and benefits (CHADS2VASC is 6)
[]Discharge weight: 126 lbs
#CODE: DNR/DNI (confirmed)
#CONTACT: ___ (stepson) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 50 mg PO BID
2. Simvastatin 40 mg PO QPM
3. Furosemide 40 mg PO DAILY
4. Potassium Chloride 20 mEq PO DAILY
5. Ferrous Sulfate 325 mg PO BID
6. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
7. Aspirin 325 mg PO DAILY
8. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First Line
9. Amiodarone 200 mg PO DAILY
10. ALPRAZolam 0.125 mg PO BID
11. Multivitamins 1 TAB PO DAILY
12. GuaiFENesin ER 600 mg PO Q12H:PRN cough
13. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
14. Acidophilus (Lactobacillus acidophilus) oral QHS
15. Losartan Potassium 25 mg PO QHS
16. DiphenhydrAMINE ___ mg PO DAILY:PRN allergies
17. Ranitidine 300 mg PO QAM
18. Tresiba FlexTouch U-100 (insulin degludec) 10 units
subcutaneous QAM
19. nystatin 100,000 unit/gram topical BID
20. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
21. Albuterol Inhaler 2 PUFF IH TID:PRN sob
22. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
23. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Discharge Medications:
1. Metoprolol Succinate XL 100 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Losartan Potassium 50 mg PO QHS
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
5. Acidophilus (Lactobacillus acidophilus) oral QHS
6. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
7. Albuterol Inhaler 2 PUFF IH TID:PRN sob
8. ALPRAZolam 0.125 mg PO BID
9. Amiodarone 200 mg PO DAILY
10. DiphenhydrAMINE ___ mg PO DAILY:PRN allergies
11. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First
Line
12. Ferrous Sulfate 325 mg PO BID
13. Furosemide 40 mg PO DAILY
14. GuaiFENesin ER 600 mg PO Q12H:PRN cough
15. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
17. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
18. nystatin 100,000 unit/gram topical BID
19. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
20. Potassium Chloride 20 mEq PO DAILY
Hold for K >
21. Ranitidine 300 mg PO QAM
22. Simvastatin 40 mg PO QPM
23. Tresiba FlexTouch U-100 (insulin degludec) 10 units
subcutaneous QAM
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Acute on chronic heart failure with reduced ejection fraction
Secondary Diagnosis:
- Hypertension
- Anxiety
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because:
- You became very short of breath at your assisted living
facility
While you were in the hospital:
- You received oxygen and a breathing mask to help you breath
- It was found that there was fluid backed up from your heart
into your lungs
- You were given a medication to help you urinate out this extra
fluid
- Your blood pressure was very high
- You were given medications to help lower your blood pressure
- Your breathing improved and you were able to be discharged
from the hospital
When you leave:
- Please take all of your medications as prescribed
- Please attend all of your follow up appointments as scheduled
- Please weigh yourself every day, call your doctor if you
notice that your weight increases by more than three pounds
It was a pleasure to care for you during your hospitalization.
Your ___ team
Followup Instructions:
___
|
10654909-DS-11
| 10,654,909 | 29,859,083 |
DS
| 11 |
2155-04-19 00:00:00
|
2155-04-19 12:24:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Compazine /
Keflex / iodine / Betadine
Attending: ___.
Chief Complaint:
Nausea, vomiting and abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w hx imperforate anus s/p anoplasty (infancy),
congenital malrotation s/p Ladd's procedure (___), VHR w mesh
(___), ex lap, LOA/SBR (___) and most recently ex lap, LOA w
SBR for chronic obstructive symptoms ___ now
returns w nausea, vomiting and epigastric pain. On recent
admission, patient had postop course notable for small wound
infection managed w staple removal and course of levofloxacin.
Last seen ___ at which time she was doing well. Now states that
she was doing well at home off all narcotics until this evening
when she noted sudden onset of epigastric pain. Described as
sharp, crampy and ___ severity. States that pain is similar to
a prior obstruction episode. Did have several episodes of
bilious
emesis. As pain persisted, patient presented to ED for
evaluation. Surgery consult obtained.
On initial surgery evaluation, patient crying out in pain and
states that she is too uncomfortable to give history. After a
few
minutes, patient states that pain subsided and relays history as
above. Reports that she had been doing well at home. Tolerating
diet. Passing flatus though did state she has been constipated w
last BM three days prior to presentation. Does describe last BM
as watery. This evening in ED passed small hard stool though
without relief of symptoms. Denies other associated symptoms
including fever, chills, chest pain, shortness of breath, sick
contacts, new foods, dysurea, blood per rectum.
Past Medical History:
PMH: congenital malrotation c/b SBOs, pseudotumor cerebri
(currently off medication), peptic ulcer disease, pancreas
divisum, hx imperforate anus, congenital C1-3 cervical fusion
PSH: anoplasty (___, infancy) open cholecystectomy ___,
___, ex lap/lysis of adhesions/Ladd's procedure ___
___, ventral hernia repair w mesh ___, ___, ex
lap/lysis of adhesions/small bowel resection ___ ___,
C-section x 2 (___), Ex lap, LOA, SB resection
(___)
Social History:
___
Family History:
noncontributory
Physical Exam:
VS: Tmax 98.9 Tc 98.4 HR 66 BP 92/50 RR 16 SaO2 99%RA
Gen: AOx3, NAD
Neuro: CN ___ grossly intact
CV: RRR no MRG
Resp: CTAB no WRC
Abd: Soft, NT, ND, dressing in place over healing 3 cm
___ surgical wound with dry gauze packing in place,
scars from multiple previous abdominal procedures apparent
Ext: 2+ pulses, no edema
Pertinent Results:
Imaging:
CT abd/pelvis w/o contrast ___
1. Postoperative changes status post recent partial small bowel
resection and end-to-end anastomosis, without evidence of small
bowel obstruction or extraluminal oral contrast to suggest the
presence of a leak.
2. Unchanged appearance of malrotation.
3. Small volume ascites.
4. Fibroid uterus.
CXR ___
Nasogastric tube terminating within the stomach. Clear lungs,
bilaterally.
Pathology: None
Micro: None
Labs:
___ 03:34AM BLOOD WBC-10.9* RBC-4.71 Hgb-10.7* Hct-34.3
MCV-73* MCH-22.7* MCHC-31.2* RDW-17.2* RDWSD-45.0 Plt ___
___ 03:34AM BLOOD Glucose-104* UreaN-10 Creat-0.5 Na-136
K-4.3 Cl-99 HCO3-25 AnGap-16
___:30PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 02:30PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE
Epi-22
Brief Hospital Course:
Mrs. ___ presented to the emergency department on the morning
of ___ c/o nausea, emesis and severe abdominal pain. Due to
her history of multiple abdominal surgeries most recently
___ ___s prior small bowel obstructions an NG tube was
placed for decompression and she was made NPO and started on IV
fluids for hydration. A CT was then performed which did not
demonstrate an SBO. She was transferred to the surgical floor
for continued observation where her abdominal exam was observed
to be much improved. She had considerable discomfort from the
NGT, including being unable to speak without becoming nauseous.
On HD 2 her NGT was observed to have had scant output since her
admission from the ED and it was removed. Following removal she
was much improved clinically, and readily ate a clear liquid
diet for breakfast. She continued to do well throughout the
morning and had no further nausea or pain. With goals of care
met she was discharged to home with directions to follow up with
Dr. ___ in two weeks
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 40 mg PO BID
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Ondansetron 4 mg PO Q8H:PRN nausea
4. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Fluticasone Propionate NASAL 2 SPRY NU DAILY
2. Omeprazole 40 mg PO BID
3. Ondansetron 4 mg PO Q8H:PRN nausea
4. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Transient small bowel obstruction
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 here at ___
___. You were admitted to our hospital for
nausea, vomiting and abdominal pain concerning for a small bowel
obstruction. You have now recovered and are ready to be
discharged to home. Please follow the recommendations below to
ensure a speedy and uneventful recovery.
ACTIVITY:
- you have no additional restrictions on your activity other
than thos in place from your surgery in ___
HOW YOU MAY FEEL:
- You could have a poor appetite for a while. Food may seem
unappealing. This is normal and should go away in a short time.
If it does not, tell your surgeon.
YOUR BOWELS:
- If you go 48 hours without a bowel movement, or have pain
moving your bowels, call your surgeon.
MEDICATIONS:
- Take all the medicines you were on before the operation just
as you did before, unless you have been told differently.
- If you have any questions about what medicine to take or not
to take, please call your surgeon.
Followup Instructions:
___
|
10655084-DS-18
| 10,655,084 | 28,969,088 |
DS
| 18 |
2150-07-16 00:00:00
|
2150-07-16 15:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
slurred speech and gait instability
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: The pt is a ___ y/o ambidextrous man who woke up with
slurred speech this morning, and feeling off balance since
yesterday. He has peripheral neuropathy and thus has some
trouble with balance, but it was worse yesterday ( he woke up
with it), did not notice a specific side to which he was
falling. He states he was catching him self on things. No
vertigo, nausea or vomiting. With regards to his speech he woke
up with it, he also states that he has to think about the answer
to questions. He himself did not realize that his speech was
slurred. No weakness, headache, changes to vision, no trouble
with swallowing water. He went to ___ first, was
given a full dose aspirin and then sent here.
Past Medical History:
Stroke ___
DM dx at
Ruled out MS for many brain lesions
HTN
asthma
pineal cyst s/p resection
peripheral neuropathy
Social History:
___
Family History:
Mother with DM.
Physical Exam:
Admission PE
Physical Exam:
Vitals: T98.4 66 153/74 20 98% 2L nasal
General: Awake, cooperative, NAD. obese
HEENT: NC/AT, MMM.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND.
Extremities: High arched.
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. There were no paraphasic errors. Pt. was able
to name ___ card items and read ___ card sentences. Speech
was dysarthric (lingual sounds). Able to follow both midline and
appendicular commands. Pt. was able to register 3 objects and
recall ___ at 5 minutes. Current knowledge demonstrated with
knowledge of president's name. There was no evidence of apraxia
or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam limited.
III, IV, VI: EOMI without nystagmus. corrective saccades to the
left (hypo metric).
V: Facial sensation intact to light touch.
VII: right NL 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.
Slow ___ hz vertical ossilation of the left outstretched arm.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5
-Sensory: decreased LT, cold sensation. Pinprick decreased to
the
elbows b/l and to the knees b/l. Decreased proprioception.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 0 0
R 2 2 2 0 0
Plantar response was mute bilaterally.
-Coordination: rebounding on the left. Hypo metric arm movements
on the left FNF.
-Gait: Limited in the ED, wide based, did not try tandem.
- Some retropulsion on sitting bed with arms crossed and eyes
closed.
Discharge PE:
mildly slurred speech. otherwise, the rest of his PE is
essentially WNL
Pertinent Results:
Labs
___ GLUCOSE-111* UREA N-21* CREAT-0.9 SODIUM-138
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-25 ANION GAP-15
___ BLOOD WBC-10.7 RBC-4.85 Hgb-14.4 Hct-42.6 MCV-88
MCH-29.7 MCHC-33.9 RDW-12.5 Plt ___
___ BLOOD %HbA1c-6.9* eAG-151*
___ BLOOD Triglyc-212* HDL-55 CHOL/HD-4.7 LDLcalc-163*
Imaging
MRI/A ___: IMPRESSION:
1. Subacute infarct of the left pons.
2. Bilateral periventricular and subcortical T2 FLAIR
hyperintensities likely related to microangiophatic chronic
ischemic changes.
3. Focal narrowing of the left A1 segment likely related to
atherosclerotic disease, otherwise unremarkable MRA of the Head
and Neck
Echo ___: The left atrium is mildly dilated. No thrombus/mass
is seen in the body of the left atrium. No atrial septal defect
or patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. The estimated right atrial pressure is
___ mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. No
masses or vegetations are seen on the aortic valve. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
Brief Hospital Course:
The patient was admitted to the Neurology Service at ___ on
___ for workup of slurred speech and gait instability. On
imaging, he was found to have a subacute left pons infarct but
no significant vascular stenosis.
.
During his stay, blood pressure medications were held to allow
autoregulation. You were given IV fluids. Labwork showed
hemoglobin A1c 6.7, HDL 55, LDL 163, and triglycerides 212.
.
An echocardiogram was also completed. This study showed no
thrombus or bloot clot, and did not show any acute defects.
.
The patient was started on clopidogrel and aspirin was d/c'ed.
He was also started on simvastatin 40mg daily. Otherwise, he
will continue taking other home medications.
Medications on Admission:
Metformin 750mg BID
ASA 81
MVI
requip .5 mg bid
gabapentin 100 BID
klonopin 1mg QHS
lisinopril 5mg daily
Discharge Medications:
1. metformin 500 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. ropinirole 0.25 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
4. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
5. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)) as needed for insomnia.
6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
9. Outpatient Physical Therapy
Discharge Disposition:
Home
Discharge Diagnosis:
left pontine infarction (stroke)
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 Neurology Service at ___ on ___
for workup of your slurred speech and gait instability. On
imaging, you were found to have a stroke in your brainstem.
.
During your stay, your blood pressure medication, lisinopril,
was held to allow your pressure to autoregulate. You should
restart this med on discharge. You were given IV fluids. Labwork
showed hemoglobin A1c (longterm measure of blood sugar) elevated
at 6.7, HDL (good cholesterol) 55, LDL (bad cholesterol) 163
(elevated), and triglycerides 212(elevated).
.
An echocardiogram was also completed. This study showed no
thrombus or bloot clot, and did not show any acute defects.
.
You were on aspirin at home, but were switched to clopidogrel
for continued antiplatelet management. You were also started on
simvastatin 40mg daily to help lower your cholesterol.
Otherwise, you should continue taking your other home
medications.
.
You should attend the followup appointments listed below. Thank
you for allowing us at ___ to participate in your care.
Followup Instructions:
___
|
10655111-DS-14
| 10,655,111 | 20,184,502 |
DS
| 14 |
2151-08-28 00:00:00
|
2151-08-29 15:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Clogged G-tube
Major Surgical or Invasive Procedure:
G-tube replacement
History of Present Illness:
Ms. ___ is a ___ female with a history of
schizophrenia and recent prolonged hospitalization after ___ now
with G-tube for recurrent aspiration and recent G-tube
replacement who is presenting with clogged G-tube. She has been
at rehab since her discharge from the hospital last month and
tolerating tube feeds well, though she was seen at ___ ED on
___ for a clogged G-tube. The G-tube was replaced by ___.
She denies abdominal pain or nausea/vomiting. She states that
she was cleared last ___ for clear liquids by mouth, but she
previously had not been allowed to eat or drink by mouth due to
recurrent aspiration.
On ROS, she reports right shoulder pain and decreased range of
motion. She also reports bilateral feet pain, which started one
week ago after she started walking.
In the ED, initial VS were: 96.8 ___ 16 98% RA. Bedside
unclogging was attempted and unsucessful. ___ was consulted, who
also attempted unclogging. They recommended upsize and exchange
of tube tomorrow.
ROS:
No fevers, chills. No cough, no shortness of breath, no dyspnea
on exertion. No chest pain or palpitations. No nausea or
vomiting. No diarrhea or constipation. No dysuria or hematuria.
+Weakness (right arm, bilateral legs, but improving). No
numbness.
Past Medical History:
Psychotic illness, schizophrenia (per sister) or depression with
command auditory hallucinations to self harm, suicidal ideation,
recent psychiatric hospitalization, hypothyroidism, type II
diabetes, recent prolonged hospitalization after ___ (sustained
T9 VB fracture, left diaphragmatic injury, right talar and left
ulnar fracture).
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION EXAM:
================
VS: T 97.7, HR 108, BP 109/74, RR 19, SaO2 99% RA
GEN: Alert, lying in bed, no acute distress
HEENT: MMM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: Clear to auscultation bilaterally
COR: RRR, normal S1 and S2, no murmurs
ABD: +BS, soft, non-tender, non-distended, G-tube site is c/d/i
EXTREM: Warm, well-perfused, no edema
MSK: Limited ROM of right shoulder ___ pain, limited ROM of
bilateral ankles.
NEURO: CN III-XII grossly intact, ___ strength R hip flexor,
4+/5 strength L hip flexor. Alert and oriented, slowed, able to
state days of the week backwards.
DISCHARGE EXAM:
================
VS: ___ ___ 103/57 83 20 98RA fingerstick 121
GEN: Sleepy, lying in bed, comfortable
HEENT: MMM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: Clear to auscultation bilaterally
COR: RRR, normal S1 and S2, no murmurs
ABD: +BS, soft, non-tender, non-distended, G-tube site is c/d/i
EXTREM: Warm, well-perfused, no edema
MSK: Limited ROM of right shoulder ___ pain, limited ROM of
bilateral ankles.
NEURO: CN III-XII grossly intact, ___ strength R hip flexor,
4+/5 strength L hip flexor. Alert and oriented, slowed, able to
state days of the week backwards.
Pertinent Results:
ADMISSION LABS:
================
___ 12:30AM BLOOD WBC-10.6* RBC-4.25 Hgb-13.0 Hct-40.2
MCV-95 MCH-30.6 MCHC-32.3 RDW-15.9* RDWSD-54.1* Plt ___
___ 12:30AM BLOOD Neuts-45.3 ___ Monos-8.0 Eos-0.6*
Baso-0.3 Im ___ AbsNeut-4.79 AbsLymp-4.75* AbsMono-0.85*
AbsEos-0.06 AbsBaso-0.03
___ 12:30AM BLOOD ___ PTT-48.0* ___
___ 12:30AM BLOOD Glucose-134* UreaN-10 Creat-0.5 Na-141
K-4.4 Cl-100 HCO3-24 AnGap-21*
DISCHARGE LABS:
================
___ 08:10AM BLOOD WBC-6.4 RBC-3.70* Hgb-11.1* Hct-35.8
MCV-97 MCH-30.0 MCHC-31.0* RDW-15.6* RDWSD-54.6* Plt ___
___ 08:10AM BLOOD ___ PTT-35.9 ___
___ 08:10AM BLOOD Glucose-117* UreaN-7 Creat-0.4 Na-140
K-3.8 Cl-102 HCO3-26 AnGap-16
___ 08:10AM BLOOD Calcium-9.3 Phos-4.3 Mg-1.8
IMAGING:
=========
Shoulder XR (___):
No fracture, dislocation, or degenerative change is detected and
no suspicious lytic or sclerotic lesion is identified. No
periarticular calcification or radio-opaque foreign body. The
visualized ipsilateral lung is clear. Equivocal slight pleural
thickening laterally in the right hemithorax although the
partially visualized ribs appear intact.
Brief Hospital Course:
Ms. ___ is a ___ female with a history of
schizophrenia and recent prolonged hospitalization after motor
vehicle accident with recurrent aspiration s/p G-tube with
recent G-tube replacement who presented with clogged G-tube.
# Clogged G-tube: Bedside unclogging was attempted but was
unsucuessful. She underwent a sucessful ___ G-tube
replacement/upsizing. TFs were restarted.
# Recurrent aspiration: Per patient and confirmed with rehab
facility, she was cleared for sips of thin liquids with nursing
supervision. She continues to require tube feeds for nutrition.
Transitional Issues
[ ] SBPs were in 100s; consider discontinuing her clonidine
patch (was not given during hospitalization because ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H
2. Levothyroxine Sodium 50 mcg PO DAILY
3. OxycoDONE Liquid 5 mg PO Q4H:PRN pain
4. Senna 8.6 mg PO BID:PRN Constipation
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Wheezing
6. Fluphenazine 2 mg PO Q4H:PRN aggitation
7. Fluphenazine 5 mg PO QAM
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Simvastatin 20 mg PO QPM
10. Valproic Acid ___ mg PO Q12H
11. Venlafaxine 75 mg PO BID
12. Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation
13. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QMON
14. Fluphenazine 10 mg PO QHS
15. Bisacodyl ___AILY:PRN constipation
16. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using REG Insulin
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Wheezing
3. Bisacodyl ___AILY:PRN constipation
4. Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation
5. Fluphenazine 2 mg PO Q4H:PRN aggitation
6. Fluphenazine 5 mg PO QAM
7. Insulin SC
Sliding Scale
Fingerstick q6h
Insulin SC Sliding Scale using REG Insulin
8. Levothyroxine Sodium 50 mcg PO DAILY
9. OxycoDONE Liquid 5 mg PO Q4H:PRN pain
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Senna 8.6 mg PO BID:PRN Constipation
12. Simvastatin 20 mg PO QPM
13. Venlafaxine 75 mg PO BID
14. Fluphenazine 10 mg PO QHS
15. Valproic Acid ___ mg PO Q12H
16. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QMON
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
===================
PRIMARY DIAGNOSIS
===================
Clogged G-tube
===================
SECONDARY DIAGNOSES
===================
Schizophrenia
Recurrent aspiration
Type 2 diabetes
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure participating in your care at the ___
___. You were admitted because your G-tube
was clogged. You were seen by our interventional radiologists
who exchanged your G-tube successfully. Your tube feeds were
restarted.
You will return to your rehab facility, ___. in ___
for ongoing rehabilitation.
We wish you all the best!
Your ___ Team
Followup Instructions:
___
|
10655111-DS-15
| 10,655,111 | 28,166,788 |
DS
| 15 |
2151-11-05 00:00:00
|
2151-11-05 13:45:00
|
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:
___:
1. Exploratory laparotomy.
2. Colotomy with removal foreign body.
___: Successful US-guided drainage of the left lower
quadrant collection with 100 cc of serosanguineous fluid
removed.
History of Present Illness:
___ hx of DM, schizophrenia s/p MVC in ___ resulting in
bilateral rib fractures, T8 vertebral body fracture s/p T6-10
fusion (___), and diaphragmatic injury requiring repair of
thoracoabdominal truncal hernia, complex repair of left
diaphragmatic laceration, and implantation of mesh overlay in
left flank hernia (___), presenting from rehab with left lower
abdominal bloating/pain and worsening nonbloody diarrhea
starting last week. She notes 6 bouts of diarrhea since
yesterday morning. She was in her usual state of health until
last week when she was transitioned from tube feeds (via g-tube)
to oral diet. Since then, she has had worsening nausea (no
vomiting)
after eating and persistent lower abdominal pain. Given these
symptoms her PO intake has been poor. She denies fevers, chills
or chest pain.
Past Medical History:
Psychotic illness, schizophrenia (per sister) or depression with
command auditory hallucinations to self harm, suicidal ideation,
recent psychiatric hospitalization, hypothyroidism, type II
diabetes, recent prolonged hospitalization after ___ (sustained
T9 VB fracture, left diaphragmatic injury, right talar and left
ulnar fracture).
Social History:
___
Family History:
Unclear, sister lives in a group home.
Physical Exam:
Admission Physical Exam:
Vitals: 98.4 99 123/75 20 100%RA
GEN: AOx3, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, S1/S2
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, obese, abdominal pain on palpation to lower abdomen,
no rebound or guarding, well healed left thoracoabdominal
incision with underlying firm seroma, no active draining
DRE: normal tone, no gross or occult blood, guaiac negative
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS: T: 98.7, BP: 123/73, HR: 96, RR: 18, O2: 98% RA Blood Sugar:
151
General: A+Ox3, NAD
HEENT: normocephalic, atraumatic
CV: RRR
PULM: CTA b/l
ABD: soft, non-distended, non-tender. Midline abdominal incision
with steristrips, skin well approximated and no erythema or
induration. G-tube with dressing intact.
Extremities: no edema
Pertinent Results:
___ 11:31PM HCT-30.0*
___ 06:20PM HCT-34.8
___ 07:41AM SODIUM-138 POTASSIUM-4.3 CHLORIDE-105
___ 07:41AM MAGNESIUM-1.6
___ 07:41AM HCT-42.6
___ 04:13AM ___
___ 02:30AM URINE COLOR-Yellow APPEAR-Clear SP
___
___ 02:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
___ 02:30AM URINE RBC-2 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-2
___ 09:15PM LACTATE-1.3
___ 09:10PM GLUCOSE-106* UREA N-16 CREAT-0.7 SODIUM-138
POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-24 ANION GAP-17
___ 09:10PM ALT(SGPT)-12 AST(SGOT)-16 ALK PHOS-109* TOT
BILI-0.2
___ 09:10PM LIPASE-18
___ 09:10PM ALBUMIN-4.1
___ 09:10PM WBC-11.1*# RBC-4.05 HGB-12.1 HCT-36.9 MCV-91
MCH-29.9 MCHC-32.8 RDW-13.8 RDWSD-45.2
___ 09:10PM NEUTS-50.6 ___ MONOS-8.6 EOS-4.9
BASOS-0.3 IM ___ AbsNeut-5.63 AbsLymp-3.90* AbsMono-0.96*
AbsEos-0.55* AbsBaso-0.03
___ 09:10PM PLT COUNT-246
Imaging:
___: CT Abd/Pel:
1. Colitis of the cecum and ascending colon with pneumatosis in
the same area, and the constellation of findings is highly
concerning for ischemic colitis.
2. Gastrostomy tube well positioned.
3. 12.6 x 3.0 cm collection involving the left lower anterior
abdominal wall, consistent with a postoperative seroma.
___: Tissue Pathology:
Metal foreign body, gross examination only.
___: CT ABD/Pelvis:
1. Increased fat stranding and bowel wall thickening involving
the cecum and ascending colon extending for about 10-12cm to the
proximal transverse colon at the hepatic flexure as compared to
the prior study. This may be
post-operative in nature, although focal colitis is also a
possibility.
Enteric contrast is seen to the level of the proximal transverse
colon. There is no extravasation of contrast into the peritoneal
cavity to suggest perforation. Scattered foci of at luminal air
surrounding the ascending and transverse colon are likely
postsurgical in nature. No bowel obstruction.
2. 13 cm subcutaneous low density fluid collection, likely a
postoperative
seroma.
3. Mild intra and moderate extrahepatic biliary ductal
dilatation with the
common bile duct measuring up to 12mm. The CBD tapers to a
normal caliber as it enters the ampulla. Attention on follow-up
imaging is recommended.
___: KUB:
1. No evidence of obstruction or pneumoperitoneum.
2. Contrast passes into the descending colon.
___: Left Wrist x-ray:
No acute fracture or dislocation. Extensive heterotopic new
bone formation at the site of the old ulnar fracture.
___ US ___ Procedure:
Successful US-guided drainage of the left lower quadrant
collection with 100 cc of serosanguineous fluid removed. Sample
was sent for microbiology
evaluation.
Brief Hospital Course:
Ms. ___ is a ___ year-old female who presented to ___ on
___ with complaints of abdominal pain. She had imaging
which was concerning for right colonic pneumatosis concerning
for ischemia. She was admitted to the Trauma Service for further
medical management.
On HD1, she was made NPO and was urgently taken to the Operating
Room where she underwent an Exploratory laparotomy and Colotomy
with removal foreign body. There were no adverse events in the
operating room; please see the operative note for details. Pt
was extubated, taken to the PACU until stable, then transferred
to the ward for observation.
On POD1, the patient received CT with oral contrast for
worsening abdominal pain which revealed no significant findings.
The patient was evaluated by Anesthesia for management of
post-operative surgical pain and she underwent a left sided TAP
block.
On POD6, the patient was started on a regular diet. On
___, the patient received vitamin K for INR of 3.3, most
likely nutritional related. On ___, she underwent
successful US-guided drainage of the left lower quadrant
collection with 100 cc of serosanguineous fluid removed by
Interventional Radiology.
On ___, the patient was noted to have hallucinations and
was evaluated by the Psychiatry team. Adjustments were made to
her medication regimen. Her g-tube was clamped so she could
take her medications orally.
On ___, the patient tested positive for C.Difficile and was
started on PO antibiotics. At the time of discharge, her bowel
movements were noted to be less frequent, her white blood cell
count had normalized, and she remained afebrile. She received a
fluid bolus for low urine output and was started on tube
feedings to supplement her PO nutritional intake.
On ___, every other staple was removed from the patient's
midline abdominal incision.
On ___, the patient's PO flagyl was discontinued given
increased nausea and PO vancomycin was added. She was
discharged with a course of PO vancomycin.
On ___, the remainder of the patient's abdominal staples
were removed and steri-strips were applied.
At the time of discharge, the patient was noted to be
neurologically stable and pain was managed with oral pain
medication. She remained stable from a cardiovascular
standpoint. The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization. The patient's intake and
output were closely monitored. The patient 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:
1. Acetaminophen 1000 mg PO Q8H
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Wheezing
3. Bisacodyl ___AILY:PRN constipation
4. Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation
5. Fluphenazine 2 mg PO Q4H:PRN aggitation
6. Fluphenazine 5 mg PO QAM
7. Insulin SC Sliding Scale Fingerstick q6h Insulin SC Sliding
Scale using REG Insulin
8. Levothyroxine Sodium 50 mcg PO DAILY
9. OxycoDONE Liquid 5 mg PO Q4H:PRN pain
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Senna 8.6 mg PO BID:PRN Constipation
12. Simvastatin 20 mg PO QPM
13. Venlafaxine 75 mg PO BID
14. Fluphenazine 10 mg PO QHS
15. Valproic Acid ___ mg PO Q12H
16. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QMON
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
3. Bisacodyl 10 mg PO DAILY:PRN constipation
4. Docusate Sodium (Liquid) 100 mg PO BID
please hold for loose stool
5. Fentanyl Patch 12 mcg/h TD Q72H
6. Fluphenazine 4 mg PO Q4H:PRN agitation, hallucinations
7. Fluphenazine 10 mg PO QAM
8. Fluphenazine 15 mg PO QPM
9. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
10. Glucose Gel 15 g PO PRN hypoglycemia protocol
11. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
12. Levothyroxine Sodium 50 mcg PO DAILY
13. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
14. Milk of Magnesia 30 mL PO Q6H:PRN CONSTIPATION
15. Multivitamins W/minerals 1 TAB PO DAILY
16. OxycoDONE Liquid ___ mg PO Q4H:PRN pain
do NOT drink alcohol or drive while taking this medication
17. Simvastatin 20 mg PO QPM
18. Venlafaxine 75 mg PO BID
19. Valproic Acid ___ mg PO Q12H
20. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Foreign body in the hepatic flexure with no evidence of
compromised right colon and no obvious perforation.
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 presented to the ___ on
___ with complaints of abdominal pain. Imaging was
concerning for free intra-abdominal air indicating perforation
or necrosis. You were admitted to the Acute Care Surgery team
and were urgently taken to the Operating Room for an exploratory
laparotomy.
In the Operating Room, you were found to have a foreign body
which was removed, and there was no evidence of compromised
colon or perforation. You were transferred to the step-down
surgical floor for pain control and to await return of bowel
function.
On ___, you were taken to Interventional Radiology and had
drainage of an intra-abdominal fluid collection.
You tested positive for clostridium difficile, a bacteria found
in the intestines, and were started on antibiotics. Please
complete the full course of antibiotics.
The Psychiatric Team followed you during your stay, adjusted
your medications, and monitored your response. You also worked
with Physical Therapy who recommends your discharge to rehab to
continue your recovery. You are now tolerating a regular diet
with supplemental tube feeds and your pain is better controlled.
You are now medically cleared to be discharged to rehab to
continue your recovery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*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:
___
|
10655200-DS-18
| 10,655,200 | 25,134,140 |
DS
| 18 |
2128-06-30 00:00:00
|
2128-07-01 15:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
heparin
Attending: ___
Chief Complaint:
G-Tube check
Major Surgical or Invasive Procedure:
Percutaneous G-tube replacement
History of Present Illness:
___ is a ___ year olf man with PMHX notable for
Schizoaffective disorder, parkinsonism, and epilepsy seizure
discorder with a G-tube who presents to the ___ ED for
evaluation of his G-tube. He had a prolonged hosptialization at
___ from ___ to ___ for FUP and
encephalopathy. Discharged with diagnosis of autonomic syndrom
with parkinsons and fever due to encephalopathy and aspiration
PNA. PEG tube was placed on that hospitalization and he was made
NPO. Per report from the ___ facility as the patient is
non-verbal he pulled out the G-tube on ___ and it was
placed back in but the nursing home is unsure if it was placed
correctly and so he was sent to ___ for a check. Per the
___ facility he has had erythema concerning for a
cellulitis around the G-tube site ___ (the day the tube was
pulled), with waxing and waning fever. He has been on
Ceftriaxone for coverage since then. Tube places before ___ at
OSH
In the ED the patient was noted to have the G-tube out of place
on a G-tube check. The area around the site was concerning for
vcellulitis and he was give Vancomycin and CTX. His IV
infiltrated with the vanco and he had some overlaying erythema.
A 10 point ROS was unable to be ontained due to his AMS.
Past Medical History:
schizoaffective disorder
parkinsonism
epilepsy
aspiration pneumonia ___ ___ ___
Social History:
___
Family History:
He denies any neurologic disease in the family, specifically a
tremor or parkinsonism.
Physical Exam:
Admission Physical Exam:
99.3, 121.76, 91, 20, 97%RA
GEN: Laying in bed.
HEENT: MMM, EOMI
NECK: Supple, no ragidty
CV: RRR
RESP: CTAB anteriorly, unable to listen posterior.
ABD: +BS, G-tube in place over the Left upper quadrant
SKIN: Outlined area of erythema with central area at the site of
the G-tube.
EXT: No ___ pitting edema
NEURO: Unable to participate in exam due to AMS
PSYCH: Unable to discuss with patient.
Pertinent Results:
___ 04:05PM BLOOD WBC-7.1 RBC-3.74*# Hgb-11.1*# Hct-34.2*#
MCV-91 MCH-29.7 MCHC-32.5 RDW-14.3 RDWSD-47.7* Plt ___
___ 04:05PM BLOOD Neuts-80.2* Lymphs-11.1* Monos-7.7
Eos-0.0* Baso-0.4 Im ___ AbsNeut-5.73 AbsLymp-0.79*
AbsMono-0.55 AbsEos-0.00* AbsBaso-0.03
___ 04:05PM BLOOD Glucose-90 UreaN-31* Creat-1.0 Na-139
K-4.3 Cl-101 HCO3-25 AnGap-17
___ 04:21PM BLOOD Lactate-1.3
G-Tube Check:
FINDINGS:
A percutaneous catheter is seen with tip terminating in the
region of the left
mid abdomen. Following the injection of oral contrast material
through the
gastrostomy catheter, the contrast appears to extravasate
outside the confines
of the stomach suggesting malpositioning of the gastrostomy
catheter. A small
amount of contrast material however is noted within the fundus
of the stomach.
Clips are seen within the right lower quadrant of the abdomen.
Moderate
amount of stool is noted throughout the colon.
IMPRESSION:
Findings concerning for malpositioned percutaneous gastrostomy
catheter with
extraluminal contrast noted.
___ EEG
IMPRESSION: This is an abnormal continuous video monitoring
study
because of generalized slowing in the theta range with rare
bifrontally predominant admixed semi-rhythmic admixed delta
activity. This is indicative of a moderate encephalopathy which
is non-specific with regards to etiology and possible
intermittent midline dysfunction. Compared to prior day's
recording, rare broad-based sharp and slow wave discharges in
the
right central parietal region are no longer seen.
___ eeg
IMPRESSION: This is an abnormal continuous video monitoring
study
because of generalized slowing in the theta range with
intermittent bifrontally predominant admixed semi-rhythmic
admixed delta activity. This is indicative of a moderate
encephalopathy which is non-specific with regards to etiology
and possible intermittent midline dysfunction. In the beginning
of the recording, infrequent broad-based sharp wave discharges
are seen in the right central parietal region indicative of
underlying cortical irritability. There are no electrographic
seizures.
___ CT head
1. Study is moderately degraded by motion. Within this
limitation, no acute intracranial process.
In addition to the above impression: There is slight asymmetric
prominence of the periventricular hypodensity of the right
frontal lobe, almost certainly secondary to technical
differences. There is no loss parenchymal volume to
suggest chronic infarcts/encephalomalacia. The gray-white
differentiation is preserved. However, MRI when clinically
feasible is recommended for further evaluation.
RECOMMENDATION(S): When clinically feasible, MRI of the brain
would be more sensitive.
___ cxr
Low lung volumes with patchy opacities in the lung bases as well
as within the left upper lung field, potentially atelectasis
though aspiration or infection is not excluded.
Brief Hospital Course:
___ h/o seizure d/o, schizoaffective d/o and parkinsonism, with
several month decline and more recent accelerated decline with
altered mental status and frequent falls over last few weeks.
Recent 2-week hospitalization for altered mental status and
fever, found to have aspiration pneumonia, had G-tube placed.
Sent from ___ home with malpositioned G-Tube which he self
removed. Hospital course notable for abd ___ cellulitis and
progressive encephalopathy with catatonia.
.
#Acute/subacute encephalopathy: Ongoing for weeks to months, was
evaluated during recent hospitalization at ___
___, diagnosed with autonomic syndrome. Likely
multifactorial etiology, psychiatry and neurology consulted
here. Initial Ddx encephalopathy in the setting of recent
pneumonia, PEG site infection, polypharmacy (Zyprexa Zydis and
morphine), and subclinical seizures. 24 hour EEG on ___ showed
generalized slowing consistent with moderate encephalopathy.
Neuro recommended keppra 1500 BID, administered IV when pt
unable to take po. No obvious signs of infection, electrolytes
wnl. His LP on prior admission showed 13 WBC, 79% lymphs, 0 RBC,
P=78, G=55 concerning for aseptic meningitis. Lyme and HSV as
well as cultures were negative. TSH normal. B12 high. On ___ pt
had waxy flexibility, mimickry and echolalia most consistent
with catatonia, for which psychiatry recommended discontinuing
zyprexa, which can worsen catatonia. He was started on ativan
1mg IV TID. His mental status improved, and at the time of
discharge was alert but mumbling, calm, not answering questions
or following commands. Per psychiatry, lorazepam should be
tapered by 0.5mg/day/week, and he needs close outpatient f/u.
#G-tube malposition, self d/c'ed: G-tube replaced on ___,
enteral feeding resumed ___, tolerating without problem.
#abdominal ___ cellulitis: finished 7 day course of vanc/CTX
___ for cellulitis at site of G-tube.
#Seizure disorder: on keppra 1500 BID, switched from
carbamezapime per neurology after it appeared that patient did
not tolerate it well and may have contributed to encephalopathy.
Patient was also receiving lorazepam scheduled, as his
catatonia was thought to potentially be secondary to seizures.
Lorazepam taper is recommended as above.
#parkinsonism: Carbidopa-levodopa was discontinued on admission.
Per neurology, as he clinically improved, this suggests that his
parkinsonism may be related to his history of neuroleptic
medication.
#HTN: monitor, resume metoprolol once enteral feeding is
restarted.
Code Status: DNR/DNI but ok for NIV per MOLST form
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Duloxetine 90 mg PO DAILY
2. Metoprolol Tartrate 12.5 mg PO BID
3. Pravastatin 40 mg PO QPM
4. Meclizine 25 mg PO BID
5. Morphine Sulfate (Concentrated Oral Soln) 2 mg PO Q1H:PRN
Pain
6. Fondaparinux 2.5 mg SC DAILY
7. LeVETiracetam 1500 mg PO BID
8. Pantoprazole 40 mg PO Q24H
9. Saccharomyces boulardii 250 mg oral BID
10. Calcitriol 0.5 mcg PO DAILY
11. Carbamazepine (Extended-Release) 200 mg PO BID
12. Carbidopa-Levodopa (___) 1 TAB PO TID
13. Ferrous Sulfate 325 mg PO BID
14. ClonazePAM 1 mg PO QHS
Discharge Medications:
1. Carbidopa-Levodopa (___) 1 TAB PO TID
2. Ferrous Sulfate 325 mg PO BID
3. Metoprolol Tartrate 12.5 mg PO BID
4. Pravastatin 40 mg PO QPM
5. Saccharomyces boulardii 250 mg oral BID
6. Acetaminophen 650 mg PO Q6H:PRN Pain/fever
7. Lorazepam 1 mg PO TID
PLEASE TAPER BY 0.5MG PER DAY PER WEEK
8. Calcitriol 0.5 mcg PO DAILY
9. Fondaparinux 2.5 mg SC DAILY
10. LeVETiracetam 1500 mg PO BID
11. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
metabolic encephalopathy
catatonia
Abdominal ___ Cellulitis
SECONDARY:
seizure disorder
Schizoaffective disorder
parkinsonism
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:
You were admitted for altered mental status and the psychiatry
and neurology teams were consulted. It was felt that this was
most likely from medications for your seizure disorder. You were
switched to a different seizure medication (Keppra) which you
should take twice daily. It is unclear why you have had such a
decline in the last few mos, and you need very close follow up
with your neurologist and psychiatrist.
While here you removed your Gtube and you were treated for a
skin infection. After your skin infection resolved, a G-tube was
replaced by radiology and you tolerated this well.
Followup Instructions:
___
|
10655528-DS-6
| 10,655,528 | 20,782,757 |
DS
| 6 |
2114-02-16 00:00:00
|
2114-02-16 18:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PODIATRY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left Foot Pain, Abscess
Major Surgical or Invasive Procedure:
___: Left Foot Incision & Drainage
___: Left Foot Debridement
___: Left Foot Incision & Drainage
___: Left foot debridement with amputation of left
third digit and primary closure.
History of Present Illness:
___ with history of HTN who presents with 5 days of L foot
swelling, pain, and erythema. He was seen ___ Urgent Care 2 days
ago and was given IM and PO NSAIDs without improvement ___ his
symptoms. He reports that today he noticed a blister developing
over his forefoot and that the area of erythema on the ball of
his foot had become dusky-appearing. Denies preceding trauma but
states that he has had prior episodes ___ swelling, for which
he was previously seen ___ ___ clinic without apparent
diagnosis. However, he has never developed blisters. No known
h/o
diabetes. Currently, admits to tenderness to the left foot.
Denies any other pedal complaints. Denies any n/v/f/c/sob.
Past Medical History:
HTN
Social History:
___
Family History:
non-contributory
Physical Exam:
================
ED PHYSICAL EXAM
================
AVSS
General: NAD, A&Ox3
Lungs: CTA, no whales, crackles, rhonchi
Heart: RRR
Abd: non-tender, non-distended, normal bowel sounds
Left Lower Extremity Exam: ___ pulses palpable. There is 3-4cm
abscess formation to the dorsal/plantar aspect of left forefoot
near digits 3 and 4. Area is slightly dusky plantarly. Fluctuant
on palpation dorsally. Very tender to palpation both dorsally
and
plantarly. Erythema surrounding abscess formation dorsally but
limited to the left forefoot. No proximal streaking. Mixture of
purulent/sanguinous drainage noted upon I&D.
=======================
DISCHARGE PHYSICAL EXAM
=======================
GENERAL: [x]NAD [x]A/Ox3 []intubated/sedated
CARDIAC: [x]RRR [x]no MRG []NL S1S2 [] abnormal
LUNGS: [x]No respiratory distress []abnormal
ABD: []NBS [x]soft [x]nontender [x]nondistended []no rebound/
guarding
EXTREMITIES: Left lower extremity with dry, sterile, dressing
intact with no strikethrough noted. Brisk capillary refill all
remaining digits. Incision site well coapted with all sutures
___
tact. No drainage, surrounding erythema, proximal streaking or
malodor present.
Pertinent Results:
==============
ADMISSION LABS
==============
___ 11:27PM BLOOD WBC-11.1* RBC-5.15 Hgb-13.2* Hct-38.6*
MCV-75* MCH-25.6* MCHC-34.2 RDW-14.0 RDWSD-37.2 Plt ___
___ 11:27PM BLOOD Neuts-69.5 Lymphs-17.5* Monos-7.3 Eos-4.7
Baso-0.5 Im ___ AbsNeut-7.67* AbsLymp-1.94 AbsMono-0.81*
AbsEos-0.52 AbsBaso-0.06
___ 11:27PM BLOOD ___ PTT-25.5 ___
___ 11:27PM BLOOD Glucose-124* UreaN-17 Creat-1.4* Na-142
K-4.2 Cl-104 HCO3-22 AnGap-16
___ 11:27PM BLOOD CRP-91.4*
___ 11:37PM BLOOD Lactate-1.3
==============
DISCHARGE LABS
==============
___ 05:10AM BLOOD WBC-12.9* RBC-4.88 Hgb-12.7* Hct-36.8*
MCV-75* MCH-26.0 MCHC-34.5 RDW-14.5 RDWSD-38.9 Plt ___
___ 05:10AM BLOOD Glucose-119* UreaN-13 Creat-1.2 Na-137
K-3.8 Cl-102 HCO3-24 AnGap-11
============
MICROBIOLOGY
============
___ 11:27 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
=====
___ 11:37 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
=====
___ 12:34 am SWAB Source: left foot abscess.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ CLUSTERS.
WOUND CULTURE (Final ___:
THIS IS A CORRECTED REPORT ___.
Reported to and read back by ___ ___ ___ ___
13:30.
STAPHYLOCOCCUS ___. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
PREVIOUSLY REPORTED AS (ON ___ TO ___ ___
___ AT
8:11AM). STAPH AUREUS COAG +.
WHICH WAS PREVIOUSLY REPORTED AS (ON ___.
STAPHYLOCOCCUS COAGULASE NEGATIVE.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS ___
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
====
___ 2:36 pm TISSUE Site: TOE
LEFT ___ TOE BONE CURRENTLY TAKING VANCOMYCIN,ZOCYN.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
====
___ 2:20 pm SWAB LEFT FOOT ABSCESS INNER SPACE.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
=====
PATHOLOGY
=====
Tissue (Left ___ Proximal Phalanx) (___): Left third toe
bone: Scant fragments of bone with necrosis and acute
inflammation; multiple levels
examined.
___ Pathology Pending
=======
IMAGING
=======
Left Foot X-Ray (___):
FINDINGS:
No acute fracture is seen. Degenerative changes are noted at
the first tarsal metatarsal joint, along the navicular bone, at
the tibiotalar joint. Subtle irregularity at the lateral base of
the second proximal phalanx may also relate to degenerative
change. Pes planus deformity is noted. There is a small
calcaneal spur.
=====
Left Foot X-Ray (___):
IMPRESSION:
There is soft tissue swelling and bandaging material about the
forefoot which limits fine bony detail. No definite bony
erosions are seen. No acute fractures or dislocations are
identified. There are degenerative changes worse at the first
TMT and naviculocuneiform joints. Degenerative changes of
talonavicular joint is also seen. There are degenerative
changes with spurring of the anterior tibia. There is a
prominent medial process of the navicular.
=====
Left Foot Ultrasound (___):
IMPRESSION:
Phlegmon measuring up to 1 cm dorsal to the head of the third
metatarsal,
inferior to the ulcer. Diffuse cellulitis.
=====
Left Foot X-Ray (___):
IMPRESSION:
There is soft tissue swelling along the dorsal aspect of the
forefoot. No
radiopaque foreign bodies identified. There is no acute
fracture or
dislocation. Degenerative changes are noted ___ the
talonavicular and first
tarsometatarsal joints. There are no erosions.
=====
Left Foot X-Ray (___):
IMPRESSION:
There are postsurgical changes from amputation of the third toe.
No acute
fracture or dislocation is identified. There are no radiopaque
foreign
bodies. There are degenerative changes of the talonavicular,
naviculocuneiform and first tarsometatarsal joints. There is a
plantar
calcaneal spur.
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the podiatric surgery team. The patient was found
to have a left foot abscess and was admitted to the podiatric
surgery service. The patient was taken to the operating room on
___ for a more extensive incision and drainage, and on
___ for further debridement and washout, and the wound was
closed primarily. Post-operatively, the patient did well,
however his white blood cell count did rise substantially, and
an ultrasound of the foot was obtained to evaluate for abscess.
Unfortunately the US did reveal a phlegmon surrounding the third
metatarsal. The patient was informed of this finding, and of
the need to take him back to the OR for repeat washout. The
patient underwent an I&D of the left foot on ___.
Intra-operatively, it was found that the bleeding ability of the
medial ___ digit tissue was not ideal. Over the next few days,
the third toe worsened ___ appearance, looking dusky with
increasingly sluggish capillary refill. The patient was
informed that amputation of the ___ digit was possible
considering its poor viability. It was discussed that remaining
viable skin from the ___ toe could be used and rearranged to
cover the soft tissue deficit and close the wound primarily.
The patient eventually elected to undergo this procedure on
___, which he tolerated well. Post-operatively, white
blood cell count continued to downtrend, and patient's healing
was as expected.
For full details of the procedures please see the separately
dictated operative reports. The patient was taken from the OR
to the PACU ___ stable condition and after satisfactory recovery
from anesthesia was transferred to the floor after all
procedures. The patient was initially given IV fluids and IV
pain medications, and progressed to a regular diet and oral
medications. 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 ___ the left lower extremity. 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. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg ___
tablet(s) by mouth q6hrs Disp #*30 Tablet Refills:*0
2. Clindamycin 300 mg PO Q6H Duration: 10 Days
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth Every 6 hours
Disp #*40 Capsule Refills:*0
3. Levofloxacin 500 mg PO Q24H Duration: 10 Days
RX *levofloxacin 500 mg 1 tablet(s) by mouth Daily Disp #*10
Tablet Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg ___ tablet(s) by mouth q4-6hrs Disp #*40
Tablet Refills:*0
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
RX *sennosides [Senna Laxative] 8.6 mg 1 tablet by mouth twice a
day Disp #*20 Tablet Refills:*0
6. Hydrochlorothiazide 25 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left Foot Abscess, Left Foot Infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you at ___. You were admitted
to the Podiatric Surgery service surrounding your left foot
surgeries. You were given IV antibiotics while here. You are
being discharged home with the following instructions:
ACTIVITY:
There are restrictions on activity. Please remain non weight
bearing to your left foot until your follow up appointment. You
should keep this site elevated when ever possible (above the
level of the heart!)
No driving until cleared by your Surgeon.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness ___ or drainage from your leg wound(s).
New pain, numbness or discoloration of your foot or toes.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
EXERCISE:
Limit strenuous activity for 6 weeks.
No heavy lifting greater than 20 pounds for the next ___ days.
Try to keep leg elevated when able.
BATHING/SHOWERING:
You may shower immediately upon coming home, but you must keep
your dressing CLEAN, DRY and INTACT. You can use a shower bag
taped around your ankle/leg or hang your foot/leg outside of the
bathtub.
Avoid taking a tub bath, swimming, or soaking ___ a hot tub for 4
weeks after surgery or until cleared by your physician.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods ___ your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
DIET:
There are no special restrictions on your diet postoperatively.
Poor appetite is not unusual for several weeks and small,
frequent meals may be preferred.
FOLLOW-UP APPOINTMENT:
Be sure to keep your medical appointments.
If a follow up appointment was not made prior to your discharge,
please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are ___
through ___.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE.
FOLLOW UP:
Please follow up with your Podiatric Surgeon, Dr. ___. You will
have follow up ___ the Podiatric Surgery Clinic ___ ___ days
post-operation for evaluation. Call ___ to schedule
appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Followup Instructions:
___
|
10655850-DS-20
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DS
| 20 |
2167-08-17 00:00:00
|
2167-08-17 15:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
vomiting and lightheadedness
Major Surgical or Invasive Procedure:
pericardiocentesis and pericardial drain placement: ___
pericardial window: ___
History of Present Illness:
Ms. ___ is a ___ year old woman, with Stage IV lung
adenocarcinoma (EGFR wild-type, ALK FISH negative), currently on
C2 Pembrolizumab (___ (___), complicated with malignant
pleural effusion s/p pleurx catheter, with metastatic disease
with possible RP lymphadenopathy, and probable adrenal mass.
Patient now being admitted for hypotension, with likely
pericardial effusion.
Patient started feeling unwell about 1 week ago, at which point
she started having increased nausea without appetite. Over the
weekend, she then stopped eating, and went to an urgent care
about 2 days ago, was started on omeprazole for GERD. At that
appointment, she reports that she couldn't get a blood pressure.
No blood work on ___. Patient then went home, and continued
to feel unwell. When she would stand up quickly, she felt cold
and pre-syncopal and lightheadedness, no loss of consciousness.
Patient reported some mild chest pressure, thought to be ___ to
coughing, no frank chest pain. Patient's family could visibly
see tachypnea, although patient reports some baseline dyspnea
specifically on exertion, but that has started to improve with
thoracentesis. Patient was seen at urgent care today, with
increased dry heaves, vomiting, decreased PO intake and
increased fatigue. Received phone call from physician at urgent
care. Patient presented today with dry heaves, decreased PO
intake and fatigue. SBP 78. BUN 42, Cr 3.3. Receiving IV
hydration. Patient was reluctant to go to the ED. Recommended
that patient be transferred to the ED as soon as possible. She
also reports that she had decreased urine output, but may be ___
to low PO intake.
Of note, patient was recently hospitalized (___) for
dyspnea with new diagnosis of bilateral segmental and
subsegmental PEs and prior pericardial effusion. She was
admitted to the MICU previously, with CTA showing bilateral RL
subsegmental branches, RLL consllidation likely ___ to pulmonary
infarct. During a prior admission to this, patient was also
found to have a small echodense pericardial effusion with
echocardiographic evidence of impaired right ventricular filling
in late systole/early diastole, consistent with borderline
tamponade physiology. She then had repeat echocardiographic
imaging which showed small circumferential pericardial effusion
without definite echocardiographic evidence of tamponade
physiology, with normal biventricular size and global systolic
function. Patient therefore was discharged with enoxaparin 80 mg
BID, lisinopril 10 mg, and simvastatin.
In the ED initial vitals were: 98.0 60 SBP 80 18 74% Nasal
Cannula
Patient was started on levophed 0.03
EKG: Sinus rhythm, low voltage QRS
Labs/studies notable for: WBC 14.3, Hgb 9.4 (baseline ___, Cr
3.4, K 6.0, lactate 3.3, BNP 501, trop 0.01
CXR: Large left and moderate right pleural effusion, increased
in volume since ___
Patient was transferred to cath lab for emergent
pericardiocentesis given echocardiographic concerns for
tamponade. 600 cc sero-sanguineous fluid was drained and
pericardial drain was left in place
On arrival to the CCU, the patient is reporting pain around
drain site but does not have chest pain or shortness of breath
REVIEW OF SYSTEMS:
Positive per HPI.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS
- Hypertension
- Hyperlipidemia
2. CARDIAC HISTORY
- Pericardial Effusion
3. OTHER PAST MEDICAL HISTORY
- Lung Cancer dx ___
- h/o Mycosis Fungoides (___)
- Hypertension
- irritable bowel syndrome
- diverticulosis
- Hyperlipidemia
- osteoarthritis
Social History:
___
Family History:
Father: colon cancer, heart disease
Paternal grandmother: esophageal cancer
Mother: ___ disease
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: T 98.0 BP 111/72 HR 90 RR 37 O2 SAT 100% on NRB
GENERAL: Well developed, well nourished in NAD.
HEENT: Normocephalic atraumatic. Sclera anicteric.
NECK: Supple.
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs or
rubs
LUNGS: Bibasilar crackles, no accessory muscle use
ABDOMEN: Soft, non-tender, non-distended. BS+
EXTREMITIES: Cool to touch. 2+ pitting edema LLE > RLE
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAM
=======================
VS: T 97.7 HR 85 (70-90) BP 129/79 (110-140/70-90) O2 Sat 92%RA
GENERAL: well-appearing woman, lying comfortably in bed, alert
and awake, speaking in full sentences, in NAD
HEENT: Normocephalic atraumatic. Sclera anicteric. EOMI
NECK: Supple with JVP 1-2 cm above clavicle
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs or
rubs
LUNGS: Decreased breath sounds at bases without crackles,
wheezes or rhonchi, no accessory muscle use
ABDOMEN: +BS, soft, non-tender, non-distended, no rebound or
guarding
EXTREMITIES: WWP, trace LLE edema, 1+ RLE edema
SKIN: No significant skin lesions or rashes.
Pertinent Results:
ADMISSION LABS
==============
___ 10:09PM URINE COLOR-Red APPEAR-Hazy SP ___
___ 10:09PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.5 LEUK-TR
___ 10:09PM URINE RBC-8* WBC-7* BACTERIA-NONE YEAST-NONE
EPI-2 TRANS EPI-1
___ 10:09PM URINE HYALINE-47*
___ 10:09PM URINE MUCOUS-OCC
___ 08:40PM GLUCOSE-108* UREA N-46* CREAT-2.8* SODIUM-133
POTASSIUM-4.2 CHLORIDE-95* TOTAL CO2-20* ANION GAP-22*
___ 08:40PM CALCIUM-7.5* PHOSPHATE-7.3* MAGNESIUM-2.0
___ 08:40PM LACTATE-1.8
___ 06:10PM OTHER BODY FLUID TOT PROT-5.3 GLUCOSE-21
LD(LDH)-350 ALBUMIN-2.8
___ 06:10PM OTHER BODY FLUID TNC-___* ___
POLYS-7* LYMPHS-6* ___ MACROPHAG-35* OTHER-52*
___ 05:37PM LACTATE-3.3*
___ 05:05PM GLUCOSE-97 UREA N-44* CREAT-3.4*# SODIUM-133
POTASSIUM-6.0* CHLORIDE-95* TOTAL CO2-17* ANION GAP-27*
___ 05:05PM estGFR-Using this
___ 05:05PM cTropnT-0.01
___ 05:05PM proBNP-501*
___ 05:05PM CALCIUM-8.0* PHOSPHATE-7.9* MAGNESIUM-2.1
___ 05:05PM WBC-14.3*# RBC-3.51* HGB-9.4* HCT-30.3*
MCV-86 MCH-26.8 MCHC-31.0* RDW-17.7* RDWSD-51.0*
___ 05:05PM NEUTS-90* BANDS-0 LYMPHS-9* MONOS-0 EOS-1
BASOS-0 ___ MYELOS-0 NUC RBCS-5* AbsNeut-12.87*
AbsLymp-1.29 AbsMono-0.00* AbsEos-0.14 AbsBaso-0.00*
___ 05:05PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-1+
___ 05:05PM PLT SMR-HIGH PLT COUNT-444*
___ 05:05PM ___ PTT-37.2* ___
NOTABLE LABS:
=============
___ 05:05PM BLOOD proBNP-501*
___ 05:05PM BLOOD cTropnT-0.01
___ 04:46AM BLOOD TSH-0.73
___ 04:46AM BLOOD T4-6.5
___ 04:46AM BLOOD ___ * Titer-1:40
___ 05:37PM BLOOD Lactate-3.3*
___ 08:40PM BLOOD Lactate-1.8
MICROBIOLOGY
============
Blood cx (___): NGTD
Urine cx (___): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES),
CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.
IMAGING
=======
CXR (___):
FINDINGS:
AP portable chest radiograph demonstrates a large left pleural
effusion and moderate right pleural effusion. Pleural fluid
appears to track along the lateral left chest wall and to the
apex, since ___, increased in volume. Heart borders
are obscured. Opacity at the right lung base is
probably atelectatic in etiology. There is no pulmonary edema
or
pneumothorax. There is no air under the diaphragm.
IMPRESSION:
Large left and moderate right pleural effusion, increased in
volume since ___.
CXR (___):
IMPRESSION:
In comparison with the study of ___, there is continued
large left and moderate right pleural effusions with underlying
compressive atelectasis. Otherwise, little overall change.
CXR (___):
IMPRESSION:
There is a large partially loculated left pleural effusion which
is stable
allowing for patient positioning. Moderate right-sided pleural
effusion has increased slightly. Skin folds project over the
right upper lobe without definite signs for pneumothoraces.
CARDIAC STUDIES
===============
___ 06:10PM PERICARDIAL FLUID ___-___* ___
Polys-7* Lymphs-6* ___ Macro-35* Other-52*
___ 06:10PM PERICARDIAL FLUID TotProt-5.3 Glucose-21
LD(LDH)-350 Albumin-2.8
Pericardial fluid analysis (___):
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary):
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
VIRAL CULTURE (Pending):
Fluid Culture in Bottles (Preliminary): NO GROWTH.
TTE (___):
The left ventricular cavity is small with overall preserved
systolic function (LVEF>55%). There is a large circumferential
pericardial effusion (2.5cm anterior to the right ventricle and
apex and 1.9 cm laterally. There is right ventricular diastolic
collapse, consistent with impaired fillling/tamponade
physiology.
IMPRESSION: Large circumferential pericardial effusion with
right ventricular diastolic collapse consistent with tamponade
physiology.
Compared with the prior study (images reviewed) of ___,
the pericardial effusion is now much larger and tamponade
physiology is now suggested.
TTE (___):
The estimated right atrial pressure is ___ mmHg. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There is a very small
pericardial effusion, most prominent around the right atrium.
There are no echocardiographic signs of tamponade physiology.
Bilateral pleural effusions are present.
Compared with the prior study (images reviewed) of ___,
the effusion has largely resolved and tamponade physiology is no
longer present.
DISCHARGE LABS
==============
___ 05:00AM BLOOD WBC-10.0 RBC-3.60* Hgb-9.7* Hct-31.0*
MCV-86 MCH-26.9 MCHC-31.3* RDW-18.2* RDWSD-52.7* Plt ___
___ 05:00AM BLOOD ___ PTT-35.3 ___
___ 05:00AM BLOOD Glucose-138* UreaN-25* Creat-0.6 Na-135
K-3.7 Cl-98 HCO3-27 AnGap-14
___ 05:00AM BLOOD Calcium-8.3* Phos-2.0* Mg-2.0
Brief Hospital Course:
Ms. ___ is a ___ year old woman, with Stage IV lung
adenocarcinoma (EGFR wild-type, ALK FISH negative), currently on
C2 Pembrolizumab (C2D15 (___), c/b malignant pleural
effusion s/p pleurx catheter, who presented with cardiac
tamponade and obstructive shock, s/p pericardiocentesis and
pericardial window.
# Cardiac Tamponade/Obstructive Shock
# Pericardial Effusion: Patient admitted with hypotension, and
found to be in obstructive shock with large pericardial effusion
and evidence of cardiac tamponade on bedside ECHO in the ED,
compared with prior evidence of small pericardial effusion on
TTE ___. Patient went to the cardiac catherization lab for
emergent pericardiocentesis and had 600cc serosanguinous fluid
removed, with pericardial drain placed on ___. Etiology of
effusion likely secondary to lung adenocarcinoma versus less
likely adverse effect of Pembrolizumab (1.1% incidence). Also
was felt to be possible that therapeutic lovenox in the setting
of acute renal failure may have contributed to effusion given
significant hemorrhagic component. Due to concern for
pembrolizumab as the cause for her presentation, she was started
on 80 mg prednisone per her outpatient oncologist. TFTs were
normal. ___ mildly positive at 1:40. On ___, repeat TTE without
concern for tamponade physiology; however, pericardial drain
continued to have output with 700cc. Given large output, patient
received pericardial window with thoracic surgery on ___, and
pericardial drain was pulled on ___. Patient's home lisinopril
and lovenox were held in the setting of cardiac tamponade.
Patient was maintained on subQ heparin while Lovenox was held,
and Lovenox was restarted after drain was pulled. Pericardial
effusion cytology results were pending at time of discharge.
# History of Bilateral PE. Diagnosed in ___, has been on
Lovenox and compliant. Lovenox was held in the setting of
hemorrhagic pericardial effusion and patient was maintained on
DVT prophylaxis with subcutaneous heparin. Pericardial drain was
pulled on ___ and lovenox was restarted.
# Acute renal failurure. Baseline Cr 0.4. On admission Cr was
elevated to 3.3. There was originally concern for hypovolemia
versus pembrolizumab induced AIN but patient's Cr improved to
normal after pericardiocentesis and IVF. UA was clean and Urine
cx negative. Cr was 0.6 at discharge.
# Anemia: Hgb on admission 9.4. Remained stable during
admission. Most likely ___ anemia of chronic disease and
possible contribution from hemorrhagic effusion.
# Lung adenocarcinoma, Stage IV. EGFR wild-type, ALK FISH
negative, currently on C2 Pembrolizumab (C2D15 (___), c/b
malignant pleural effusion s/p pleurx catheter and bilateral
thoracentesis. Next dose of pembrolizumab is due on ___.
Patient was seen by hem/onc in the ED and per their
recommendeation received IV methylprednisolone 125 mg in the ED
for reversal of pembrolizumab given possibility that pericardial
effusion is a reported form of PDL1-inhibitor toxicity. She was
continued on prednisone 80mg daily, with a plan to continue that
on ___, and reassess on ___.
# Hypertension: Pt's home lisinopril was held on admission in
the setting of cardiac tamponade. Her BPs remained stable in
120s/80s so it was not restarted prior to discharge.
TRANSITIONAL
============
- Held medications: Lisinopril
- New medications: Prednisone 40 mg daily, Folic acid,
omeprazole, vitamin D
- Pericardial effusion cytology results pending at time of
discharge. Please follow up cytology results.
- Per outpatient oncologist, taper prednisone to 40 mg daily.
Will take 40 mg prednisone until sees oncologist on ___ and
will decide further taper schedule.
- Started on vitamin D and omeprazole due to steroids. Please
discontinue when steroids discontinued.
- Next dose of Pembrolizumab is due on ___. Will discuss with
outpatient oncologist whether she will continue this treatment
or start chemotherapy instead. She was given Vitamin B12 shot
and folic acid 1g daily in preparation for possible
chemotherapy.
- If patient is not going to start chemotherapy, can consider
discontinuing the folic acid.
- Interventional pulmonology will drain pleural effusions on
___.
- Oncologist appointment with Dr. ___ is on ___.
- Patient needs PET-scan this week per oncologist Dr. ___.
- Follow up blood pressures and restart home Lisinopril as
needed.
- Discharge Cr 0.6
# CODE: FULL CODE (confirmed)
# CONTACT/HCP: Husband ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Lisinopril 10 mg PO DAILY
3. Enoxaparin Sodium 80 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
3. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*6 Tablet
Refills:*0
4. Vitamin D 1000 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
5. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
6. Enoxaparin Sodium 80 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
7. HELD- Lisinopril 10 mg PO DAILY This medication was held. Do
not restart Lisinopril until your doctor tells you to restart
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Pericardial effusion
Acute kidney injury
Obstructive shock
Secondary Diagnosis:
Stage IV lung adenocarcinoma
Pleural effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It has been a pleasure taking care of you at ___.
Why was I here?
- You were admitted to ___ for pericardial effusion (fluid
around your heart) and low blood pressure and kidney injury.
- You had the fluid around your heart drained and you had a
surgical procedure called a pericardial window to prevent
re-accumulation of fluid around your heart.
- Your kidney function improved with improvement in the fluid
around your heart.
- You were started on prednisone in case the effusion was caused
by your pembrolizumab treatment.
What should I do when I go home?
***You need to call the oncology office tomorrow (___) to
schedule a PET scan this week.
- You should continue to take your prednisone taper as
instructed.
- You should follow up with interventional pulmonology on
___.
- You should follow up with your oncologist on ___.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10655850-DS-24
| 10,655,850 | 29,556,055 |
DS
| 24 |
2168-12-14 00:00:00
|
2168-12-14 12:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / levofloxacin
Attending: ___
Chief Complaint:
slurred speech
Major Surgical or Invasive Procedure:
none
History of Present Illness:
REASON FOR CONSULTATION: Code stroke
HPI:
This is a ___ year old woman with a history of Stage IV lung
adenocarcinoma (EGFR neg, ALK neg, ROS1 neg, KRAS mutation, 90%
PDL expression) with known mets to pleural space esophagus
without indication of known CNS mets and history of PE on
lovenox, who presents as ED to ED transfer for acute stroke and
NSTEMI.
History provided by patient, husband, and per chart review
___ records and in OMR). Per patient and husband, she
was
feeling mostly in her usual state of health over the past few
weeks, although confounded by general malaise from esophageal
mass limiting PO intake and from side effects of resulting xRT.
She had PEG placed last week without complications and stopped
her lovenox prior to this procedure for just one dose and
subsequently resumed her lovenox. Three days ago she may have
missed one dose of lovenox in the setting of general malaise
from
her recent procedures and some complications with clogging of
the
PEG tube. On the evening of ___, she suddenly developed acute
substernal chest pain. She thus presented to ___ ED at ___ AM
for evaluation of chest pain. She had no aphasia, weakness,
sensory deficits at this time. Of note, when presenting to the
ED
yesterday morning, she also missed her lovenox.
At ___, there was initial concern for NSTEMI with
elevated
troponin and significant substernal chest pain. She was admitted
for evaluation and during the day suddenly developed acute
aphasia and right-sided weakness for which code stroke was
called.
Per ___ records:
"
___ female with history of non-small cell lung cancer
with metastatic lesions to her esophagus presenting to the
emergency department for slurred speech and word finding
difficulty. The husband left for work at approximately 10 AM
and when he returned at approximately 12 ___ noticed that she
was
having trouble swallowing her saliva and had slurred speech. He
also notes that since yesterday she has been noting substernal
chest discomfort and some shortness of breath. The patient is
currently on Lovenox for PE. She notes she did not give herself
her dose of Lovenox this morning.Patient had a pleurocentesis 1
week ago for fluid in her right lower lobe.
12:52 Code stroke called as patient had slurred speech and word
finding difficulty on initial exam. ___ stroke scale of 2. Last
known well ~10 am.-Slurred speech resolved upon return from CT
scan. Evaluated by telemetry neurology who does not have concern
for stroke at this time. Patient had return of stroke symptoms
at 5:00 ___ with right-sided facial droop, right great grip
discrepancy and right leg weakness with associated slurred
speech and word finding difficulty. Repeat head CT was
performed and there was no evidence of acute she did
receive hemorrhagic stroke. This was discussed with the
telemetry neurologist and testing for babesiosis and radiology
who recommended MRI/MRA head and neck. MRI/MRA shows multiple
small infarcts with a larger infarct in the right occipital
lobe
with question of embolic phenomenon. Stroke fellow paged.
-Patient also has elevated troponin at 0.169; No evidence of
acute ischemic changes on EKG. this was discussed with
cardiology who suspects possible NSTEMI that occurred yesterday;
they are recommending heparin drip however we will pend heparin
until discussed with stroke fellow"
Regarding oncologic history, the patient was diagnosed in ___
s/p 20 cycles of pemetrexed
with new lesion in esophagus found on ___ for which she was
subsequently started on atezolizumab as well as 2 weeks of
palliative xRT (completed ___.
Review of systems notable for above findings. Otherwise negative
on time of exam for current chest pain, current headache.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
- Stage IV non-small-cell lung cancer, adenocarcinoma of the
lung (EGFR wild-type, ALK FISH negative, ROS1 FISH negative,
KRAS
G12C mutation and PD-L1 IHC 22C3 TPS 90%).
1. Status post 2 cycle/doses of pembrolizumab 200 mg on ___
and ___
2. Status post 3 cycles of carboplatin and pemetrexed on
___ and ___.
PAST MEDICAL HISTORY:
- h/o mycosis fungoides (___)
- hypertension
- irritable bowel syndrome
- diverticulosis
- hyperlipidemia
- osteoarthritis
Social History:
___
Family History:
Father: colon cancer, heart disease
Paternal grandmother: esophageal cancer
Mother: ___ disease
Physical Exam:
NIHSS performed within 6 hours of presentation at: _123___, ___
NIHSS Total: 10
1a. Level of Consciousness: 2
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 1
4. Facial palsy: 1
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: 1
10. Dysarthria: 1
11. Extinction and Neglect: 1
PHYSICAL EXAMINATION on admission:
Vitals: afebrile, HR108, RR18, BP 112/65, SaO2 97
General: Awake, cooperative, tearful and appears frustrated
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: trace pedal edema
Neurologic:
MS: alert, regards examiner, follows simple midline and
appendicular commands, does not follow two-step commands without
mimic. Difficulty naming low frequency objects. Initially
thought
she was ___ years old. did not know month. knows she is at ___.
Frequent paraphasic errors with reading. Recognizes situation
and
husband.
CN: ___, EOMI, no nystagmus, Rigght NLFF w delayed activation,
tongue midline. ? right homonymous hemianopsia in right upper
quadrant
Motor: Right upper and lower extremity ___ in UMN. No
adventitious movements.
Sensory: 50% to light touch and temp on right upper and lower
compared to left. extinguishes to DSS on right.
___: dysmetria w FNF on right, slow finger tapping and hand
opening on right with diminutive amplitudes. HKS intact
+
+
+
+
+
+
+
+
+
+
+
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Exam at the time of transfer from Neurology to Oncology:
Tmax: 37.7 °C (99.9 °F)
Tcurrent: 37.2 °C (98.9 °F)
HR: 84 (84 - 97) bpm
BP: 113/58(75) {110/55(75) - 132/80(93)} mmHg
RR: 27 (14 - 29) insp/min
SpO2: 97%
Heart rhythm: SR (Sinus Rhythm)
General: Awake, cooperative, NAD.
HEENT: MMM
Pulmonary: Breathing comfortably, no tachypnea nor increased
WOB
Cardiac: skin warm, well-perfused.
Abdomen: soft, distended
Extremities: Symmetric, no edema.
Neurologic:
MS: Awake, alert, oriented x3. Follows simple midline and
appendicular commands. Difficulty naming low frequency objects
likely related to expressive aphasia. Frequent paraphasic
errors.
Recognizes situation.
CN: ___, EOMI, no nystagmus, Right NLFF w delayed activation,
tongue midline. Right homonymous hemianopsia in right upper
quadrant.
Motor: Right upper and lower extremity ___ in UMN. Left full
strength. No
adventitious movements.
Sensory: Reduced to LT on right upper and lower
compared to left. Extinguishes to DSS on right.
___: Dysmetria w FNF on right, slow finger tapping and hand
opening on right with diminutive amplitudes. HKS intact.
Gait: deferred.
+
+
+
+
+
+
+
+
+
+
+
+
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
discharge exam
VITAL SIGNS: RR: 12 Pain Score: ___
GEN: pleasant female, temporal wasting, NAD
NEURO: alert, appropriate with right sided facial droop, some
difficulty with speech and word finding. she was c/o
nausea/anxiety and after receiving 2 mg iv ativan, became
sedated, arousable to tactile stimulation
Pertinent Results:
MRI/MRAHEAD WO/NECK MRA &BRAIN
IMPRESSION: 1. Multiple supra- and infratentorial infarcts,
predominantly in cortical, subcortical and watershed areas,
although a many of the lesions appear embolic in nature. 2.
Regions of punctate and gyriform enhancement of the left caudate
head and right occipital and parietooccipital lobes, felt likely
to represent sequela of subacute infarct. However given the
patient's known presumed metastatic disease of the T6 vertebral
body, recommend short interval follow-up in 3 months to document
resolution of enhancement to exclude more worrisome process. 3.
The intracranial and cervical vasculature is patent without
TTE
___
CONCLUSION: The left atrial volume index is normal. There is no
evidence for an atrial septal defect by 2D/color Doppler. The
estimated right atrial pressure is ___ mmHg. There is mild
symmetric left ventricular hypertrophy with a normal cavity
size. There is normal regional and global left ventricular
systolic function. No thrombus or mass is seen in the left
ventricle. Quantitative biplane left ventricular ejection
fraction is 61 %. There is no resting left ventricular outflow
tract gradient. Normal right ventricular cavity size with normal
free wall motion. The aortic sinus diameter is normal for gender
with mildly dilated ascending aorta. The aortic arch diameter is
normal with a mildly dilated descending aorta. The aortic valve
leaflets (3) appear structurally normal. No masses or
vegetations are seen on the aortic valve. There is no aortic
valve stenosis. There is mild [1+] aortic regurgitation. The
mitral valve leaflets are mildly thickened with no mitral valve
prolapse. No masses or vegetations are seen on the mitral valve.
There is trivial mitral regurgitation. The tricuspid valve
leaflets are mildly thickened. No mass/ vegetation are seen on
the tricuspid valve. There is physiologic tricuspid
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is a trivial pericardial effusion. A liver cyst
measuring ~2.5x2.5 cm is seen. There is also a heterogeneous,
irregular appearing echodensity external to the posterior left
atrium, measuring approximately 1.1x1.4 cm, for which chest
imaging (eg CT) may be considered if clinically indicated.
IMPRESSION: No structural cardiac source of embolism (e.g.patent
foramen ovale/atrial septal defect, intracardiac thrombus, or
vegetation) seen. Mild aortic regurgitation
CT CHEST W/CONTRAST INDICATION
___
___ woman with history of metastatic lung cancer status
post treatment with immune therapy complicated by pericarditis
status post pericardiocentesis and window now receiving systemic
chemotherapy. TECHNIQUE: Multi detector CT of the chest was
performed after the administration of intravenous contrast.
Axial coronal and sagittal reconstructions were acquired.
Maximum intensity projections were also acquired DOSE:
Acquisition sequence: 1) Spiral Acquisition 5.3 s, 70.2 cm;
CTDIvol = 13.0 mGy (Body) DLP = 914.8 mGy-cm. 2) Spiral
Acquisition 2.6 s, 34.2 cm; CTDIvol = 12.1 mGy (Body) DLP =
413.4 mGy-cm. 3) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol =
3.3 mGy (Body) DLP = 1.7 mGy-cm. 4) Stationary Acquisition 2.4
s, 0.5 cm; CTDIvol = 13.3 mGy (Body) DLP = 6.7 mGy-cm. Total DLP
(Body) = 1,336 mGy-cm. ** Note: This radiation dose report was
copied from CLIP ___ (CT ABD AND PELVIS WITH CONTRAST)
COMPARISON: To a prior study done on ___ FINDINGS:
THORACIC INLET: The thyroid is unremarkable. There are no
enlarged supraclavicular lymph nodes. BREAST AND AXILLA : There
are no enlarged axillary lymph nodes. MEDIASTINUM: Small
mediastinal nodes are stable. There is moderate cardiomegaly.
There is no pericardial effusion. The esophagus is patulous and
dilated with evidence of wall thickening involving the GE
junction, unchanged. No discrete hilar lymph nodes are seen.
Infiltrative soft tissue surrounding the left hilum and left
lower lobe bronchus is unchanged. There is no pericardial
effusion PLEURA: There is a moderate loculated right pleural
effusion. There is also small loculated left pleural effusion
associated with pleural thickening. There is evidence of pleural
thickening associated with the right pleural fluid, unchanged
since the prior study. LUNG: The interstitium is prominent.
Several nodular opacities in the posterior segment the right
upper lobe (302, 71) are slightly more prominent. There is
worsening of a peripheral interstitial reticular opacities in
both lower lobes which appear to be more confluent (302, 92.
Bands of atelectasis are seen in both lower lobes. Consolidative
opacity in the left lower lobe (302, 136) is unchanged. No new
or growing pulmonary nodules. BONES AND CHEST WALL : Review of
bones shows stable osseous metastasis. UPPER ABDOMEN: Limited
sections through the upper abdomen shows multiple liver lesions
consistent with known metastasis. Please refer to dedicated
report on abdomen which has been dictated separately.
IMPRESSION: Stable bilateral pleural effusions right greater
than left, both associated with pleural thickening and both a
partially loculated. Prominent interstitium bilaterally with
several scattered nodular opacities. Peripheral reticular
opacities bilaterally in both lower lobes posteriorly more
confluent are more prominent than on the prior study, could
represent disease progression however pneumonitis cannot be
excluded. Attention to this on follow-up imaging is recommended.
Osseous metastasis. Hepatic metastasis
CT ABDOMEN PELVIS WITH CONTRAST INDICATION:
___
___ year old woman with metastatic lung cancer s/p treatment with
immunotherapy complicated by pericarditis s/p pericardiocentesis
and window, now receiving systemic chemotherapy.// Interval
change in disease burden? Requested per oncologist. TECHNIQUE:
Oncology 2 phase: Multidetector CT of the abdomen and pelvis was
done as part of CT torso with IV contrast. A single bolus of IV
contrast was injected and the abdomen and pelvis were scanned in
the portal venous phase, followed by scan of the abdomen in
equilibrium (3-min delay) phase. Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on
PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.3 s,
70.2 cm; CTDIvol = 13.0 mGy (Body) DLP = 914.8 mGy-cm. 2) Spiral
Acquisition 2.6 s, 34.2 cm; CTDIvol = 12.1 mGy (Body) DLP =
413.4 mGy-cm. 3) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol =
3.3 mGy (Body) DLP = 1.7 mGy-cm. 4) Stationary Acquisition 2.4
s, 0.5 cm; CTDIvol = 13.3 mGy (Body) DLP = 6.7 mGy-cm. Total DLP
(Body) = 1,336 mGy-cm. COMPARISON: CT abdomen pelvis from ___. FINDINGS: LOWER CHEST: Please refer to separate
report of CT chest performed on the same day for description of
the thoracic findings. ABDOMEN: HEPATOBILIARY: Innumerable
peripherally enhancing hypoattenuating lesions throughout the
liver are increased in size and number. For example, a
conglomeration of these lesions near the right hepatic dome
measure 7.5 x 6.5 x 4.0 cm in aggregate (2:43, 601:32),
previously less than 2 cm. The gallbladder is unremarkable.
There is no intrahepatic or extrahepatic biliary dilatation. The
portal and hepatic veins remain patent. No ascites. PANCREAS:
The pancreas is unremarkable. SPLEEN: New wedge-shaped areas of
hypoenhancement in the lateral and medial aspects of the spleen
(03:20) likely represent infarction. No focal mass lesions are
identified. ADRENALS: The adrenal glands are unremarkable.
URINARY: Bilateral subcentimeter hypoattenuating lesions are too
small to characterize, but are unchanged. The kidneys are
otherwise unremarkable. No hydronephrosis. GASTROINTESTINAL:
There has been interval placement of a gastrostomy tube, which
appears appropriately positioned. Small and large bowel loops
are normal in caliber. PELVIS: The urinary bladder is
unremarkable. There is small free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus and bilateral adnexa are
unremarkable. LYMPH NODES: A large necrotic gastrohepatic node
measures 4.7 x 4.5 x 4.4 cm (2:48, 601:28). No pathologically
enlarged periaortic, mesenteric, pelvic or inguinal lymph nodes
are seen. VASCULAR: There is no abdominal aortic aneurysm.
BONES: A 1.8 cm sclerotic lesion in the L3 vertebral body (2:70)
is unchanged. No new suspicious osseous lesions are identified.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits. Multiple hyperattenuating areas in the low anterior
abdominal subcutaneous fat are likely related to injections.
IMPRESSION: 1. Progression of disease involving the liver and a
gastrohepatic node. 2. New splenic infarcts. 3. Unchanged
sclerotic lesion in the L3 vertebral body. 4. Please refer to
separate report of CT chest performed on the same day for
description of the thoracic findings.
Brief Hospital Course:
Ms. ___ is a ___ with stage IV lung cancer with known
metastases to the pleural space and esophagus s/p x20 cycles
chemo and palliative XRT recently started on adazalinumab who
initially presented with chest pain and was found to have NSTEMI
at OSH with hospital course complicated by acute aphasia, right
sided weakness found to have multiple diffuse embolic strokes.
She was admitted to the Neurology stroke service with expressive
aphasia and right sided weakness secondary to an multiple acute
supra- and infratentorial infarcts, predominantly in cortical,
subcortical and watershed areas, although a many of the lesions
appear embolic in nature. Her symptoms mainly localized to the
left MCA territory (right sided weakness, aphasia, dysarthria.
Of note the read from ___ noted "Regions of punctate and
gyriform enhancement of the left caudate head and right
occipital and parietooccipital lobes, felt likely to represent
sequela of subacute infarct. Her stroke was most likely
secondary to a cardioembolic event given the distribution. Her
known active malignancy and missing doses of lovenox are likely
contributing factors. TTE was negative for cardioembolic source.
She was started on a heparin gtt with PTT maintained in 50-70
range. She was transitioned to lovenox at 1mg/kg BID after
discussion with Oncology and Cardiology.
Further hospital course for other systems:
# CV: NSTEMI: Cardiology was consulted and followed throughout
the admission. Serial troponin were stable. No further chest
pain was reported. Starting aspirin was deferred after
discussing the risks and benefits with cardiology. There was no
evidence of afib on telemetry or EKG. A TTE showed EF 61%, mild
AR, trivial pericardial effusion. BP was allowed to autoregulate
and no PRN medications for hypertension had to be given.
# Oncology: Oncology was consulted, her primary Oncology team
was informed of the admission. As requested by Oncology a CT
torso was obtained showing stable bilateral pleural effusions
right greater than left, a rominent interstitium bilaterally
with several scattered nodular opacities concerning for disease
progression however pneumonitis cannot be excluded. On abdominal
CT progression of disease involving the liver and a
gastrohepatic node, new splenic infarcts and unchanged sclerotic
lesion in the L3 vertebral body were noted. Decision was made to
transfer to the Oncology Service in light of these findings.
# GI/Nutrition: Was kept NPO. PEG feeds were started per home
regimen but were poorly tolerated with nausea and large
residual. Continuous feeds at a KUB was obtained showing no
acute obstruction or free but a distended stomach c/w
dysmotility. PEG feeds held and MIVF were maintained. She did
not want to use her PEG tube anymore due to pain with every use,
even with just medication administration.
On ___ the patient and her family decided to redirect care in
the setting of evidence of disease progression. A decision was
made for comfort measures only as documented in a separate note.
The PACT team and social work teams were consulted and continued
to follow. Medical intervention such as PEG feeds, IVF and blood
draws were stopped. Per discussion with the family and the
primary oncology team, therapy with lovenox was continued but
changed to daily injections of 120mg. She was started on a
fentanyl patch. She can only take medications IV (ie dex,
morphine, zofran), and so was discharged to Hospice.
CODE: confirmed DNR/DNI/CMO and do not transfer to hospital
unless needed for comfort
Nutrition: thin liquids, ground solids for comfort, no tube
feeds
Billing: >30 min spent coordinating care for discharge
Medications on Admission:
Medications - Prescription
1% LIDOCAINE 1% BENADRYL 1% MAALOX - 1% lidocaine 1% benadryl 1%
maalox . Rinse mouth with ___ ml prior to meals four times a
day as needed for pain Dispense - 500 ml solution
ENOXAPARIN - enoxaparin 120 mg/0.8 mL subcutaneous syringe. 120
mg sc daily
FLUOCINONIDE - fluocinonide 0.05 % topical cream. 1 application
twice a day - (Prescribed by Other Provider) (Not Taking as
Prescribed)
FOLIC ACID - folic acid 1 mg tablet. 1 tablet(s) by mouth daily
LISINOPRIL - lisinopril 10 mg tablet. 0.5 (One half) tablet(s)
by
mouth daily - (Prescribed by Other Provider; Dose adjustment -
no new Rx)
LORAZEPAM [ATIVAN] - Ativan 0.5 mg tablet. 1 tablet(s) by mouth
twice a day as needed for nausea/anxiety do not drink or drive
while taking. this medication can cause sedation.
ONDANSETRON - ondansetron 8 mg disintegrating tablet. 1
tablet(s)
by mouth every 8 hours as needed for nausea or vomiting
Inability
to swallow pills; ICD10- C___.89
ONDANSETRON HCL - ondansetron HCl 8 mg tablet. 1 tablet(s) by
mouth every 8 hours as needed for nausea ICD 10 C34.90 C34.90
MALIGNANT NEOPLASM OF LUNG
PANTOPRAZOLE [PROTONIX] - Protonix 40 mg granules
delayed-release
packet. 40 mg by mouth two times daily Inability to swallow
pills; ICD10- C___.89 Secondary malignant neoplasm of other
digestive organs
POTASSIUM CHLORIDE - potassium chloride 20 mEq/15 mL oral
liquid.
20 mEq by mouth daily
PROCHLORPERAZINE MALEATE - prochlorperazine maleate 5 mg tablet.
___ tablet(s) by mouth every 6 hours as needed for nausea and
vomiting
Medications - ___
ACETAMINOPHEN [ACETAMINOPHEN EXTRA STRENGTH] - Acetaminophen
Extra Strength 500 mg tablet. 2 tablet(s) by mouth twice a day
as
needed for pain - (OTC)
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - Vitamin D3 1,000
unit
tablet. 1 tablet(s) by mouth daily - (OTC)
DOCUSATE SODIUM - docusate sodium 100 mg capsule. 1 capsule(s)
by
mouth twice a day as needed for Constipation - (Prescribed by
Other Provider; ___)
LACTOSE-REDUCED FOOD WITH FIBR [ISOSOURCE 1.5 CAL] - Isosource
1.5 Cal 0.07 gram-1.5 kcal/mL liquid for tube feed. 5 cartons
daily by PEG (1250ml/day) BOLUS
LIDOCAINE HCL-MENTHOL [ICY HOT(LIDOCAINE HCL-MENTHOL)] - Icy Hot
(lidocaine HCl-menthol) 4 %-1 % topical cream. Apply to painful
area on back three times daily as needed for pain
PHENOL [CHLORASEPTIC THROAT SPRAY] - Chloraseptic Throat Spray
1.4 % aerosol. 5 SPRY PO every 2 hours as needed for sore throat
- (Prescribed by Other Provider)
SIMETHICONE [ANTI-GAS MAXIMUM STRENGTH] - Anti-Gas Maximum
Strength 166 mg capsule. 1 capsule(s) by mouth every 8 hours as
needed for flatulence
Discharge Medications:
1. Dexamethasone 6 mg IV DAILY
2. Enoxaparin Sodium 120 mg SC DAILY
3. Fentanyl Patch 12 mcg/h TD Q72H
4. LORazepam 0.5-1 mg IV Q4H:PRN anxiety
5. Morphine Sulfate 4 mg IV Q2H:PRN Pain or respiratory
distress
6. Ondansetron ___ mg IV Q6H:PRN nausea/vomiting
7. Sodium Chloride 0.9% Flush ___ mL IV Q8H and PRN, line
flush
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Multiple embolic strokes, NSTEMI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms ___,
You were hospitalized due to symptoms of slurred speech and word
finding difficulties resulting from an ACUTE ISCHEMIC STROKE, a
condition where a blood vessel providing oxygen and nutrients to
the brain is blocked by a clot. This was a result of your lung
cancer. You made the decision to pursue comfort measures only
and were transitioned to hospice care. Your symptoms were well
managed with morphine. We wish you the best.
Your ___ Team
Followup Instructions:
___
|
10655970-DS-5
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| 5 |
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2126-03-11 22:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
ciprofloxacin
Attending: ___
___ Complaint:
perforated gastric ulcer
Major Surgical or Invasive Procedure:
___: ___ repair of gastric ulcer
History of Present Illness:
___ w/ h/o diverticulitis and colovesicular fistula who is
s/p robotic sigmoid colectomy on ___ who now presents with
abdominal pain. He has otherwise been doing well recently,
however he had sudden onset of right-sided pain this morning. It
has since progressed to diffuse abdominal pain. His pain has
minimally improved with pain medications. He denies nausea,
vomiting. Last BM and flatus was today, and described as normal
stool without any blood. He has not had any fevers or chills, no
dietary changes.
Past Medical History:
PMH: gout
PSH: knee surgery x2
Social History:
___
Family History:
No h/o IBD, father with colon cancer, sister with breast
cancer
Physical Exam:
AFVSS
NAD
RRR, no M/R/G
Ab soft, non tender, incision clean dry and intact
Neuro grossly intact
Pertinent Results:
___ 12:24PM BLOOD Lactate-1.1
___ 12:05PM BLOOD Albumin-3.9 Calcium-8.9 Phos-3.3 Mg-2.0
___ 06:00AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.1
___ 12:05PM BLOOD Lipase-48
___ 12:05PM BLOOD ALT-15 AST-27 AlkPhos-71 TotBili-0.2
DirBili-0.2 IndBili-0.0
___ 12:05PM BLOOD Glucose-100 UreaN-34* Creat-1.1 Na-141
K-4.7 Cl-107 HCO3-22 AnGap-17
___ 06:00AM BLOOD Glucose-98 UreaN-7 Creat-0.8 Na-142 K-3.5
Cl-107 HCO3-26 AnGap-13
___ 12:05PM BLOOD ___ PTT-25.3 ___
___ 06:00AM BLOOD Plt ___
___ 12:05PM BLOOD Neuts-87.5* Lymphs-7.9* Monos-3.8*
Eos-0.4* Baso-0.2 Im ___ AbsNeut-4.43 AbsLymp-0.40*
AbsMono-0.19* AbsEos-0.02* AbsBaso-0.01
___ 12:05PM BLOOD WBC-5.1# RBC-3.36* Hgb-10.9* Hct-33.3*
MCV-99* MCH-32.4* MCHC-32.7 RDW-12.6 RDWSD-45.1 Plt ___
___ 06:00AM BLOOD WBC-6.4 RBC-2.89* Hgb-9.2* Hct-28.2*
MCV-98 MCH-31.8 MCHC-32.6 RDW-12.1 RDWSD-44.0 Plt ___
Brief Hospital Course:
Mr. ___ presented to ___ holding at ___ on ___
with a perforated gastric ulcer. He went to the OR for ___
patch repair of a perforated gastric ulcer. He tolerated the
procedure well without complications (Please see operative note
for further details). After a brief and uneventful stay in the
PACU, the patient was transferred to the floor for further
post-operative management.
Neuro: Pain was initially controlled with dilaudid PCA until
the patient had return of bowel function. At this point the
patient was transitioned to PO pain meds.
CV: no issues
Pulm: no issues
GI: NGT was kept in place until POD 4 for decompression. NGT
was removed on POD 4, and diet was subsequently advanced in a
stepwise fashion until the patient was tolerating a regular diet
without difficulty.
GU: foley was removed on POD 2, patient voided appropriately
without issue.
ID: no issues
Heme: No major issues.
On POD 5, the patient was discharged to home. At discharge, the
patient was tolerating a regular diet, passing flatus, stooling,
voiding, and ambulating independently. The patient will
follow-up in the clinic in ___ weeks. This information was
communicated to the patient directly prior to discharge.
[ ] Post-Operative Ileus resolving w/o NGT
[ ] Post-Operative Ileus requiring management with NGT
[ ] UTI
[ ] Wound Infection
[ ] Anastomotic Leak
[ ] Staple Line Bleed
[ ] Congestive Heart failure
[ ] ARF
[ ] Acute Urinary retention, failure to void after Foley D/C'd
[ ] Acute Urinary Retention requiring discharge with Foley
Catheter
[ ] DVT
[ ] Pneumonia
[ ] Abscess
[x] None
Social Issues Causing a Delay in Discharge:
[ ] Delay in organization of ___ services
[ ] Difficulty finding appropriate rehabilitation hospital
disposition.
[ ] Lack of insurance coverage for ___ services
[ ] Lack of insurance coverage for prescribed medications.
[ ] Family not agreeable to discharge plan.
[ ] Patient knowledge deficit related to ileostomy delaying
discharge.
[x] No social factors contributing in delay of discharge.
Medications on Admission:
allopurinol ___ daily, gemfibrozil 600mg BID, indomethacin
50mg daily, lorazepam 1mg qhs prn, simvastatin 20mg daily
Discharge Medications:
1. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
4. Acetaminophen 650 mg PO TID
Do not exceed 3 grams per day
RX *acetaminophen 500 mg 1 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
gastric perforation
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
You were admitted to the hospital after ___ patch repair
for surgical management of your Gastric Ulcer. You have
recovered from this procedure well and you are now ready to
return home. Samples from your colon were taken and this tissue
has been sent to the pathology department for analysis. You will
receive these pathology results at your follow-up appointment.
If there is an urgent need for the surgeon to contact you
regarding these results they will contact you before this time.
You have tolerated a regular diet, are passing gas and your pain
is controlled with pain medications by mouth. You may return
home to finish your recovery.
Please monitor your bowel function closely. You may or may not
have had a bowel
movement prior to your discharge which is acceptable, however it
is important that you have a bowel movement in the next ___
days. After anesthesia it is not uncommon for patients to have
some decrease in bowel function but you should not have
prolonged constipation. Some loose stool and passing of small
amounts of dark, old appearing blood are expected. However, if
you notice that you are passing bright red blood with bowel
movements or having loose stool without improvement please call
the office or go to the emergency room if the symptoms are
severe. If you are taking narcotic pain medications there is a
risk that you will have some constipation. Please take an over
the counter stool softener such as Colace, and if the symptoms
do not improve call the office. If you have any of the following
symptoms please call the office for advice or go to the
emergency room if severe: increasing abdominal distension,
increasing abdominal pain, nausea, vomiting, inability to
tolerate food or liquids, prolonged loose stool, or extended
constipation.
You have surgical incisions on your abdomen which are closed
with internal sutures and a skin glue called Dermabond. These
are healing well however it is important that you monitor these
areas for signs and symptoms of infection including: increasing
redness of the incision lines, white/green/yellow/malodorous
drainage, increased pain at the incision, increased warmth of
the skin at the incision, or swelling of the area. Please call
the office if you develop any of these symptoms or a fever. You
may go to the emergency room if your symptoms are severe.
You may shower; pat the incisions dry with a towel, do not rub.
If closed with steri-strips (little white adhesive strips)
instead of Dermabond, these will fall off over time, please do
not remove them. Please no baths or swimming for 6 weeks after
surgery unless told otherwise by your surgical team.
You will be prescribed narcotic pain medication. This medication
should be taken when you have pain and as needed as written on
the bottle. This is not a standing medication. You should
continue to take Tylenol for pain around the clock and you can
also take Advil. Please do not take more than 3000mg of Tylenol
in 24 hours. Do not drink alcohol while taking narcotic pain
medication or Tylenol. Please do not drive a car while taking
narcotic pain medication.
No heavy lifting greater than 6 lbs for until your first
post-operative visit after surgery. Please no strenuous activity
until this time unless instructed otherwise by Dr. ___ Dr.
___.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
Followup Instructions:
___
|
10656103-DS-13
| 10,656,103 | 21,498,355 |
DS
| 13 |
2172-06-17 00:00:00
|
2172-06-18 13:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ male PMHx of spinal stenosis c/b b/l foot drop,
wheelchair bound s/p multiple spine surgeries, who presents with
dyspnea progressive over the couple weeks. 2 weeks ago, patient
developed increasing RLE edema and 20mg BID by his NP. No
fevers.
2 days ago, patient developed increasing shortness of breath.
Worse at night, when laying flat, requiring ___ pillows. Today
at
4 AM, patient woke up with sudden shortness of breath. Constant,
even w hen sitting up. Denies any associated fevers, chills,
nausea, vomiting, chest pain, belly pain, dysuria, bowel
symptoms. Has been urinating more, thought likely ___ Lasix. Has
hx of frequent UTI, and his presenting symptoms is lethargy. He
has had RLE edema for almost ___ years but worse over the last 2
weeks. He has an ulcer on his R shin over the past couple weeks,
which a ___ comes for dressing changes.
Patient is wheelchair bound at baseline. Lives with wife. Has
home health aide and ___.
In the ED, he triggered on arrival for respiratory distress,
placed on BiPAP.
Past Medical History:
Spinal stenosis s/p spine surgery
B/l foot drop, wheelchair bound
Hx of frequent UTI
Hx of ureteral stent
Social History:
___
Family History:
No family hx of CAD, DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: Afebrile ___ 18 97% 2LNC
General: breathing comfortably on NC
HEENT: MMM. PERRL. Clear OP
Neck: JVP not elevated
CV: RRR. No mrg
Lungs: speaking in full sentences. Decent breath sounds b/l with
faint expiratory wheezing
Abdomen: Soft, NTND. +BS.
Extremities: 2+ RLE edema. ulcer on R shin with surrounding
erythema. Cool feet.
Neuro: No focal deficits. Moves all extremieties. Contracted
fingers b/l chronic.
DISCHARGE PHYSICAL EXAM:
=========================
24 HR Data (last updated ___ @ 812)
Temp: 98.2 (Tm 98.5), BP: 112/67 (104-123/55-81), HR: 108
(91-108), RR: 18, O2 sat: 95% (95-100), O2 delivery: Ra, Wt:
182.98 lb/83.0 kg
General: Alert, sitting up in bed. No acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Lungs clear to auscultation bilaterally
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext:2+ RLE edema. ulcer on R shin with improved erythema
surrounding. 1+ edema LLE
Neuro: Face grossly symmetric. Moving all limbs with purpose
against gravity. Not dysarthric.
Pertinent Results:
ADMISSION LABs:
===============
___ 06:32PM BLOOD WBC-8.0 RBC-4.52* Hgb-11.9* Hct-37.8*
MCV-84 MCH-26.3 MCHC-31.5* RDW-14.9 RDWSD-45.4 Plt Ct-UNABLE TO
___ 06:32PM BLOOD Neuts-63.8 Lymphs-17.0* Monos-9.7
Eos-8.5* Baso-0.4 Im ___ AbsNeut-5.12 AbsLymp-1.36
AbsMono-0.78 AbsEos-0.68* AbsBaso-0.03
___ 06:32PM BLOOD ___ PTT-26.8 ___
___ 06:32PM BLOOD Glucose-110* UreaN-42* Creat-2.0* Na-139
K-4.4 Cl-100 HCO3-21* AnGap-18
___ 06:32PM BLOOD CK(CPK)-91
___ 06:32PM BLOOD cTropnT-0.02*
___ 06:32PM BLOOD Calcium-8.9 Phos-4.9* Mg-2.1
___ 06:38PM BLOOD ___ pO2-47* pCO2-45 pH-7.35
calTCO2-26 Base XS-0
___ 06:38PM BLOOD Lactate-1.8
___ 06:38PM BLOOD O2 Sat-78
RELEVANT LABS:
==============
___ 12:51AM BLOOD Glucose-152* UreaN-44* Creat-2.1* Na-137
K-4.2 Cl-100 HCO3-19* AnGap-18
___ 06:32PM BLOOD CK-MB-4 proBNP-1561*
___ 06:32PM BLOOD cTropnT-0.02*
___ 12:51AM BLOOD cTropnT-0.02*
___ 12:51AM BLOOD cTropnT-0.02*
___ 06:32PM BLOOD CK(CPK)-91
___ 06:38PM BLOOD ___ pO2-47* pCO2-45 pH-7.35
calTCO2-26 Base XS-0
DISCHARGE LABS:
===============
___ 05:56AM BLOOD WBC-9.5 RBC-4.11* Hgb-11.0* Hct-33.8*
MCV-82 MCH-26.8 MCHC-32.5 RDW-15.4 RDWSD-45.7 Plt Ct-UNABLE TO
___ 05:56AM BLOOD Glucose-89 UreaN-59* Creat-2.3* Na-137
K-3.5 Cl-98 HCO3-24 AnGap-15
___ 05:56AM BLOOD Calcium-8.5 Phos-4.7* Mg-1.9
IMAGING & MICROBIOLOGY
======================
__________________________________________________________
___ 6:58 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
PSEUDOMONAS AERUGINOSA. >100,000 CFU/mL.
PREDOMINATING ORGANISM INTERPRET RESULTS WITH CAUTION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- 16 S
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- =>16 R
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ =>16 R
__________________________________________________________
___ 6:32 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 6:32 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
TTE ___
There is suboptimal image quality to assess regional left
ventricular function. Overall left ventricular systolic
function is normal. The right ventricle has normal free wall
motion. The aortic valve leaflets are moderately
thickened. Aortic valve stenosis is present (not quantified).
IMPRESSION: Very poor image quality. Grossly preserved
biventricular systolic function. Aortic
stenosis, probably mild (although not quantifiable on this
study).
___
No evidence of deep venous thrombosis in the right or left lower
extremity
veins. Subcutaneous edema is identified in both legs.
CXR ___
No acute cardiopulmonary abnormality.
TTE ___
There is no evidence for an atrial septal defect by 2D/color
Doppler. The estimated right atrial pressure is ___ mmHg. There
is mild symmetric left ventricular hypertrophy with a normal
cavity size. There is suboptimal image quality to assess
regional left ventricular function. Overall left ventricular
systolic function is normal. There is no resting left
ventricular outflow tract gradient. Diastolic parameters are
indeterminate. Normal right ventricular cavity size with normal
free wall motion. There is a normal ascending aorta diameter for
gender. The aortic valve is not well seen. The mitral valve is
not well visualized. The pulmonic valve leaflets are not well
seen. The tricuspid valve is not well seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Extremely limited study/suboptimal image quality
(unfavorable anatomy for echo). Globally preserved biventricular
systolic function. Possible aortic stenosis, but appears to be
minimal-mild. Normal pulmonary pressure.
Brief Hospital Course:
SUMMARY:
=========
___ male PMHx of spinal stenosis c/b b/l foot drop,
wheelchair bound s/p multiple spine surgeries, COPD, BPH,
recurrent UTIs, who presented with dyspnea requiring BiPAP in
the ED for which he was admitted to the MICU. He was
concurrently treated for COPD and heart failure exacerbations
with a dose of methylprednisone and nebulizers as well as a dose
of IV Lasix. His respiratory status quickly improved and he was
able to be weaned to room air. UA was concerning for infection
and CTX was started, he was also found to have a cellulitis
surrounding a chronic venous stasis ulcer on his right lower
extremity. Ultimately urine culture grew MDR pseudomonas and
patient was transitioned to ceftazidime to complete a 7 day
course. With his improved respiratory status he was transferred
out of the ICU the day after admission. He was found to be
persistently wheezing on lung exam so duo-nebs were continued
with improvement in his exam and subjective dyspnea. He was
transitioned to a daily tiotropium inhaler with a rescue
albuterol inhaler before discharge. Patient also noted to have
___ which was felt to be in the setting of recently increased
home diuretic dose and receiving IV Lasix in house. His home
dose was reduced to 40mg Daily before discharge. Recurrent UTIs
felt to be likely related to urinary retention from BPH and
tamsulosin was started while hospitalized.
TRANSITIONAL ISSUES:
====================
-Follow Up Appointments: PCP when patient leaves rehab
-Follow Up Labs: Chem Panel by ___ to ensure stable or
downtrending creatinine
-New Medications: Tamsulosin, Tiotroprium Inhaler, Albuterol
Inhaler
-Changed Medications: Furosemide 40mg BID to Furosemide 40mg
Daily
[]Patient would benefit from ongoing titration of COPD
medications
[]Doxycycline end date ___, Cetazidime end date ___
[]Patient found to be retaining urine on post-void residual
scan. Started tamsulosin given history of BPH. Would recommend
ongoing bladder scans Q6-8H to ensure does not need intermittent
catheterization.
[]Diabetes listed as diagnosis in outpatient chart, A1c checked
inpatient and was 5.3%, sugars were well controlled
#Hypoxemic Respiratory Failure
#C/f Heart failure
#COPD
Patient presented with worsening b/l ___ edema, orthopnea with
elevated proBNP consistent with HF although no pulmonary edema
seen on CXR. No fever or leukocytosis on admission so felt
unlikely to be pneumonia. PE considered as patient tachycardic
with R > L ___ edema but now with LENIs showing no DVT. Patient
able to be weaned to room air from BiPAP after only one dose of
IV Lasix 40mg in ED. Focused TTE ___ showed normal LV function.
his home Lasix dose of 40mg BID was restarted on transfer to
medicine floor. Given persi Further collateral obtained ___ from
___ NP who stated patient has a history of COPD. Patient
denies knowledge of diagnosis or lung
issues but does state has inhaler at home he occasionally uses.
Denies cough or increased sputum production prior to admission
(though notably poor historian). COPD exacerbation felt as
though could certainly be a contributor to presentation given
diffuse wheezing on transfer to floor however, notably patient
was never hypercarbic during episode of respiratory distress. He
received Duonebs Q6H while admitted with improvement in
subjective dyspnea and in wheezing on exam. At discharge he was
trasitionined to Spireva daily and an albuterol inhaler prn.
#Recurrent UTIs
#BPH
#Urinary Retention
Patient with history of frequent UTIs, denies any symptoms
currently, but UA w/ pyuria on admission so CTX started. Urine
culture ultimately grew MDR pseudomonas and plan made to
transition patient to Ceftazidime to complete ___ased
on sensitivities. Atrius chart reviewed and found history of BPH
and incontinence related to BPH. Patient was not previously on
any medications to treat this as an outpatient. Bladder scan
obtained post-void while patient admitted revealing urinary
retention which was felt to be a likely contributor to recurrent
infections. Tamsulosin was started before discharge to help
treat BPH.
___ on CKD
Cr of 2.0 on admission, has since uptrended to 2.3. Most recent
baseline per outside records was around 1.8. Unclear chronicity
to Cr elevation above 1.8. Reassuringly patient continued to
make adequate urine throughout admission. Cr rise was felt to
likely be in the setting of overdiuresis given increased home
Lasix dose prior to admission and IV Lasix on arrival. His Lasix
dose was decreased to 40mg daily prior to discharge.
#RLE ulceration/Cellulitis
Patient noted to have erythema concerning for cellulitis around
RLE ulceration on admission. Wound care was consulted and
patient was treated with ceftriaxone and doxycycline to complete
___nding ___.
#Type II Diabetes:
History per atrius chart. No recent A1c on file. Not on any
anti-hyperglycemic medications as outpatient. Blood sugars were
relatively well controlled on chem panels while inpatient. A1c
checked while in house and returned at 5.3%.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 40 mg PO BID
2. Modafinil 100 mg PO DAILY
3. Colchicine 0.6 mg PO DAILY:PRN Gout
4. ___ (cranberry extract) 500 mg oral DAILY
5. Vitamin B Complex 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN Wheezing, SOB
3. CefTAZidime 1 g IV Q24H
4. Doxycycline Hyclate 100 mg PO BID
5. Senna 8.6 mg PO BID:PRN Constipation
6. Tamsulosin 0.4 mg PO QHS
7. Tiotropium Bromide 1 CAP IH DAILY
8. Furosemide 40 mg PO DAILY
9. Colchicine 0.6 mg PO DAILY:PRN Gout
10. ___ (cranberry extract) 500 mg oral DAILY
11. Modafinil 100 mg PO DAILY
12. Vitamin B Complex 1 CAP PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Acute Hypoxic Respiratory Failure
UTI
Cellulitis
Venous Stasis Ulcer
BPH
Volume Overload
Acute Heart Failure Exacerbation
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You were admitted to the hospital because you were having
difficulty breathing at home
WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?
-You were having difficulty breathing and your oxygen level was
found to be low. We used a special mask to help you get more
oxygen into you lungs. We also gave you medications that you
breathe in and medications through your IV to help you breathe
better. Your breathing quickly improved and you were able to
breathe normally on your own again.
-A urine test was concerning for an infection so we treated this
with an antibiotic through your IV.
-You were found to have a wound on your leg likely because of
the poor blood flow. We found that the skin surrounding this
wound was likely infected as well and also treated this
infection with antibiotics.
-Your heart function was evaluated with a test called an
echocardiogram that showed the left side of your heart was
working normally
-Since you were diagnosed with COPD in the past and you were
wheezing when you breathed we continued to give you medications
that you inhaled to treat COPD and your breathing continued to
get better.
-Your kidney function was noted to be a little worse than the
last time it was checked in ___. It was felt that this was
likely due to your recently increased dose of Lasix that you
started taking before admission to the hospital. We reduced your
dose as we felt you did not need so much of this medications.
WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL?
- Continue to take all your medicines as prescribed below.
- Show up to your appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10656173-DS-10
| 10,656,173 | 25,753,489 |
DS
| 10 |
2176-08-14 00:00:00
|
2176-08-16 20:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
1. Status post fall
2. Liver failure
3. Acute kidney injury
4. Lactic acidosis
Major Surgical or Invasive Procedure:
Bedside closure of the nasal bridge laceration
History of Present Illness:
___ with alcoholic liver cirrhosis, who was admitted to the
hospital after a fall at home, whereby she slipped in the
bathroom and hit her face on the side of the sink. She was found
by her parents later in the day and was brought to the emergency
room for concern of bleeding. Her hematocrit in the ED bay was
found to be 14, and her injuries were limited to 1cm laceration
on the nasal bridge, which was closed by plastic surgery at
bedside. She was admitted to the intensive care unit for
observation.
Past Medical History:
Alcoholic liver cirrhosis
Social History:
___
Family History:
No history of liver disease
Physical Exam:
ADMISSION PHYSICAL TO THE MICU ON DAY 3 OF HOSPITALIZATION
Vitals: T 98.4, BP 110/69, HR 97, 100% RA
GENERAL: Alert, oriented x3, no acute distress, no asterixis
HEENT: Sclera icteric, MMM, oropharynx clear; + ecchymosis under
eyes and over nasal bridge
NECK: supple, JVP not elevated
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: + telangiectasias on chest, + ecchymosis under eyes
NEURO: CNII-XII grossly intact, ___ ___ strength
DISCHARGE EXAM
VS: Tc/Tm 99.4 90-110s/50-60s 60-70s 18 98
GENERAL: Alert, oriented x3, no acute distress, no asterixis
HEENT: Sclera icteric, MMM, oropharynx clear; + ecchymosis
under eyes and over nasal bridge
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: + telangiectasias on chest, + ecchymosis under eyes
NEURO: no asterixis
Pertinent Results:
ADMISSION LABS
___ 04:28PM BLOOD WBC-18.1* RBC-1.18* Hgb-4.0* Hct-14.0*
MCV-119* MCH-33.9* MCHC-28.6* RDW-16.5* RDWSD-70.2* Plt Ct-48*
___ 07:19PM BLOOD WBC-13.4* RBC-1.47* Hgb-4.7* Hct-16.0*
MCV-109*# MCH-32.0 MCHC-29.4* RDW-20.3* RDWSD-79.1* Plt Ct-33*
___ 11:45PM BLOOD WBC-8.6 RBC-1.37* Hgb-4.2* Hct-13.6*
MCV-99*# MCH-30.7 MCHC-30.9* RDW-21.4* RDWSD-73.9* Plt Ct-49*
___ 03:44AM BLOOD WBC-8.1 RBC-2.49*# Hgb-7.6*# Hct-23.1*
MCV-93 MCH-30.5 MCHC-32.9 RDW-19.0* RDWSD-57.4* Plt Ct-37*
___ 04:28PM BLOOD ___ PTT-38.7* ___
___ 03:44AM BLOOD Ret Aut-5.8* Abs Ret-0.15*
___ 04:28PM BLOOD UreaN-26* Creat-2.3*
___ 07:19PM BLOOD Glucose-94 UreaN-24* Creat-1.6* Na-135
K-5.8* Cl-102 HCO3-9* AnGap-30*
___ 11:45PM BLOOD Glucose-120* UreaN-25* Creat-1.2* Na-136
K-4.2 Cl-104 HCO3-13* AnGap-23*
___ 04:28PM BLOOD CK(CPK)-266*
___ 07:19PM BLOOD ALT-202* AST-1013* AlkPhos-154*
TotBili-6.9*
IMAGING
___ RUQ US
Coarse echogenic liver with cirrhosis and portal hypertension.
Patent umbilical vein. Numerous nodules again seen in the liver
which have been identified on the prior ultrasound as well as an
MRI of ___. These may well represent regenerative
nodules which cannot be accurately characterized, and require a
repeat MR by ___ with contrast for accurate evaluation.
Possibility of HCC cannot be excluded
___ TTE
The left atrium is mildly dilated. The estimated right atrial
pressure is at least 15 mmHg. Left ventricular wall thicknesses
are normal. The left ventricular cavity is mildly dilated.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is low normal (LVEF 50%). The
estimated cardiac index is high (>4.0L/min/m2). Tissue Doppler
imaging suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. No masses or
vegetations are seen on the aortic valve. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. No mass or vegetation is seen on the mitral valve.
Mild (1+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. No vegetation/mass is seen
on the pulmonic valve. There is a very small pericardial
effusion. There are no echocardiographic signs of tamponade.
IMPRESSION: Mildly dilated left ventricle with low normal global
systolic function with very high cardiac output (findings
consistent with known liver disease). No 2D echocardiographic
evidence of endocarditis. Very small pericardial effusion.
___ MRI LIVER W/ AND W/O
1. Cirrhotic liver with splenomegaly, esophageal and splenic
varices, and
recanalization of the paraumbilical vein consistent with portal
hypertension.
No ascites.
2. Multiple small T1 and T2 bright lesions, many of which are
fat containing,
scattered throughout the liver most consistent with regenerative
nodules.
3. Previously identified pancreatic head cyst not evaluated on
today's
examination.
4. New apparent partial filling defect within mid SMA, not seen
on prior CT
abdomen/pelvis from ___. This most likely represents
artifact,
unless the patient develops new correlative symptoms.
CULTURES
___ 12:15 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ ___
23:20.
DISCHARGE LABS
___ 05:14AM BLOOD WBC-7.2 RBC-2.36* Hgb-7.5* Hct-22.4*
MCV-95 MCH-31.8 MCHC-33.5 RDW-20.9* RDWSD-70.7* Plt ___
___ 05:14AM BLOOD Plt ___
___ 05:14AM BLOOD ___
___ 05:14AM BLOOD Glucose-109* UreaN-4* Creat-0.5 Na-132*
K-3.7 Cl-102 HCO3-22 AnGap-12
___ 05:14AM BLOOD ALT-21 AST-85* AlkPhos-161* TotBili-5.5*
___ 05:14AM BLOOD Calcium-7.9* Phos-3.9 Mg-1.6
___ 03:59AM BLOOD ___ pO2-49* pCO2-26* pH-7.45
calTCO2-19* Base XS--3
Brief Hospital Course:
Ms. ___ is a ___ y/o female with a past medical history of
EtOH cirrhosis c/b HE who presented to ___ on ___ s/p fall
c/b facial laceration and severe anemia. Patient was admitted to
the intensive care unit on ___ for hematocrit monitoring.
She was transferred to the floor on ___ for further management.
Patient was seen by the hepatology service given her ongoing
decompensated alcoholic liver cirrhosis, and per their
evaluation was transferred to hepatology service. Patient was
transferred to the MICU for management of alcohol withdrawal and
then improved and was transferred to the floor.
# Alcohol withdrawal: patient has a history of withdrawals
however denies having had seizures in the past. Patient was
started on phenobarbital protocol on ___. Upon arrival to the
MICU the patient was without hallucinations, tremors or
hemodynamic changes. Her phenobarb was continued and she was
monitored closely. She received hydroxyzine for anxiety.
# EtOH cirrhosis: MELD 24 on admission. Patient reportedly has
undergone an extensive workup prior to admission for her
cirrhosis and this has been attributed to her alcohol use. She
was continued on lactulose and started on rifaximin. RUQ US
showed evidence of liver nodules and recommended MRI to evaluate
nodules. MRI showed no evidence of HCC . Patient was on nadolol
previously. EGD was performed prior to discharge and showed no
varices requiring banding.
# Transaminitis: attributed to ischemic hepatitis and alcohol
use.
# Anemia: attributed to acute blood loss in the setting of
facial laceration. She received 5U pRBC with stabilization of
blood counts. She does have evidence of low haptoglobin,
elevated LDH and bilirubin raising the concern for hemolysis.
Coombs test was negative. She had no signs of GI bleeding.
# MSSA and GNR bacteremia: There was concern for catheter
associated bloodstream infection as patient was febrile and had
positive blood cultures with a CVL. No history of IVDU. She was
started on vanco initially and this was transitioned to
nafcillin as sensitivies grew MSSA. ID was consulted. TTE showed
no vegetations. Patient transitioned to cefazolin. When
cultures grew provetella, also started on 14 day course of
flagyl. Fevers resolved w/ treatment. Dental evaluation was
advised based on Prevotella bacteremia.
# Nasal bridge laceration: sutured w/ plastic surgery f/u.
# Communication: HCP: none chosen; contact Dr. ___,
father c: ___/ h: ___
# Code: Full, presumed
Transitional Issues:
-ABX:
-Cefazolin 2g IV Q8H x 4 weeks. Last day: ___
-Flagyl 500mg PO Q8H x 2 Weeks. Last day: ___
-Follow up with ID to reassess OPAT
-Please Draw WEEKLY: CBC with differential, BUN, Cr and Fax
results to ___ ATTN: ___ CLINIC
-Consider treatment of anxiety as outpatient as patient may be
self-medicating with alcohol
-Continue to encourage patient to seek help for alcohol
abuse/dependence
-F/u with plastic surgery for further management of facial
laceration
-Consider discontinuing lactulose in future. No history of HE,
but started empirically in ICU given decompensation of liver
disease.
Medications on Admission:
Lactulose unknown dose BID
Discharge Medications:
1. CeFAZolin 2 g IV Q8H
RX *cefazolin in dextrose (iso-os) 2 gram/50 mL 2 g IV every 8
hours Disp #*90 Intravenous Bag Refills:*0
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Lactulose 30 mL PO TID
RX *lactulose 20 gram/30 mL 30 mL by mouth three times per day
Refills:*0
4. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three
times per day Disp #*29 Tablet Refills:*0
5. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Alcoholic Cirrhosis
Sepsis
Alcohol withdrawal
hemorrhage
facial laceration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because you cut your face when
you fell and lost a significant amount of blood. We gave you
blood transfusions and put stitches in your wound. You were also
growing 2 types of bacteria in your blood so we started you on
antibiotics. You will require 4 weeks total of IV antibiotics
and 2 weeks total of oral antibiotics.
Please do not drink alcohol. If you continue to drink alcohol,
you will likely die of alcoholic liver disease.
Please follow up with your PCP and in our liver clinic and in
the plastic surgery clinic.
It was a pleasure taking care of you.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10656173-DS-11
| 10,656,173 | 25,778,760 |
DS
| 11 |
2177-10-14 00:00:00
|
2177-10-15 12:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
Intubated at OSH
___ CVL
___ Bronchoscopy
___ Re-Intubated
___ Extuabted
___ Re-Intubated
___ Bronchoscopy
___ Bronchoscopy
___ Bronchoscopy
___ Extubated
___ Fiberoptic endoscopic evaluation of the nasopharnyx,
epiglottis, true vocal cords, subglottis
History of Present Illness:
___ with history of alcoholic liver cirrhosis, who was
transferred from OSH with concern for respiratory distress. She
first presented on the evening of ___ by EMS to ___ with
shortness of breath and fatigue. Per OSH records, SOB was
described as moderate, gradual in onset but worsening over 3
days, with associated cough but no abdominal pain, chest pain,
fever, sputum or wheezing. Patient further denied any falls,
bleeding or melena. On evaluated she was found to be satting 80%
on room air, which only corrected to 89% on nonrebreather. She
was found to have a hematocrit of 8.8. She received a unit of
blood, after this first unit her respiratory distress worsened
and she was intubated. Initial lactate was 10.7 and INR was 3.7.
She received 2 more units of crossmatched RBCs. Rectal exam
notable for being guaiac negative brown stool. She was
transferred to ___ for higher level of care.
Of note, patient was last admitted to ___ ICU ___ year ago in
the setting of facial laceration and bacteremia. Since then she
has not sought out medical care and has continued drinking.
Past Medical History:
Alcoholic liver cirrhosis
Social History:
___
Family History:
No history of liver disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VITALS: see Metavision
GEN: intubated, sedated, does not respond to voice, touch or
sternal rub
HEENT: Sclera icteric, pinpoint pupils, ecchymoses under eyes
LUNGS: coarse breath sounds in upper fields, no breath sounds
appreciated at lung bases anteriorly and laterally
CV: tachycardic, normal S1 S2, no murmurs, rubs, gallops
ABD: soft, non-tender, mildly distended, bowel sounds present,
no
rebound tenderness or guarding, no fluid wave
EXT: Warm, well perfused, 3+ edema in ankle, ___ to mid-shin
SKIN: diffusely jaundiced, ecchymoses per above
NEURO: patient intubated, sedated
DISCHARGE PHYSICAL EXAM:
========================
VS: T 99.1 BP 113/66 HR 99 RR 18 O2 sat 96% RA
GENERAL: Resting comfortably in bed, NAD, jaundiced. Quiet
whispering speech. AO x 3
HEENT: Sclerae icteric, mucous membranes moist.
NECK: No JVD
HEART: RRR, normal S1+S2, systolic ejection murmur best heard at
LUSB. No gallops/rubs.
LUNGS: CTAB
ABDOMEN: Soft, NTND, +BS
EXTREMITIES: Warm and well perfused, no edema
NEURO: CN II-XII grossly intact, AOx3 but otherwise difficult to
engage to evaluate MS. ___ asterixis.
Pertinent Results:
ADMISSION LABS:
==========================
___ 12:37AM BLOOD WBC-6.6 RBC-1.93* Hgb-7.0* Hct-21.1*
MCV-109* MCH-36.3* MCHC-33.2 RDW-25.2* RDWSD-53.0* Plt Ct-26*
___ 12:37AM BLOOD Neuts-81* Bands-3 Lymphs-9* Monos-5 Eos-0
Baso-0 ___ Metas-2* Myelos-0 NRBC-4* AbsNeut-5.54
AbsLymp-0.59* AbsMono-0.33 AbsEos-0.00* AbsBaso-0.00*
___ 12:37AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-NORMAL
Macrocy-2+ Microcy-NORMAL Polychr-2+
___ 12:37AM BLOOD Plt Smr-VERY LOW Plt Ct-26*
___ 01:07AM BLOOD Fibrino-75*
___ 04:50PM BLOOD Parst S-NEGATIVE
___ 12:37AM BLOOD Ret Aut-10.6* Abs Ret-0.20*
___ 04:50PM BLOOD IPT-DONE
___ 08:34AM BLOOD FacVIII-356*
___ 12:37AM BLOOD Glucose-173* UreaN-15 Creat-0.4 Na-138
K-3.8 Cl-102 HCO3-18* AnGap-22*
___ 12:37AM BLOOD ALT-28 AST-102* LD(LDH)-577* AlkPhos-101
TotBili-27.7* DirBili-13.6* IndBili-14.1
___ 12:37AM BLOOD Lipase-75*
___ 03:00AM BLOOD CK-MB-8 cTropnT-0.11*
___ 12:37AM BLOOD Calcium-8.9 Phos-4.4 Mg-1.4* Iron-194*
___ 12:37AM BLOOD calTIBC-203* Hapto-<10* Ferritn-317*
TRF-156*
___ 05:12PM BLOOD HBsAg-Negative HBsAb-Positive
HBcAb-Negative HAV Ab-Positive IgM HBc-Negative IgM HAV-Negative
___ 05:12PM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 03:00AM BLOOD AFP-12.6*
___ 05:12PM BLOOD IgG-1805* IgA-597* IgM-275*
___ 12:37AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:59AM BLOOD HIV Ab-Negative
___ 05:12PM BLOOD HBV VL-PND HCV VL-PND
___ 01:59AM BLOOD HIV1 VL-PND
___ 12:42AM BLOOD Lactate-5.3*
___ 03:37AM BLOOD Glucose-190* Lactate-3.4*
___ 12:42AM BLOOD Hgb-6.7* calcHCT-20 O2 Sat-54
___ 12:42AM BLOOD freeCa-1.15
Blood type: A positive
INTERIM LABS:
=============
___ 04:50PM BLOOD Parst S-NEGATIVE
___ 08:34AM BLOOD FacVIII-356*
___ 01:09PM BLOOD Inh Scr-NEG Lupus-NEG
___ 05:12PM BLOOD HBsAg-Negative HBsAb-Positive
HBcAb-Negative HAV Ab-Positive IgM HBc-Negative IgM HAV-Negative
___ 01:09PM BLOOD ANCA-NEGATIVE B
___ 05:12PM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 01:09PM BLOOD ___ Titer-1:40
___ 09:30PM BLOOD PEP-POLYCLONAL FreeKap-38.6*
FreeLam-64.1* Fr K/L-0.60 IgG-1690* IgA-558* IgM-257* IFE-NO
MONOCLO
___ 01:09PM BLOOD C3-53* C4-9*
___ 01:59AM BLOOD HIV Ab-Negative
___ 02:30AM BLOOD tTG-IgA-10
___ 05:12PM BLOOD HCV Ab-Negative
___ 01:59AM BLOOD HIV1 VL-NOT DETECT
___ 01:09PM BLOOD CARDIOLIPIN ANTIBODIES (IGG,
IGM)-NEGATIVE
___ 01:09PM BLOOD Beta-2-Glycoprotein 1 Antibodies
IgG-NEGATIVE
___ 01:09PM BLOOD ANTI-GBM-NEGATIVE
___ 11:56AM BLOOD METHYLMALONIC ___
DISCHARGE LABS:
================
___ 04:09AM BLOOD WBC-6.5 RBC-2.08* Hgb-7.6* Hct-23.0*
MCV-111* MCH-36.5* MCHC-33.0 RDW-UNABLE TO RDWSD-UNABLE TO Plt
Ct-29*
___ 04:09AM BLOOD Plt Ct-29*
___ 04:09AM BLOOD Glucose-125* UreaN-14 Creat-0.2*# Na-137
K-3.9 Cl-107 HCO3-20* AnGap-14
___ 04:09AM BLOOD ALT-44* AST-48* LD(LDH)-364* AlkPhos-182*
TotBili-17.5*
___ 04:09AM BLOOD Calcium-7.6* Phos-4.3 Mg-1.7
___ 04:09AM BLOOD ALT-44* AST-48* LD(___)-364* AlkPhos-182*
TotBili-17.5*
IMAGING:
===========
___ LIVER OR GALLBLADDER US
Cirrhotic liver. Splenomegaly measuring up to 15.4 cm.
Reversed flow within the main portal vein. Right and left
portal veins are patent.
Stones and sludge in a minimally distended gallbladder.
___ CT ABD & PELVIS WITH CO
1. No hematoma or source of hemorrhage in the abdomen and
pelvis.
2. Findings of portal hypertension with splenomegaly, large
portosystemic
collateral vessels and lower esophageal varices.
3. Numerous low-attenuation lesions throughout the liver.
Although many of these appear to have decreased in size from
prior CT, they are incompletely characterized on the current
exam.
4. Gallstones with gallbladder wall edema/pericholecystic fluid.
While this may be related to patient volume status and chronic
liver disease, if the patient has right upper quadrant abdominal
pain, further evaluation with nuclear medicine HIDA scan would
be helpful.
___ CT CHEST W/CONTRAST
Radioogical findings suggests hyperacute diffuse pulmonary
hemorrhage or
aspiration/aspiration pneumonia.
Due to the lack of interstitial thickening pulmonary edema and
TRALI are
considered unlikely.
Complete left lower lobe atelectasis with an associated moderate
left-sided pleural effusion. Mild posterior basal right lower
lobe atelectasis.
ETT in situ 17 mm proximal to carina slight retraction is
advised.
For abdominal findings please refer to CT abdomen report.
___ ECHO
Normal biventricular cavity sizes with preserved regional and
low normal global left ventricular systolic function. Moderate
mitral regurgitation. Mild PA systolic hypertension.
___ LUE ___:
1. No evidence of deep vein thrombosis in the left upper
extremity, although the left internal jugular is not visualized
due to overlying bandage.
2. Superficial thrombophlebitis of the left cephalic vein.
CXR ___:
Compared to chest radiographs ___ through ___.
Previous extensive bilateral pulmonary consolidation improved
progressively between ___ and ___. Today it has worsened,
particularly in the right lung. Severe left lower lobe
consolidation worsened between ___ and ___, and is now
accompanied by new left upper lobe consolidation and increasing
large left pleural effusion. Severe enlargement of the cardiac
silhouette is stable. Pulmonary edema is probably present, but
the heterogeneity of findings in the right lung suggests
concurrent pneumonia, perhaps due to aspiration.
Indwelling, right jugular line ends in the right atrium.
CXR ___:
The right IJ central line tip remains in the right atrium and
could be pulled back 3-4 cm for more optimal placement. Enteric
tube is again seen. There is marked cardiomegaly. There are
diffuse airspace opacities bilaterally, left retrocardiac
opacity, and bilateral effusions, unchanged.
CT chest w/o ___:
IMPRESSION:
Findings most likely represent diffuse alveolar hemorrhage.
Hypodensity of the blood pool suggesting anemia. Cardiomegaly.
Moderate left nonhemorrhagic pleural effusion and trace
right-sided pleural effusion with mild left lower lobe
atelectasis and moderate right lower lobe atelectasis.
Dilated pulmonary arteries suggest pulmonary hypertension.
Cirrhotic liver with sequela of portal hypertension as described
above.
Hyperdense material in the gallbladder may represent hyperdense
sludge,
vicarious excretion of contrast or calcified gallstones.
___ NJ:Successful post-pyloric advancement of a Dobhoff feeding
tube. The tube is ready to use.
CXR ___:
A Dobbhoff type tube is present, tip extending beneath
diaphragm, off film.
Cardiomediastinal silhouette, extensive left-sided opacity,
increased
retrocardiac density, obscuration of left hemidiaphragm, and
right base
opacity are similar to the prior film.
CXR (___):
Compared to chest radiographs ___ through ___.
Residual moderate left pleural effusion left lower lobe
atelectasis, improved substantially since ___ is unchanged
since ___. Right lung is clear. Mild enlargement of the
cardiac silhouette shows similar improvement. No pneumothorax.
Feeding tube passes into the mid stomach and out of view. Right
PIC line ends in the mid SVC.
BILATERAL LOWER EXTREMITY US ___ IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
VIDEO SWALLOW STUDY ___ IMPRESSION:
Silent aspiration with thin and nectar thick liquids with
teaspoons only.
Penetration with consecutive sips of thin liquid consistency.
CT HEAD W/O CONTRAST ___
IMPRESSION:
1. No acute intracranial process. No hemorrhage.
2. Age advanced brain parenchymal atrophy.
MICRO:
======
Viral respiratory screen ___ -NEGATIVE
UCx ___ - NEGATIVE
UCx ___: yeast
BCx ___ x2, ___ x2, ___ x2, ___ x2 - NEGATIVE
BCx ___ x2 - PENDING
URINE LEGIONELLA ___: NEGATIVE
SPUTUM Cx ___: NEGATIVE
MRSA SCREEN ___: NEGATIVE
C Diff ___: NEGATIVE
BAL ___-
___ microorganisms or PMNs on gram stain, no growth on Cx,
Legionella negative, PCP negative, fungus negative, nocardia
negative, Acid fast smear negative, prelim AFP culture negative
___: 2+ PMNs on gram stain, no growth on culture
___: no PMNs, no growth
___: Blood culture x2 negative
___: C diff negative
___: RPR negative
___: Blood cx negative
___: Urine culture with ___
___: Urine culture with yeast
___: C diff negative
___: Urine culture- mixed flora
Brief Hospital Course:
___ with history of alcoholic cirrhosis, esophageal varices,
MSSA/Prevotella bacteremia who was transferred from OSH with
decompensated alcoholic cirrhosis with acute alcoholic
hepatitis, severe hemolytic anemia (Hgb 3), and respiratory
distress requiring intubation. Hospital course was complicated
by multiple reintubations, portal gastropathy with bleeding,
spur cell anemia with recurrent hemolysis and diffuse alveolar
hemorrhage, coagulopathy as well as hepatic encephalopathy.
Patient was intubated on arrival and treated in MICU.
Hematology/oncology was consulted due to severe anemia. Etiology
was thought to be multifactorial in the setting of spur cell
hemolytic anemia as well as oozing portal gastropathy, which was
seen on EGD on ___. Regarding her respiratory failure patient
was intubated and extubated several times. She was treated for
VAP and was also found to have diffuse alveolar hemorrhage for
which she was started on steroids for (___). She was also
diuresed with IV Lasix to optimize respiratory status. Her
course was also complicated by encephalopathy thought to be
related to her acute illness and alcoholic hepatitis/cirrhosis.
#Anemia:
Presented to OSH with Hb 3.0 and initial labs most consistent
with hemolytic anemia (low hapto, high retic, low fibrinogen,
elevated indirect bilirubin). Heme/onc was consulted due to
concern for DIC (also had elevated coags). Her smear was notable
for numerous cells, targets, and polychromatophils and frequent
spherocytes, with rare schistocytes. Her anemia was thought to
be due to spur cell hemolytic anemia in setting of alcoholic
cirrhosis. She was transfused for hgb >7, plt >20, fibrinogen
>100. Her anemia stabilized. However on ___ after being
extubated she was noted to be spitting up frank blood and her
h/h dropped. She was reintubated and underwent bedside EGD. She
was found to have oozing from portal hypertensive gastropathy.
Small varices were also noted but were low risk and
non-bleeding. She was treated with octreotide drip x3 days and
with IV PPI. As above, DAH was also thought to be contributing
to her anemia. Her h/h stabilized upon treatment of above issues
until ___ when she was noted to have a melenic stool and Hgb
drop to 7 prompting return to the ICU from the floor. She was
started back on octreotide and given 1 dose vanc/zosyn,
subsequently switched to ceftriaxone. Throughout her
hospitalization, she required supportive care for her
coagulopathy and anemia. She was transfused pRBCs w/goal of Hb
>7, Platelets w/goal of >20, and cryo w/goal of fibrinogen >
100. She received a total of 17U pRBC, 8U FFP, 7U platelets, and
16U cryoprecipitate.
Overall, the cause of her anemia was though to be
multifactorial, due to a
combination of spur cell hemolytic anemia, acute blood loss
(DAH, GI), and inflammatory block in the setting of advanced
cirrhosis and active alcohol abuse
# Hypoxemic respiratory failure:
# DAH:
# Aspiration pneumonia:
Initially presented to an outside hospital with dyspnea over
several days. She was 80% on NRB on presentation and had
worsening respiratory distress requiring intubation. She was
transferred to ___. Initially her hypoxemia was thought to be
due to aspiration pneumonia and she was treated with a course of
azithro/cefepime/vancomycin for pneumonia. She underwent
bronchoscopy which did not show any gross blood, just thin pink
tinged secretions not consistent with DAH. She was ultimately
weaned down on her O2 support and was extubated. However, she
had worsening tachypnea and hypoxemia and required reintubation
x2. Ultimately she had worsening bilateral pulmonary infiltrates
and underwent another bronchoscopy with still bloody fluid on
BAL, also had repeat CT chest with GGO and consolidations with
peripheral sparing, consistent with diffuse alveolar hemorrhage.
Started on Solumedrol 500 bid (___) for DAH, transitioned to
200 BID ___, with improvement in oxygenation/gas exchange.
Autoimmune workup and TTE for cause of DAH was unrevealing; DAH
thought to be in setting of liver disease and hemolytic anemia /
coagulopathy. She was diuresed with IV Lasix. She was finally
extubated for the ___ time on ___ and her O2 was weaned to 2L
prior to transfer to the floor. On the medical floor, her O2
requirement slowly improved, and patient was satting well on
room air at the time of discharge.
#Acute alcoholic hepatitis:
#Cirrhosis ___ alcoholism:
Patient has a history of alcoholic cirrhosis with MELD of 34 on
admission. Patient reportedly has undergone an extensive workup
prior to admission for her cirrhosis and this has been
attributed to her alcohol use. She has been hospitalized at
___ in the past for acute alcoholic intoxication and
withdrawal. Upon admission her LFTs were elevated in a pattern
consistent with alcoholic hepatitis. She initially did not
receive steroids for alcoholic hepatitis despite elevated
discriminant function (145) due to concern for infection. She
subsequently received 3 doses of prednisolone but then there was
concern for recurrent aspiration pneumonia so steroids were
stopped. As above, she ultimately was on high dose steroids for
DAH. She was gradually initiated on lactulose, rifaxamin, folic
acid, multivitamins. She was transferred to the hepatology
service, where steroids were initially continued but stopped 2
weeks after initiation due to lack of improvement in bilirubin.
Initiation of diuresis was deferred given ongoing anemia and
tachycardia, and lack of significant volume overload on exam.
# Delirium with intermittent agitation:
After extubation she was noted to have ongoing hyperactive
delirium, while on high dose steroids. Exam was not consistent
with hepatic encephalopathy and she was having adequate stool
output on rifaximin/lactulose. She was started on Precedex and
then transitioned to seroquel. She was also given standing
oxycodone to avoid opioid withdrawal, as she'd been on fentanyl
persistently while intubated. She was continued on lactulose +
rifaximin. TSH was nl. Pt was treated with high dose IV thimaine
and started on PO thiamine and folate. On the medical floor,
mental status improved, though patient was intermittently
encephalopathic despite adequate stool output from lactulose.
Neurology was consulted, and felt that altered mental status was
in the setting of ongoing illness and poor neurologic substrate.
___'s encephalopathy was not thought to be the cause due to
lack of ophthalmoplegia and her prior treatment with high dose
IV thiamine. Mental status improved and patient was AxO x3 with
mild intermittent confusion upon discharge.
#Coagulopathy:
Coags persistently abnormal during admission. As above initially
there was concern for a DIC-like picture in setting of spur cell
hemolytic anemia. There was likely also a component of
nutritional deficiency, on backdrop of cirrhosis. She received
multiple doses of IV vitamin K without improvement of her INR.
Received total of 16 units of cryoglobulin.
# Respiratory alkalosis with metabolic compensation:
Bicarb noted to be persistently low with pH 7.5; most likely
appropriate metabolic compensation for developing respiratory
alkalosis. She will need continued monitoring of bicarb and
respiratory status, no need for active treatment
# Nutrition:
Initially presented intubated with OG tube, which was removed
with initial extubation. Patient failed her speech and swallow
evaluation at that time and had a witnessed aspiration event,
likely contributing to her need to be reintubated. She had a
feeding tube placed again with TFs started for nutritional
support. Patient continued tube feeds on medical floor. She was
repeatedly evaluated by speech and swallow, and was eventually
cleared for modified regular diet. NGT kept in for supplemental
nutrition in the setting of alcoholic hepatitis. She will need
continued assessment by speech and swallow.
# Vocal cord trauma:
Patient had persistent dysphonia and vocal hoarseness after
repeated intubations. ENT was consulted for evaluation, and
endoscopy was performed, which found no evidence of vocal cord
paralsysis. Conservative therapy with saline nasal spray was
recommended.
# Tachycardia:
HR consistently in 100s and to 130s with exertion. Culture data
with only yeast in urine. No clots on bilateral ___.
Tachycardia was though to be related to anemia and
deconditioning in the setting of acute illness. Anemia was
controlled with blood product transfusion as above.
# Yeast-uria:
Pt had several different urine culture which grew yeast. These
were thought to be due to skin contamination due to foley and
were not treated.
# Hypernatremia:
Was intermittently hypernatremic during her course, thought ___
hypotonic losses with lactulose, diuresis, with poor PO intake.
Given D5W intermittently to good effect.
#Hyperglycemia:
Patient was on long acting insulin as well as ISS while on high
dose steroids. Blood sugars downtrending after steroids stopped
though still with insulin requirement. Blood sugar should be
continuously monitored and insulin may be able to be weaned off.
# Thrombocytopenia:
Platelets had previously been between ___ at baseline, likely
secondary to liver disease and alcohol abuse. Platelets were
trended and she was transfused for plts >20 during periods of
active bleeding and hemolysis. Received total of 7 units of
platelets.
# H/o Alcohol use:
Unclear how much she had been drinking prior to admission. She
was treated for possible alcohol withdrawal with phenobarbital.
She was given folate, MV, thiamine. Social work was consulted
for alcohol use history.
TRANSITIONAL ISSUES:
**ALL DISCHARGE MEDICATIONS ARE NEW MEDS**
[] Patient will be discharged without PO diuretics, and had no
significant volume overload on exam. Please monitor daily
weights and consider initiating PO diuretics if evidence of
volume overload.
[] Please continue to monitor FSG now that patient not on
prednisone and evaluate need for ongoing insulin.
[] Patient will require continued speech and swallow evaluation
prior to upgrading diet. Will need follow up video swallow study
around ___. Can be done at rehab.
[] Seroquel started in ICU for agitation and delirium. Continue
to wean Seroquel as tolerated with improvement in mental status.
[] Please monitor mental status and use delirium precautions.
[] Non urgent liver MRI is recommended for numerous incompletely
characterized low-attenuation lesions throughout the liver on
CT abdomen/pelvis.
[] Please provide ongoing social work support for alcohol abuse
as patient is more able to engage with improved mental status.
[] Patient should have labs with CBC, fibrinogen, Chem10, and
LFTs drawn every other day. Please transfuse pRBC for Hgb <7,
cryo for fibrinogen <100, and platelets for platelets <20.
Please monitor bicarbonate and other electrolytes as patient had
hypernatremia during stay.
[] Please transition IV pantoprazole to PO PPI once patient able
to tolerate PO medications OR she can be transitioned to
lansoprazole oral disintegrating tablet if this medication is
carried at rehab
[] Patient will need to establish care with primary care
physician and hepatologist. Please ensure that these follow up
appointments are arranged.
[] Please ensure follow up with Dr. ___ in clinic one to two
weeks after discharge
# Communication: HCP: none chosen; contact Dr. ___,
father c: ___/ h: ___
# Code: Full, confirmed with next of kin
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
2. FoLIC Acid 1 mg PO DAILY
3. Glargine 6 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
4. Lactulose 15 mL PO/NG TID
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. Pantoprazole 40 mg IV Q12H
7. QUEtiapine Fumarate 25 mg PO BID agitation
8. Rifaximin 550 mg PO BID
9. Senna 8.6 mg PO BID:PRN Constipation
10. Sodium Chloride Nasal ___ SPRY NU TID
11. Thiamine 100 mg PO DAILY
12. Zinc Sulfate 220 mg PO DAILY Duration: 7 Days
to end on ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Alcoholic hepatitis
Secondary Diagnosis:
Alcoholic cirrhosis
Hemolytic anemia
Portal gastropathy
Ventilator-associated pneumonia
Vocal cord injury
Alcohol use disorder
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 Ms. ___,
It was a pleasure treating you at ___.
Why was I admitted to the hospital?
-You were admitted because you were having difficulty breathing
and you were found to have inflammation in your liver and very
low blood counts.
What happened while I was admitted?
-At first, you had a breathing tube and were on a ventilator to
help you breathe, but then you were able to come off the tube
and breathe on your own.
-We gave you antibiotics for a possible pneumonia.
-We treated the inflammation in your liver with steroids.
-You were found to have bleeding in your stomach, so we gave you
blood transfusions to bring your blood level up.
What should I do when I return home?
-It is very important to stop drinking alcohol, which is the
most important thing you can do for your health.
-Please continue to work with physical therapy to rebuild your
strength.
-Please take all your medications as directed and follow-up with
your doctors as directed below. You have been started on many
new medications, which you should take.
It was a pleasure taking care of you.
-Your ___ Team
Followup Instructions:
___
|
10656173-DS-12
| 10,656,173 | 27,208,647 |
DS
| 12 |
2178-07-14 00:00:00
|
2178-07-14 20:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
hyponatremia, sent in from outpatient labs
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ female with history of
alcoholic cirrhosis, portal hypertension (with EV, portal
hypertensive gastropathy), hemolytic anemia, on liver transplant
list, presenting with hyponatremia. ___ reports that gets
routine weekly labs as part of transplant workup. Last week,
labs
showed hyponatremia for which she was instructed to reduce
dosing
of Lasix/Spironlactone regimen by half. Routine labs this week
showed worsening hyponatremia to 124, prompting ED referral by
her liver team.
___ reports feeling well aside from mild cold that she had
last week. At present she denies nausea, vomiting,
lightheadedness, headaches, change in appetite, numbness,
tingling, weakness.
In the ED, initial VS were: 97.8 106 157/65 20 100% RA
Labs showed: Na 126. ALT 39/AST 71/AP 210/T. bili 13.9/INR 2.6
(stable from recent baseline). Hgb 10, plts 40 (both at recent
baseline)
Imaging showed:
RUQUS: 1. Cirrhotic liver with bidirectional flow within the
main
portal vein.
Numerous small liver lesions better assessed on prior MRI.
Please
note,
___ is scheduled for an outpatient MRI tomorrow where these
lesions can be
better assessed.
2. No ascites.
3. Splenomegaly.
4. Cholelithiasis without evidence of cholecystitis.
Consults:
___ F with ETOH cirrhosis c/b HCC, portal hypertension (with
EV,
PHG), and hemolytic anemia currently on the transplant list
referred to the ED for hyponatremia to 124.
Asymptomatic.
Na in ___ was 137. Recently cut down on diuretics.
Recommend
- Repeat labs pending
- Hold diuretics
- Give albumin 25% 50g IV x 1
- Liver ultrasound w/ doppler
- Diag para if tappable pocket
- Admit to ET under Dr. ___
___ received: 50g 25% albumin
Transfer VS were: 98.6 95 104/56 18 100% RA
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
Alcoholic liver cirrhosis
Social History:
___
Family History:
No history of liver disease. No known history of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.7PO 108 / 56 99 18 99 RA
GENERAL: NAD, AAOx3
HEENT: AT/NC, EOMI, PERRL, +icteric sclera, MMM
NECK: supple, no LAD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing. Mild ankle edema bilaterally
without pitting component
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose. No
asterixis
SKIN: warm and well perfused. +Jaundiced
DISCHARGE PHYSICAL EXAM:
VS: Temp 98.1 BP 118 / 69. HR 103. RR 18 O2 sat 99% on RA
GENERAL: NAD, AAOx3
HEENT: AT/NC, scleral icterus, MMM
NECK: supple, no LAD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing. Mild ankle edema bilaterally
without pitting component
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose. No
asterixis
SKIN: warm and well perfused. +Jaundiced
Pertinent Results:
ADMISSION LABS
___ 07:08PM BLOOD WBC-6.0 RBC-2.55* Hgb-10.0* Hct-29.2*
MCV-115* MCH-39.2* MCHC-34.2 RDW-13.4 RDWSD-55.8* Plt Ct-40*
___ 07:08PM BLOOD Neuts-73.8* Lymphs-11.9* Monos-12.9
Eos-0.3* Baso-0.3 Im ___ AbsNeut-4.41 AbsLymp-0.71*
AbsMono-0.77 AbsEos-0.02* AbsBaso-0.02
___ 07:08PM BLOOD ___ PTT-34.0 ___
___ 07:08PM BLOOD Glucose-125* UreaN-14 Creat-0.7 Na-126*
K-4.3 Cl-93* HCO3-17* AnGap-16
___ 07:08PM BLOOD ALT-39 AST-71* AlkPhos-210* TotBili-13.9*
___ 07:08PM BLOOD DirBili-7.0*
___ 07:08PM BLOOD Albumin-3.4*
___ 07:08PM BLOOD Calcium-7.9* Phos-3.7 Mg-1.7
___ 07:08PM BLOOD Osmolal-267*
___ 01:25AM URINE Hours-RANDOM Na-<20
___ 01:25AM URINE Osmolal-307
PERTINENT INTERVAL LABS
___ 05:41AM BLOOD WBC-3.7* RBC-2.26* Hgb-8.7* Hct-24.8*
MCV-110* MCH-38.5* MCHC-35.1 RDW-13.0 RDWSD-51.7* Plt Ct-39*
___ 05:41AM BLOOD Glucose-111* UreaN-15 Creat-0.6 Na-132*
K-4.1 Cl-99 HCO3-18* AnGap-15
___ 05:41AM BLOOD ALT-30 AST-54* AlkPhos-200* TotBili-11.0*
___ 05:41AM BLOOD Calcium-8.3* Phos-3.4 Mg-1.8
___ 05:41AM BLOOD ___ PTT-39.6* ___
DISCHARGE LABS
IMAGING AND STUDIES
___ LIVER AND GB US
1. Cirrhotic liver with bidirectional flow within the main
portal vein. Numerous small liver lesions better assessed on
prior MRI. Please note, ___ is scheduled for an outpatient
MRI tomorrow where these lesions can be better assessed.
2. No ascites.
3. Splenomegaly.
4. Cholelithiasis without evidence of cholecystitis.
___ CT CHEST W/O CONTRAST
IMPRESSION: 2 small ground-glass opacities in the right lower
lobe are unchanged the third ground-glass opacity is not seen
well on the current study. Another subpleural right lower lobe
pulmonary nodule is unchanged. No new pulmonary nodules.
Bibasilar atelectasis.
Cirrhosis. Lack of intravenous contrast limits evaluation for
liver lesions.
Brief Hospital Course:
___ SUMMARY
Ms. ___ is a ___ yo F w/ alcoholic cirrhosis (MELD 32, childs
class C) c/b portal HTN with esophageal varices and hypertensive
gastropathy, hemolytic anemia, now on the liver transplant list,
who presented with hyponatremia noted on outpatient monitoring
labs. Her lab was notable for Na 126, UNa<20, Serum osm 267,
Uosm 307 at admission, and her RUQ US did not show sign of
ascites in the ED. She responded well to 50 g of 25 % albumin IV
infusion, with normalization of her Na level to 132 prior to
discharge. Given the lack of peripheral edema and ascites, we
decided to discontinue her diuretics regimen.
ACUTE ISSUES
#Hyponatremia: Na stable at 132 prior to discharge. Her exam
did not show evidence of peripheral edema or ascites. Potential
etiologies of her hypotonic hyponatremia, given her euvolemic to
hypovolemic status on exam, include extra-renal causes (given
her UNa<___) such as insensible losses and inadequate PO intake
(presumably due to her recent URI episode), as well as SIADH
(given her h/o HCC). Plan to continue holding diuretics on
discharge. Pt instructed to weigh herself daily (dry weight
today 130 lbs), contact hepatology if weight increases by more
than 3 lbs, and use compression stockings.
CHRONIC ISSUES
#ETOH Cirrhosis. Child Class C. MELD-Na 32. Currently listed for
transplant. HE: Continue lactulose and rifaximin. GIB/Varices:
Last EGD in ___ - 2 cords of small well covered varices in
lower esophagus. Plan for repeat in 6 months. Ascites: None seen
on Doppler Abd US. Pt reports history of ascites ___ year ago.
Will hold Lasix/Spironolactone at present as above. SBP: Not
currently on SBP ppx. No tappable ascites at present. HCC: had
CT chest while inpatient, had MRI scheduled but could not have
it done bc was admitted, will have rescheduled per transplant
coordinator.
#Anemia. h/o Spur cell hemolytic anemia. Currently at recent
baseline. No active blood loss at this time.
TRANSITIONAL ISSUES
[] Diuretics: Pt has been discontinued on her home diuretics
(Lasix 20 mg PO QD and spironolactone 50 mg PO QD) regimen.
[] Outpatient MR imaging: Pt was originally scheduled for her MR
on ___. This has been rescheduled to next ___.
[] Continue to monitor volume status (for signs of ascites and
peripheral edema) and restart diuretics as needed.
[] Consider testing for alpha1-antitrypsin deficiency given sign
of emphysema on CT chest.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Lactulose 30 mL PO TID
4. Omeprazole 20 mg PO DAILY
5. Rifaximin 550 mg PO BID
6. Spironolactone 50 mg PO DAILY
7. Calcium 600 (calcium carbonate) 600 mg calcium (1,500 mg)
oral DAILY
8. Magnesium Oxide 400 mg PO BID
9. Multivitamins 1 TAB PO DAILY
10. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Calcium 600 (calcium carbonate) 600 mg calcium (1,500 mg)
oral DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Lactulose 30 mL PO TID
4. Magnesium Oxide 400 mg PO BID
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Rifaximin 550 mg PO BID
8. Thiamine 100 mg PO DAILY
9. HELD- Furosemide 20 mg PO DAILY This medication was held. Do
not restart Furosemide until your doctor tells you it is safe to
do so.
10. HELD- Spironolactone 50 mg PO DAILY This medication was
held. Do not restart Spironolactone until your doctor tells you
it is safe to do so.
11.Outpatient Lab Work
ICD-10: ___
Labs: Complete metabolic panel
Date: ___
Fax to: ___ (___)
# ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
- Hyponatremia, hypovolemic
Secondary Diagnoses
- Cirrhosis
- Hepatocellular carcinoma
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!
WHY DID YOU COME TO THE HOSPITAL?
- The sodium levels in your blood were dangerously low.
WHAT HAPPENED TO YOU DURING YOUR HOSPITAL STAY?
- We monitored your sodium levels to make sure they returned to
normal at a safe pace.
- We stopped your diuretics (also known as water pills) as we
are worried they were causing your sodium levels to be too low.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
1) Stop these medications
* Furosemide (lasix)
* Spironolactone
2) Attend all of your follow-up appointments with your
hepatologist as scheduled. ___ contact you with more
details.
3) Please weigh yourself every morning and call your
hepatologist if your weight increases or decreases by more than
3 pounds per day. Your weight on discharge is 130 pounds.
4) You need to get a blood test tomorrow (___) to make sure
your electrolytes are normal. You were given a lab slip for
this, and it can be done at any lab. There are instructions on
the slip for the results to be faxed to ___ and she will
follow-up with you.
We wish you the best in your recovery and it was a pleasure to
care for you.
Followup Instructions:
___
|
10656938-DS-15
| 10,656,938 | 23,559,884 |
DS
| 15 |
2121-10-31 00:00:00
|
2121-10-31 14:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
metoprolol / Sulfa (Sulfonamide Antibiotics) / metformin /
itraconazole
Attending: ___.
Chief Complaint:
Cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ year old female with PMHx of CAD (MI in
___, s/p PCI
currently on ASA/plavix), HTN, HLD, PVD, CHF (unknown EF),
presenting from assisted living facility with fever, cough,
weakness, found to have right
lower lobe pneumonia, admitted to the FICU with septic shock.
Patient noted one day prior to presentation development of
productive cough with yellow sputum, associated with fatigue,
and difficult breathing. Felt progressively weak and difficult
to walk to the bathroom. Denied any chest pain or lower
extremity swelling.
ED Course notable for:
Initial VS: T 101.5 HR 82 BP 133/82 RR 16 O2 93%RA
On exam:
Gen: Mildly tachypneic with a respiratory rate of 27, no
increased respiratory effort
HEENT: NC/AT. EOMI.
Neck: No swelling. Trachea is midline. No JVD
Cor: RRR. No m/r/g.
Pulm: Diffuse rhonchi, no focal consolidations appreciated
Abd: Soft, NT, ND. Bowel sounds present
Ext: No edema, cyanosis, or clubbing.
Skin: No rashes. No skin breakdown
Neuro: AAOx3. Gross sensorimotor intact.
Psych: Normal mentation.
Heme: No petechia. No ecchymosis.
Labs Notable for:
- WBC 6.8, Hb 12.4, PLT 134
- Na 142, K 4.5, bicarb 18, BUN 47, Cr 1.4, glucose 130
- Troponin 0.05
- lactate 1.5
- UA bland
- Flu negative
Imaging:
CXR ___:
1. Right lower lobe opacification is concerning for pneumonia.
2. Possible trace right pleural effusion.
Administered:
___ 02:18 IH Albuterol 0.083% Neb Soln 1 NEB
___ 02:18 IH Ipratropium Bromide Neb 1 NEB
___ 02:18 PO Acetaminophen 1000 mg
___ 03:22 IV CefTRIAXone
___ 03:38 IV CefTRIAXone 1 gm
___ 03:59 IV CefePIME
___ 04:59 IV CefePIME 2 g
___ 05:00 IV Vancomycin (1000 mg ordered)
Consults: None
In the emergency department, had worsening hypotension to 86/46.
EKG showed 2mm STE in III, avF, 3mm STD in I and avL, deeper
compared to prior EKG. Elevated troponin was thought to be
demand
in the setting of sepsis.
On arrival to the FICU, the patient confirmed the above history.
She states that she saw her cardiologist at ___ Dr. ___ on
___ and at that time had a bit of a cough and was tired, but
was otherwise fine. Her fatigue and cough then progressed. She
now notes that her breathing feels off from what it usually is.
Otherwise, does not report chest pain, nausea, vomiting,
abdominal pain, and dysuria.
Past Medical History:
# HTN/HLD
# 3v CAD (s/p MI ___, LHC (R dominant) - stenting RCA,OM1 ___
# chronic sCHF EF 35%
# PVD
Social History:
___
Family History:
Mother died of a heart attack. Father died of a GU malignancy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T 97.6, HR 63, BP 149/87, RR 18, O2 sat 100% on 3L NC
GENERAL: Alert, oriented, mildly irritable, tired-appearing, no
acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Decreased breath sounds at the bilateral bases, otherwise
clear to auscultation bilaterally, no wheezes, rales or rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: dry, warm, no rashes or other lesions
NEURO: A&Ox3, moving all 4 extremities with purpose
Pertinent Results:
ADMISSION LABS
___ 01:52AM BLOOD WBC-6.8 RBC-4.01 Hgb-12.4 Hct-37.9 MCV-95
MCH-30.9 MCHC-32.7 RDW-13.2 RDWSD-46.0 Plt ___
___ 01:52AM BLOOD Neuts-83.7* Lymphs-8.0* Monos-6.8
Eos-0.9* Baso-0.3 Im ___ AbsNeut-5.65 AbsLymp-0.54*
AbsMono-0.46 AbsEos-0.06 AbsBaso-0.02
___ 01:52AM BLOOD ___ PTT-26.6 ___
___ 01:52AM BLOOD Glucose-130* UreaN-47* Creat-1.4* Na-142
K-4.5 Cl-107 HCO3-18* AnGap-17
___ 01:52AM BLOOD ALT-11 AST-22 CK(CPK)-89 AlkPhos-122*
TotBili-0.5
___ 07:50AM BLOOD cTropnT-0.23*
___ 01:52AM BLOOD cTropnT-0.05*
___ 01:52AM BLOOD CK-MB-5
___ 07:50AM BLOOD CK-MB-6
___ 01:52AM BLOOD Albumin-3.9 Calcium-9.4 Phos-3.4 Mg-2.0
___ 02:02AM BLOOD ___ pO2-90 pCO2-31* pH-7.41
calTCO2-20* Base XS--3
___ 02:02AM BLOOD Lactate-1.5
MICRO
Blood culture x2 (___)- pending
Urine culture (___)- pending
IMAGING
CXR ___:
1. Right lower lobe opacification is concerning for pneumonia.
2. Possible trace right pleural effusion.
TTE ___:
Mild dilated LV with moderate LV systolic dysfunction and
regional wall motion abnormality including basal inferior
aneurysm. Moderate to severe mitral regurgitation. Mild
pulmonary hypertension. Left pleural effusion.
DISCHARGE LABS
___ 07:15AM BLOOD Creat-1.3* Na-144 K-3.9 Cl-109* HCO3-20*
AnGap-15
Brief Hospital Course:
Ms. ___ is a ___ year old female with PMHx of CAD(MI in ___,
s/p PCI currently on ASA/plavix), HTN, HLD, PVD, CHF (unknown
EF), presenting from assisted living facility with fever, cough,
weakness, found to have right lower lobe pneumonia admitted with
septic shock.
#Septic shock
#RLL PNA
Patient presenting with 1 day history of fever, productive
cough, found on chest x-ray to have right lower lobe pneumonia.
Patient had worsening hypotension in the ED with SBP 80/40s
likely septic shock from pulmonary infectious source. Initially
received ceftriaxone in the ED and was then broadened to
vancomycin and cefepime.
Although she had hypoxemia requiring 3L, there was a lower
suspicion for distributive etiology such as PE. Lactate was
within normal limits. It was thought to be less likely
cardiogenic given lack of volume overload on exam. A few hours
later, she was off of pressors and improving. She was narrowed
back to CAP coverage with plan for a 5 day course of ceftriaxone
and azithromycin (day ___. Flu test returned negative.
She was transferred to the inpatient floor. She received
guaifenesin as needed for symptomatic treatment. She is treated
with incentive spirometer and airway clearance device. There
was evidence of pulm edema on CXR and so she additionally
received PO lasix. After completion of the CTX/Azithro and
diuresis, her oxygenation improved significantly. She was on RA
satting >94% and was able to ambulate without any significant
desaturations.
#CAD
#Elevated troponin
#Acute on chronic systolic CHF
#Mitral regurgitation.
Patient with troponin 0.05 on admission, MB 5 which uptrended to
0.23 and 6 respectively. Trop peaked to 0.3. EKG on admission
with 2mm STE in III, avF, 3mm STD in I and avL, deepened
compared to prior EKG. Patient does have a significant cardiac
history, known three-vessel CAD s/p RCA stenting and OM1 ___.
Denied chest pain. Differential diagnosis included acute
coronary syndrome vs demand ischemia. Cardiology was consulted
and they recommended continued medical management. TTE was
obtained and it showed: mild dilated LV with moderate LV
systolic dysfunction and regional wall motion abnormality
including basal inferior aneurysm. Moderate to severe mitral
regurgitation. Mild pulmonary hypertension. She remained on a
heparin ggt drip without bolus until troponins were
downtrending. She was continued on home ASA 81mg daily, Plavix
75mg daily, and atorvastatin 40mg.
She has EF 33% and severe MR with largely posterior mitral
valve involvement. This is most c/w impaired healing and likely
structural integrity loss of the post-valve chordae in setting
of past IMI. To help with afterload reduction, lisinopril was
restarted.
She had stable Left pleural effusion.
Metoprolol was held due to ? reported past intolerance. Due
to the very low dose, it may be held until her follow up with
her primary care doctor.
___
Creatinine of 1.4 on admission from a baseline of ~1.1. This was
felt to be likely prerenal in setting of sepsis physiology.
Lisinopril and Lasix were held temporarily and restarted on
discharge. .
#Alcohol use disorder: Patient drinks ___ glasses of wine daily.
She had no withdrawal symptoms at the time of admission. She was
monitored closely with ___ Q4h for development of withdrawal
symptoms. This was discontinued.
DISPO: Home w/ services. She was seen by ___ and cleared for
discharge home. She has 24 hours nursing assistance/aide.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Clopidogrel 75 mg PO DAILY
3. Gabapentin 100 mg PO TID
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. melatonin 3 mg oral QHS
7. Metoprolol Succinate XL 12.5 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY
9. Cyanocobalamin 500 mcg PO DAILY
10. Furosemide 20 mg PO DAILY:PRN fluid overload
11. Aspirin 81 mg PO DAILY
12. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever
13. GuaiFENesin 5 mL PO Q4H:PRN cough
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Clopidogrel 75 mg PO DAILY
5. Cyanocobalamin 500 mcg PO DAILY
6. Furosemide 20 mg PO DAILY:PRN fluid overload
7. Gabapentin 100 mg PO TID
8. GuaiFENesin 5 mL PO Q4H:PRN cough
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. Lisinopril 10 mg PO DAILY
11. melatonin 3 mg oral QHS
12. Polyethylene Glycol 17 g PO DAILY
13. HELD- Metoprolol Succinate XL 12.5 mg PO DAILY This
medication was held. Do not restart Metoprolol Succinate XL
until your follow up appointment with your doctor
Discharge Disposition:
Home With Service
Facility:
___
___:
Septic shock
RLL Pneumonia
Acute hypoxemic respiratory failure
Pulmonary edema and effusion
Type 2 NSTEMI
CAD with known three-vessel CAD s/p RCA stenting and OM1 ___
Elevated troponin
Likely prerenal azotemia with resultant ATN
Chronic systolic 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:
Dear ___,
___ was a pleasure looking after you. You were admitted with
pneumonia that caused your blood pressure to drop low. We
treated with supportive therapy and antibiotics. Your symptoms
improved and we were able to take you off supplemental oxygen.
You also had some fluid build up on your lungs that was treated
with a medication to help you eliminate excess fluid.
Your heart was stressed by this, but will be treated with
medications as recommended by cardiology. You should continue
using the incentive spirometer and airway clearance device.
Continue to ambulate as tolerated.
Your medications has largely been unchanged. The only
medication we recommend holding for now is the metoprolol - due
to questions about your ability to tolerate this medication. We
would recommend discussing this with your primary care doctor on
your follow up visit. Also, due to persistence of mild excess
fluids in your lungs, we recommend taking the Furosemide (lasix)
for the next ___ days to help further with your breathing.
Again, it was a pleasure and we wish you quick recovery!
Your ___ Team
Followup Instructions:
___
|
10657092-DS-19
| 10,657,092 | 26,587,944 |
DS
| 19 |
2149-03-07 00:00:00
|
2149-03-07 12:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
headache, lightheadedness, memory
problems
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ yo. left-handed ___ w/PMH of recent
vertebral dissection in ___, multiple TBIs, NASH, palpitations,
who presents today for several days of the above symptoms, the
most bothersome to him being a new memory deficit. First symptom
was a sudden-onset bilateral occipital headache that radiated to
his neck (right > left). This occurred 2 days prior to admission
(i.e., ___ at work. Of note, pt sees Dr. ___ in clinic
since
his dissection, who has been prescribing gabapentin 300 mg TID
for occipital headaches. However, this headache, although only
moderate in severity, was worse than his usual headaches that
have been well controlled with the gabapentin. Moreover, the
nearly instantaneous onset is unusual. Mr. ___ only got
partial
relief from taking an early dose of gabapentin. Since the
headache, Mr. ___ has not been feeling well and "not quite
like
myself". He also developed a new memory problem, describing
episodes of forgetting earlier parts of conversations,
forgetting
tasks and details etc. For instance, although he recalls
watching
the ___ game earlier today, he doesn't remember who they
played. He further endorses a feeling of feeling lightheaded and
"dazed" but not vertiginous. He also has had a tingling
sensation
over his forehead. Finally, he has been feeling as if he is
falling over to the right, and has had to catch himself but has
not had frank falls. This occurs both in the light and in the
dark.
On neurologic review of systems, denies difficulty with
producing
or comprehending speech.
Denies photophobia, loss of vision, blurred vision, diplopia,
vertigo, tinnitus, hearing difficulty, dysarthria, or dysphagia.
Denies muscle weakness.
Denies loss of sensation.
Denies bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss.
Denies chest pain, dyspnea, or cough. Endorses history of
palpitations that have been worse than usual recently.
Some nausea recently. Denies vomiting, diarrhea, constipation.
Endorses one episode of severe abdominal pain last week that
resolved by the folloging day. Denies dysuria, hematuria,
incontinence.
Past Medical History:
PMH/PSH: recent vertebral dissection in ___, NASH,
palpitations,
multiple TBIs (work related from bumping into things), some with
brief loss of consciousness
Social History:
___
Family History:
Family History: Healthy parents, sibs & child
Physical Exam:
Neuro: MS: alert and oriented x3, intact fluency and
comprehension, six digit forward and four digit backward span.
able to name 20 animals in a minute, remembers Obama and both
Bushes but forgot ___, remembers weather on his wedding day
correctly. intact naming and repetition, able to spell world
backwards, follows cross body commands
CN: left eye hypertropia, mild diplopia with rightward gaze, no
primary gaze nystagmus, with leftward gaze he has horizontal
rotatory nystagmus. head thrust did not produce refixation
saccades, ___ with head turned to the left produced
vertigo and horizontal rotatory nystagmus to the left. ___ to the right did not produce vertigo or nystagmus.
perrla, intact hearing bilaterally, intact light touch and
pinprick bilaterally, intact muscles of mastication strength,
intact t/u/p
Motor: normal tone, bulk, and ___ Strength of all four
extremities, no drift
Sensory: intact light touch of all four ext. without DSS light
touch extinction
Reflexes: 2+ UE and ___ bilaterally, toes downgoing bilaterally
Coord: intact fnf, hs, ram bilaterally
mild cerebellar rebound of the arms bilaterally
Gait: intact stance and stride
Heent: no high arched palate, no hypertelorism
Chest: no pectus excavatum
Ext: no hyperextensibility of the elbows, wrists, knees. He is
able to bend over and touch his toes (placing a couple inches of
his fingers on the floor).
Discharge exam:
___ to the left, worse with head movements, most
likely peripheral vertigo, likely BPPV
Pertinent Results:
___ 08:30AM ALT(SGPT)-105* AST(SGOT)-48* CK(CPK)-142 ALK
PHOS-51 TOT BILI-0.5
___ 08:30AM CK-MB-2 cTropnT-<0.01
___ 08:30AM TOT PROT-6.3* ALBUMIN-4.5 GLOBULIN-1.8*
CALCIUM-9.6 PHOSPHATE-3.3 MAGNESIUM-2.1 CHOLEST-168
___ 08:30AM TRIGLYCER-54 HDL CHOL-56 CHOL/HDL-3.0
LDL(CALC)-101
___ 08:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 08:30AM WBC-7.1 RBC-5.01 HGB-15.8 HCT-46.3 MCV-92
MCH-31.6 MCHC-34.2 RDW-12.1
___ 08:30AM NEUTS-60.3 ___ MONOS-5.6 EOS-1.2
BASOS-0.5
___ 08:30AM PLT COUNT-221
___ 08:30AM ___ PTT-41.5* ___
Brief Hospital Course:
Mr ___ is a ___ yo. left-handed ___ w/PMH of recent vertebral
dissection in ___, multiple TBIs, NASH, palpitations, who
presented for several days of headache, lightheadedness and
amnesia that was appreciable on exam.
Initial concern in the setting of his PMH of vertebral
dissection, his new sudden-onset occipital/neck pain was
concerning for re-occurrence of dissection. His amnesia was
concerning for impairment of the memory pathways, which may
include the hippocampi uni- or bilaterally as well as the
thalami. However this has been a long standing problem and was
thought to be likely related to his previous TBI. He and his
wife expressed interest in more extensive neuropsychiatric
testing and therefore he was referred to the cognitive neurology
clinic ___ clinic).
As for the concern for recurrence of dissection of his vertebral
arteries, he was very briefly started on heparin but had an MRI
which did not demonstrate any recurrence or ischemic disease.
He was continued on his Aspirin 81 mg daily for prophylaxis and
should follow up with Vascular neurology for his vascular risk
factors.
*of note at time of discharge final read of MRI was not posted
and therefore he should follow up with his Neurologists/PCP on
the final report.*
On further exam he did have a positive ___ to the left.
His symptoms were worse with head movements and therefore made
a peripheral vertigo the likely etiology with BPPV the most
likely etiology. He was referred for vestibular therapy to be
done as an outpatient.
Of note his stroke risk factors were checked. His cholesterol
was normal at (LDL at 101, and Triglycerides at 54).
Medications on Admission:
Medications: ASA 81 mg daily, metoprolol 50 mg BID for
palpitations.
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever
2. Gabapentin 300 mg PO TID
3. Aspirin 81 mg PO DAILY
4. Metoprolol Tartrate 50 mg PO BID
5. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth q8 Disp #*15 Tablet
Refills:*0
6. Outpatient Physical Therapy
___ rehab. Eval and treat. Dx. Peripheral vestibulopathy.
Discharge Disposition:
Home
Discharge Diagnosis:
peripheral vestibulopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
You were admitted for a dizziness and difficulty with walking.
With the history of a vertebral dissection, there was initial
concern that this may have been related to either a stroke or
transient ischemic attack, however you had a normal MRI of your
brain and normal vessels and your symptoms appear more
consistant with a peripheral vestibulopathy. You should follow
up with physical therapy and make appointments with w Drs.
___ in ___ clinic.
Your stroke risk factors were checked. You should not smoke.
Your cholesterol was normal at (LDL at 101, and Triglycerides at
54). You need to continue your blood pressure control. You
should continue to eat a low fat healthy diet.
It was a pleasure taking care of you.
Followup Instructions:
___
|
10657243-DS-10
| 10,657,243 | 21,954,250 |
DS
| 10 |
2120-10-31 00:00:00
|
2120-10-31 20:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Dicloxacillin / Diclofenac
Attending: ___.
Chief Complaint:
Weakness and fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with DM, HTN, CKD and recently diagnosed pancreatic cancer
with concern for metastatis vs. additional colon and/or gastric
primary, presenting with weakness and fall. ___ morning, she
stood up from chair, felt lightheaded with wobbly legs, and was
lowered to the ground by her family. No head strike, LOC, CP,
SOB, palpitations, change in diet, neurological symptoms,
including headache, muscle weakness, tingling. She was recently
prescribed oxycodone 5 mg for pain but took 10 mg on day of
presentation, though family notes weakness started before taking
medication. Family also reports confusion since ___.
Of note, she was recently admitted to ___ ___ for
hematochezia and intermittent constipation/diarrhea, where she
underwent colonoscopy on ___ that found "2 large partially
circumferential submucosal colonic lesions (1 non-obstruction
lesion in rectum, 1 partially obstructing lesion in sigmoid), as
well as smaller polyps." CEA was noted to be 24.7. Hgb noted to
be stable upon discharge at 10.9.
She was noted to have masses in the upper abdomen during that
admission, and for these underwent EUS with biopsy of pancreatic
mass showing adenocarcinoma and biopsy of gastric antral mass
suggestive of smooth muscle neoplasm based on appearance.
In the ED, initial VS were: 97.6 110 142/57 18 97% RA
Exam notable for:
"Tachycardic, afebrile
RRR, no murmurs
CTABL
No CVAT
S/NT/ND
Abrasions to B/L knees, no lacerations. Mildly tender. Full
active flexion to 45, extension to 90 without pain. No
valgus/varus instability.
CN ___ intact, ___ strength bilateral upper/lower extremities,
normal sensation to light touch grossly"
EKG: "111 NSR, NA, NI, NI, low voltage lat precordial leads,
unchanged prior"
Labs showed: WBC 11.5 (from 8.8 in ___, Hgb 9.5 (12 in
___ but has been in 8 range going back to ___, Cr 1.4
(baseline), Na 132 (most recently 140s)
Imaging showed:
-CT abdomen with 5x4x6 cm pancreatic tail mass, no acute process
-CT head unremarkable
-CXR with low lung volumes, no consolidation
Consults: none
Patient received:
___ 01:24 IVF NS ( 1000 mL ordered)
___ 01:24 IM Tetanus-DiphTox-Acellular Pertuss (Adacel)
.5
mL
___ 01:24 IV Morphine Sulfate 4 mg
Transfer VS were: 98 122/61 16 98% RA
On arrival to the floor, patient confirms the above history. She
is feeling better and does not have any acute complaints.
Past Medical History:
ANEMIA
ANXIETY
B12 DEFICIENCY
BIPOLAR DEPRESSION
ECZEMA
HEADACHES
HYPERCHOLESTEROLEMIA
HYPERTENSION
KNEE PAIN
OSTEOARTHRITIS
OSTEOARTHRITIS
RECTAL BLEEDING
SHOULDER PAIN
SPINAL STENOSIS
TINNITUS
TRICUSPID REGURGITATION
VITAMIN D DEFICIENCY
? IRRITABLE BOWEL SYNDROME
DIABETES TYPE II
RENAL INSUFFICIENCY
NARCOTICS AGREEMENT
KNEE SURGERY ___
CATARACT SURGERY
bilateral
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.7 PO 146 / 77 100 20 98 Ra
GENERAL: NAD, hard of hearing, A&Ox3
HEENT: dry oral mucosa
NECK: no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nontender, nondistended, obese
EXTREMITIES: trace pitting edema
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: no rashes
DISCHARGE PHYSICAL EXAM:
Temp: 98.9 (Tm 98.9), BP: 125/71 (123-150/71-74), HR: 115
(109-122), RR: 18 (___), O2 sat: 95% (93-96), O2 delivery: Ra
GENERAL: alert, oriented, pleasant, in NAD
NECK: no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: no ttp, nondistended, no rebound or guarding
EXTREMITIES: 1+ edema to ankles
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: superficial skin abrasions over bilateral knees
Pertinent Results:
ADMISSION LABS:
___ 09:20PM BLOOD WBC-11.4* RBC-3.09* Hgb-9.5* Hct-28.2*
MCV-91 MCH-30.7 MCHC-33.7 RDW-12.8 RDWSD-42.3 Plt ___
___ 09:20PM BLOOD Neuts-82.8* Lymphs-5.7* Monos-10.3
Eos-0.2* Baso-0.2 Im ___ AbsNeut-9.40* AbsLymp-0.65*
AbsMono-1.17* AbsEos-0.02* AbsBaso-0.02
___ 09:20PM BLOOD Glucose-268* UreaN-21* Creat-1.4* Na-132*
K-3.8 Cl-93* HCO3-25 AnGap-14
___ 08:45AM BLOOD ALT-16 AST-26 AlkPhos-94 TotBili-1.2
___ 08:45AM BLOOD Calcium-8.5 Phos-1.9* Mg-1.2*
___ 09:20PM BLOOD Osmolal-284
IMAGING:
CT HEAD ___
1. There is no evidence of acute intracranial process or
hemorrhage.
2. No calvarial fracture.
3. Paranasal sinus disease with possible erosion in the
posterior wall of the
frontal sinus on the left as described above, if clinically
warranted,
correlation with dedicated CT of the paranasal sinuses is
recommended
RECOMMENDATION(S): Paranasal sinus disease with thinning of the
posterior
wall of the frontal sinus on the left suggesting bone erosion,
if clinically
warranted, correlation with dedicated CT of the paranasal
sinuses is
recommended.
CT ABD ___
1. No bowel obstruction.
2. Ill-defined heterogeneously hypoattenuating pancreatic tail
mass measuring approximately 5.0 x 3.9 x 5.8 cm, corresponding
to reported history of newly diagnosed pancreatic cancer.
Low-density components of the mass tether and appear to invade
the posterior gastric body. There is occlusion of the splenic
artery and vein with collateral vessel formation.
3. No definite colonic mass is identified, noting that
evaluation CT is
markedly limited, especially in the setting of an unprepped
colon. Please
correlate with endoscopic findings for evaluation of the
reported colonic
mass.
4. Omental and peritoneal nodules in the abdomen and pelvis with
small amount of free fluid consistent with peritoneal
carcinomatosis.
5. Bilateral trace pleural effusions.
KNEE XRAY ___
No fracture or dislocation. Small left knee joint effusion.
Degenerative
changes in the left knee. Status post right total knee
arthroplasty without hardware associated complications.
CT SINUS ___
1. Compared to most recent prior study, unchanged opacification
of the
bilateral frontal sinuses, with possible erosion of the anterior
and posterior walls of the left frontal sinus. Given the
patient's history, a bone metastasis cannot be excluded.
Correlation with MRI brain and orbits with and without contrast
is advised for further characterization.
2. Narrowed right ostiomeatal unit. Rightward nasal septal
deviation with a left bone spur.
3. Significant degenerative changes of the bilateral
temporomandibular joints.
RECOMMENDATION(S): Compared to most recent prior study,
unchanged
opacification of the bilateral frontal sinuses, with possible
erosion of the anterior and posterior walls of the left frontal
sinus. Given the patient's history, a bone metastasis cannot be
excluded. Correlation with MRI of the brain and orbits with and
without contrast is advised for further characterization.
___ MRI HEAD
1. Moderate motion degraded examination.
2. No definite evidence for intracranial metastatic disease.
3. No acute intracranial finding.
4. Severe multifocal sinus disease with left frontal sinus
posterior wall
abnormality better seen on CT.
5. Background of moderate global parenchymal volume loss and
evidence of mild chronic small vessel ischemic disease.
___ CTA CHEST
IMPRESSION:
No evidence of pulmonary embolism or aortic abnormality.
No evidence of pulmonary metastatic disease.
Mild perihepatic ascites. Small bilateral pleural effusions.
MICRO:
Blood culture x3 negative
Urine culture: mixed bacterial flora
DISCHARGE LABS:
___ 05:55AM BLOOD WBC-8.5 RBC-2.79* Hgb-8.3* Hct-26.6*
MCV-95 MCH-29.7 MCHC-31.2* RDW-14.0 RDWSD-49.0* Plt ___
___ 06:05AM BLOOD Glucose-154* UreaN-15 Creat-1.3* Na-143
K-4.6 Cl-100 HCO3-27 AnGap-16
___ 06:05AM BLOOD Calcium-8.1* Phos-4.4 Mg-1.7
Brief Hospital Course:
for Outpatient Providers: ___ with DM, HTN, CKD and recently
diagnosed pancreatic cancer with concern for peritoneal
carcinomatosis and sigmoid adenocarcinoma concerning for primary
gastric malignancy vs. pancreatic mets presented with weakness
and fall found to be septic from suspected gastric translocation
treated with cipro/flagyl and discharged to rehab with close
oncology followup.
#Sepsis
#Abdominal pain
Patient initially presented with weakness thought to be in the
setting of both infection and poor PO intake. On hospital day
one, she spiked a fever, was tachycardiac and hypoxemic and was
started on broad spectrum antibiotics. Cultures were unrevealing
and she was narrowed to cipro/flagyl. Because of her abdominal
tenderness and pain, her sepsis was thought to be likely gut
translocation from sigmoid tumor or secondary peritonitis from
gastric invasion of pancreatic tumor. On discharge the patient
was continued on cipro/flagyl for suppression and for treatment
of sinusitis as below.
#Hypoxia
Briefly required supplemental O2 on ___ in setting of IVF
resuscitation. This improved spontaneously without diuresis. No
known history of CHF. CXR neg for pna. CTA pursued given
persistent tachycardia, negative for PE.
#sinusitis
Patient was found to have paranasal sinus disease on initial
head CT. This was further evaluated with an MRI and dedicated CT
with no definite results. The patient was evaluated by ENT who
recommended a two week course of antibiotics for day one ___.
#Advanced stage pancreatic cancer:
Patient presented with recent diagnosed pancreatic cancer with
invasion into the stomach, peritoneal carcinomatosis, sigmoid
adenocarcinoma (primary vs. pancreatic mets?). The patient had
CT scans of chest and MRI of brain both of which were
unrevealing for metastatic disease. During her admission the
patient's pathology slides were requested from ___ and were
delivered to the ___ pathology lab. Close oncology follow up
was scheduled for ___. The patient was in severe abdominal
pain initially during her admission. On discharge her medication
regimen was:
Pain:
-Tylenol 1g q6
-ocycontin 15mg BID
-oxycodone 10mg q4h prn
Constipation:
-lactulose 45 ml PO daily
-senna 17.2 mg PO daily
-docusate 100 mg PO BID
-Bisacodyl 10mg daily PR PRN constipation
Nausea:
-Zofran 4mg q8h PRN nausea
Nausea/Anxiety:
-Lorazepam .5mg PO q6h PRN
#tachycardia
Patient had tachycardic throughout admission that was
unresponsive to fluid boluses. Due to concern for PE a CTPA was
obtained which was negative. Her tachycardia was thought to be a
stress response to underlying malignancy and holding home beta
blocker in setting of sepsis. Beta blocker was restarted on day
of discharge. HR prior to beta blockade was 100-110.
#Anemia
Thought to be likely in setting of known GI malignancy. Hgb
remained stable throughout admission.
#Acute on chronic kidney disease
Patient initially presented with an elevated Cr that improved
with fluids.
CHRONIC ISSUES
DM
Pt had frequent early morning hypoglycemia while on home Lantus
dosing. She was decreased to 60u in the morning and 40u in the
evening. Home sitagliptin 50mg was continued on discharge.
HTN - held home lisinopril given recent contrast load. Continued
on home HCTZ.
=======================
TRANSITIONAL ISSUES:
=======================
[ ] patient aware of cancer diagnosis but prefers not to know
details. ___ MD team communicate through daughter, ___, who
is very supportive.
[ ] restart lisinopril as BPs tolerate
[ ] closely monitor blood sugars as outpt and uptitrate to home
dose as appetite improves
[ ] discuss suppressive antibiotic course with oncology
MEDICATIONS:
- New Meds:
1) Tylenol 1g q6h
2) ocycontin 15mg BID
3) oxycodone 10mg q4h prn
4) Tylenol 1g q6h
5) Bisacodyl 10mg daily PR PRN constipation
6) Ciprofloxacin 500mg BID
7) Metronidazole 500mg q8h
8) lactulose 45 ml PO daily
9) senna 17.2 mg PO daily
10) docusate 100 mg PO BID
11) Zofran 4mg q8h PRN nausea
12) Lorazepam .5mg PO q6h PRN
- Stopped Meds:
1) Lisinopril 10mg daily
- Changed Meds:
1) Glargine 70u BID changed to 60u at breakfast, 40u at bedtime
FOLLOW-UP
- Follow up: Oncology ___
- Tests required after discharge: None
- Incidental findings: None
OTHER ISSUES:
- Hemoglobin prior to discharge: 8.3
- Cr at discharge: 1.3
- Antibiotic course at discharge: Cipro/flagyl for 2w from day
one ___, may consider long term suppressive antibiotic
pending oncology follow up.
# CONTACT: daughter ___ ___
# CODE: Full (presumed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. Metoprolol Succinate XL 200 mg PO DAILY
4. Glargine 70 Units Breakfast
Glargine 70 Units Bedtime
5. LamoTRIgine 25 mg PO DAILY
6. Simvastatin 80 mg PO QPM
7. Omeprazole 20 mg PO DAILY
8. Citalopram 40 mg PO DAILY
9. SITagliptin 50 mg oral DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Moderate
2. Bisacodyl ___AILY:PRN constipation
3. Ciprofloxacin HCl 500 mg PO Q12H
4. Docusate Sodium 100 mg PO BID
5. Lactulose 45 mL PO DAILY
6. LORazepam 0.5 mg PO Q8H:PRN refractory nausea or anxiety
7. MetroNIDAZOLE 500 mg PO Q8H
8. Ondansetron 4 mg PO Q8H:PRN nausea
9. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN BREAKTHROUGH
PAIN
RX *oxycodone 10 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
10. OxyCODONE SR (OxyconTIN) 15 mg PO Q12H
RX *oxycodone [OxyContin] 15 mg 1 tablet(s) by mouth twice a day
Disp #*10 Tablet Refills:*0
11. Senna 17.2 mg PO HS
12. Glargine 60 Units Breakfast
Glargine 40 Units Bedtime
13. Citalopram 40 mg PO DAILY
14. Hydrochlorothiazide 12.5 mg PO DAILY
15. LamoTRIgine 25 mg PO DAILY
16. Metoprolol Succinate XL 200 mg PO DAILY
17. Omeprazole 20 mg PO DAILY
18. Simvastatin 80 mg PO QPM
19. SITagliptin 50 mg oral DAILY
20. HELD- Lisinopril 10 mg PO DAILY This medication was held.
Do not restart Lisinopril until you see your primary care doctor
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Sepsis
Secondary diagnoses:
Weakness
Toxic metabolic encephalopathy
Pancreatic Cancer
Colon cancer
DM2
HTN
CKD stage 3
Sinus infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you during your admission to ___.
Below you will find information regarding your stay.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted because you were having some weakness and
some confusion.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You had a CT scan of your head that showed no abnormalities in
the brain.
- You had a fever while in the hospital and you were started on
antibiotics.
- You had a MRI that showed you were having a sinus infection.
- You were started on pain medications and medications to help
your nausea and constipation.
- You were seen by the physical therapists who recommended you
go to rehab to regain your strength.
WHAT SHOULD I DO WHEN I GO HOME?
-Take your medications as prescribed
-Keep your follow up appointments with your team of doctors
Thank ___ for letting us be a part of your care!
Your ___ Care Team
Followup Instructions:
___
|
10657324-DS-7
| 10,657,324 | 20,273,170 |
DS
| 7 |
2126-11-25 00:00:00
|
2126-11-25 20:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
amiodarone / atorvastatin
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ male with a history of COPD on ___
at home, lung cancer, PE on fondaparinux, presenting as a
transfer from ___. Initially presented to ___
with chief complaint of worsening shortness of breath for 2
days.
Having dyspnea at rest. Associated with cough. Feels he is
producing more sputum, but not able to really bring it up with
coughing. Denies chest pain, fevers, chills, nausea, emesis,
abdominal pain. Evaluation at ___ notable for CT that large
R hilar mass with encasement of the RLL branch of the pulmonary
artery. He was transferred to ___ for thoracic surgery
evaluation.
- In the ED, initial vitals were:
Temp 98.4 | HR 74 | BP 130/87 | RR 18 | SpO2 98% 2L NC
- Exam was notable for:
Decreased breath sounds bilaterally to auscultation, but without
no wheezing or crackles heard.
- Labs were notable for:
BNP 256
Trop <0.01
- The patient was given:
Ceftriaxone 1g IV
Azithromycin 500mg IV
- Thoracic surgery was consulted. Recommended symptomatic
control. Will not need emergent thoracic surgical intervention
overnight. Will evaluate for possible tissue diagnosis while
inpatient, and will follow patient closely
On arrival to the floor, patient reports he feels well. Still
having some dyspnea.
Past Medical History:
Afib
Squamous cell lung ca s/p R lobectomy ___
___ Stage IIIB (cT3, cN2, cM0) s/p carboplatin/paclitaxel in
___
MI s/p CABG and PCI circa ___
R nephrectomy in ___ for recurrent pyelonephritis
Anxiety
COPD, on 2L
PEs on ___
Suprapubic catheter for urinary retention
HFpEF
Social History:
___
Family History:
No known family history
Physical Exam:
ADMISSION EXAM
VITALS: Temp: 98.4 BP: 134/79 HR: 85 RR: 18 O2 sat: 93% O2
delivery: 2L
GENERAL: Sitting in bed, in no acute distress.
HEENT: Sclera anicteric and without injection. MMM.
CARDIAC: Normal rate and rhythm. Loud S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Expiratory wheezes bilaterally. No rhonchi or rales.
ABDOMEN: Soft, non distended, non-tender to deep palpation in
all
four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema.
NEUROLOGIC: AAOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
DISCHARGE EXAM
VITALS:
24 HR Data (last updated ___ @ 734)
Temp: 98.4 (Tm 98.7), BP: 123/66 (118-144/66-82), HR: 87
(81-88), RR: 18 (___), O2 sat: 93% (93-95), O2 delivery: 2l
GENERAL: Laying in bed, does not appear to be in distress
HEENT: Sclera anicteric and without injection. MMM.
CARDIAC: Regular rate and rhythm. Normal S1 and S2. No
murmurs/rubs/gallops.
LUNGS: NC in place. Moderate air movement. Diffuse expiratory
wheezes throughout all lung fields. No accessory muscle use.
EXTREMITIES: No clubbing, cyanosis, or edema.
Pertinent Results:
ADMISSION LABS
___ 08:55PM BLOOD WBC-5.0 RBC-3.74* Hgb-10.7* Hct-35.6*
MCV-95 MCH-28.6 MCHC-30.1* RDW-16.3* RDWSD-57.1* Plt ___
___ 08:55PM BLOOD Glucose-132* UreaN-14 Creat-0.8 Na-138
K-4.5 Cl-104 HCO3-24 AnGap-10
___ 07:10AM BLOOD Calcium-9.0 Phos-3.7 Mg-1.9
___ 08:55PM BLOOD cTropnT-<0.01 proBNP-256*
DISCHARGE LABS
___ 06:23AM BLOOD WBC-11.5* RBC-4.29* Hgb-12.1* Hct-38.9*
MCV-91 MCH-28.2 MCHC-31.1* RDW-16.1* RDWSD-53.8* Plt ___
___ 06:23AM BLOOD Glucose-117* UreaN-18 Creat-0.8 Na-139
K-4.8 Cl-101 HCO3-27 AnGap-11
MICRO
___ 1:20 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING
CTA CHEST ___ ___ Radiology ___ Read):
FINDINGS:
CHEST PERIMETER: No thyroid findings require any further imaging
evaluation.
No supraclavicular or axillary adenopathy. No soft tissue
abnormality in the
chest wall. This study is not appropriate for subdiaphragmatic
diagnosis
especially with regard to the liver, but shows no adrenal mass.
CARDIO-MEDIASTINUM: Esophagus is unremarkable. Atherosclerotic
calcification
moderate in head and neck vessels and heavy in native coronary
arteries.
Patient has had median sternotomy and saphenous bypass graft.
This study does
not assess patency of the grafts. There are no findings to
suggest
postoperative complications.
Aorta is normal size. Pericardium is physiologic.
PULMONARY ARTERIES:
Right pulmonary artery is enlarged, 30 mm.
Right basal trunk pulmonary has either been ligated as part of
prior lobectomy
or is occluded by mass at the surgical site in the right hilum.
There are no filling defects in the remainder of the branches of
the right
pulmonary artery.
Left pulmonary artery and branches are intact of the
subsegmental level.
THORACIC LYMPH NODES: As follows:
Numerous left lower paratracheal mediastinal nodes range in
diameter up to 12
mm, 05:45. Large infiltrative right hilar mass, at least 57 x
45 mm, 5:70,
extends from the right pulmonary artery to the left atrium,,
invading the
pericardium, and is inseparable from the right wall of the
esophagus, 5:63.
LUNGS, AIRWAYS, PLEURAE:
4 cm long stent in the right main bronchus extends into the
bronchus
intermedius. The precise right bronchial anatomy is uncertain
in the absence
of clear surgical history, but aside from a probe patent middle
lobe bronchus,
there is no patent bronchus distal to the stent which is
partially occluded
with mucus or tumor in growth, 06:59.
Circumferential right pleural thickening is irregular, and
contiguous with
linear nodular extensions into the right lung, for example 20 x
6 mm nodule,
06:58, all of which could be due to malignant recurrence.
Left upper lobe is clear. A linear array of consolidation in
the left lower
lobe, posterior basal segment, 5: 98-100 108 is more likely
infectious than
malignant. There is no left pleural abnormality.
CHEST CAGE: No compression or pathologic fracture or large
destructive bone
lesion. Although there are no bone lesions in the imaged chest
cage
suspicious for malignancy or infection, it should be noted that
radionuclide
bone and FDG PET scanning are more sensitive in detecting early
osseous
pathology than chest CT scanning.
IMPRESSION:
Large infiltrative right hilar mass occludes nearly all the
bronchial tree
distal to a right main bronchus stent. Similarly, the right
descending
pulmonary artery is occluded at the site of the mass. Which
structures have
been ligated in previous right lobectomy is uncertain. No
pulmonary emboli
left lung.
CXR ___:
IMPRESSION:
No comparison radiograph, a CT from ___ is available.
No low lung
volumes at the level of the right hemithorax. Clips projecting
over the left
hilus. Stable alignment of the sternal wires. Moderate
elevation of the
right hemidiaphragm. Minimal scarring at the bases of the right
lower lung.
The left lung parenchyma is unremarkable. The extensive
masslike structure at
the level of the right hilus as well as the multiple changes at
the level of
the lung parenchyma, visualized on the previous CT examination,
are not seen
on the chest x-ray.
Brief Hospital Course:
Mr. ___ is a ___ year old male with history of ___ s/p
___ (last ___ follows with oncologist Dr. ___
___, COPD, who initially was transferred from ___
___ for increased dyspnea and further evaluation of right
lung mass. He had a CTA chest that showed a large infiltrative
right hilar mass occluding nearly all the bronchial tree distal
to his right main bronchus stent, also with occlusion of right
descending pulmonary artery distal to the mass. Also with
extensive pleural thickening and nodular extensions with
possible malignant recurrence. He was initially evaluated by
thoracic surgery for potential consideration of biopsy, however
on further review, he has had repeat CT staging scans both in
___ and ___, with findings that appear to be stable. Attempts
were made to contact his outpatient oncologist in order to
confirm comparison between the current CTA chest and his prior
scans. We were unable to reach his primary oncologist, however
on review of his prior scans and reports, the current findings
were thought to largely be stable. His shortness of breath was
ultimately thought to be more so related to COPD exacerbation,
and he was treated with a course of azithromycin and steroid
burst. He will continue with a steroid taper on discharge and
also with follow-up with his PCP and oncologist.
TRANSITIONAL ISSUES:
====================
[ ] NEW/CHANGED MEDICATIONS
- Started steroid taper plan prednisone 30mg x 2 days (starting
___, then 20mg x 2 days, then 10mg x2 days, then off
- Stopped his combivent inhaler and replaced instead with
tiotropium 1 capsule daily
- Started guaifenasin ER 600mg PO BID for 1 week
[ ] Patient was started on LAMA therapy and discontinued
combivent. PCP to consider referral to pulmonologist on
discharge
[ ] CTA chest at ___ showing per our radiologist's read
here on ___ read large infiltrative right hilar mass occluding
nearly all the bronchial tree distal to his right main bronchus
stent, also with occlusion of right descending pulmonary artery
distal to the mass. Also with extensive pleural thickening and
nodular extensions with possible malignant recurrence.
Outpatient oncologist to consider additional work-up as
indicated including potential repeat biopsy and/or treatment.
ACUTE/ACTIVE ISSUES:
====================
#Acute COPD exacerbation
#Dyspnea - Patient presented with shortness of breath diffuse
wheezing, increased sputum production, with likely COPD
exacerbation. Patient was initially on ___ O2 at rest and was
unable to walk very far, even with 2L O2. He only uses O2 at
home (2L) with exertion so he was having an increased O2
requirement on admission. CTA at ___ was negative for PE
with additional findings as mentioned below. Patient was
initially started on CTX/azithro in the ED for presumed PNA, but
CT from ___ without any evidence of consolidation, and
there were no lung findings on exam concerning for this. He was
also afebrile without leukocytosis, so we discontinued the CTX
and continued only the azithromycin for 5 days. He was also
given standing albuterol and ipratropium. He was treated with
prednisone 40mg x 5 days and discharge with steroid taper
prednisone 30mg x 2 days (starting ___, then 20mg x 2 days,
then 10mg x2 days, then off. His combivent was discontinued on
discharge and instead was started on Spiriva.
#Right lung mass - Per most recent outpt onc note at ___ (Dr.
___ ___, "He has had restaging scans in ___ at ___ and more recently ___ at ___
during hospital admissions. I reviewed these with thoracic
radiology, and there is no clear evidence of progressive
malignancy. There is soft tissue encasing the R hilum which
appears stable and is likely
related to post-radiation changes." He had a CTA chest at
___ showing per our radiologist's read here on ___ read
large infiltrative right hilar mass occluding nearly all the
bronchial tree distal to his right main bronchus stent, also
with occlusion of right descending pulmonary artery distal to
the mass. Also with extensive pleural thickening and nodular
extensions with possible malignant recurrence.
Given the above findings on serial CT scans most recently in
___, his current CTA findings may represent stable findings or
potentially some progression of disease. These findings were
communicated to his outpatient oncologist via email and attempts
were made to discuss this with their office and was communicated
to practice NP. Outpatient oncologist to consider additional
work-up as indicated including potential repeat biopsy and/or
treatment.
CHRONIC/STABLE ISSUES:
======================
#PE - He was continued on home fondaparinux 10mg daily.
#HFpEF - He was continued on home metoprolol succinate 100mg
daily.
#Anxiety - He was continued on home quetiapine 150mg qhs and
venlafaxine XR 150mg
daily.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.5 mg PO QID:PRN Anxiety
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN Dyspnea
3. Fluticasone-Salmeterol Diskus (250/50) 2 INH IH BID
4. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
5. Metoprolol Succinate XL 100 mg PO DAILY
6. QUEtiapine Fumarate 150 mg PO QHS
7. Venlafaxine 150 mg PO DAILY
8. Fondaparinux 10 mg SC DAILY
Discharge Medications:
1. GuaiFENesin ER 600 mg PO BID
Take for 1 week
RX *guaifenesin [Mucinex] 600 mg 1 tablet(s) by mouth twice a
day Disp #*14 Tablet Refills:*0
2. PredniSONE 10 mg PO DAILY Duration: 2 Doses
This is dose # 3 of 3 tapered doses
RX *prednisone 10 mg 3 tablet(s) by mouth once a day Disp #*12
Tablet Refills:*0
3. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 once a
day Disp #*1 Capsule Refills:*3
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN Dyspnea
5. ALPRAZolam 0.5 mg PO QID:PRN Anxiety
6. Fluticasone-Salmeterol Diskus (250/50) 2 INH IH BID
7. Fondaparinux 10 mg SC DAILY
8. Metoprolol Succinate XL 100 mg PO DAILY
9. QUEtiapine Fumarate 150 mg PO QHS
10. Venlafaxine 150 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
___:
COPD exacerbation
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 did you come to the hospital?
-You initially came to the hospital because of worsening
shortness of breath
What happened during your hospitalization?
-You had a CAT scan that showed a large mass on the right side
of your lung, which may be stable compared to your prior CT scan
in ___
-You were also treated for a COPD exacerbation with inhalers and
also steroids
What should you do when you leave the hospital?
-Continue to take all your medications as prescribed and
follow-up with your appointments as scheduled below
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10657422-DS-14
| 10,657,422 | 25,649,292 |
DS
| 14 |
2167-10-31 00:00:00
|
2167-10-31 23:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hypotension and lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
PCP: ___
___ yo F no known PMH (patient has not seen a physician in
decades) who presents with RLE pain and hypotension. Patient
reports that she had increasing lethargy and fatigue throughout
the day that was associated with intermittent RLE pain. The
patient also reports extreme thirst and increased urination.
Patient's husband called EMS. On arrival, EMS found that she was
hypotensive to "40 over palp." FSBG was in the 200's. IVF were
initiated.
In the ED, initial vital signs were 95, 77, 95/60, 22, and 100%
RA. Exam was notable for large area of lymphedema of RLE with
deformation of right ankle and foot without tenderness,
fluctuance, or erythema. Rectal exam with guaiac negative stool.
Labs were remarkable for a WBC 19.2, H/H 6.8/20.9, Plt 445, HCO3
15, Cr 1.5, glucose 272, and lactate 3.5. Serum and urine tox
screens were negative. UA was grossly positive. Bedside US
preformed showed hyperdynamic cardiac activity and flat IVC. CTA
chest showed no PE. She recieved 3 L IVF, vancomycin, and
cefepime. She was admitted to the ICU for further evaluation and
management.
On arrival to the MICU, patient reports that she is feeling
better and would like to go home. She reports that her right leg
"went numb" earlier today but this has resolved. Otherwise she
reports that she is feeling completely fine. Denies fever,
chills, fatigue, lethargy, chest pain, palpitations, SOB, cough,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, dysuria, urgency, frequency, headache, weakness, and
numbness.
Review of systems: As per HPI
Past Medical History:
- Chronic RLE swelling and deformation
- Previously treated for "underative thyroid"
- Not in care for decades
Social History:
___
Family History:
Uncle with heart disease. Parents alive and healthy.
Physical Exam:
Vitals: 98.1, 100, 140/83, 20, 99% RA
General: Chronically ill-appearing female
HEENT: Sclera anicteric, mucous membranes dry, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes/rales/rhonchi
CV: RRR, nl S1/S2, no MRG
Abdomen: Soft, NTND, normoactive bowel sounds
GU: No Foley
Ext: Warm, well-perfused, marked RLE edema and deformity, 2+
pulses
Neuro: AAOx3, CN II-XII intact, motor function grossly normal
Pertinent Results:
___ 08:30PM BLOOD WBC-19.2* RBC-2.51* Hgb-6.2* Hct-20.9*
MCV-83 MCH-24.7* MCHC-29.6* RDW-17.6* Plt ___
___ 08:30PM BLOOD Neuts-80.0* Lymphs-15.0* Monos-3.4
Eos-0.9 Baso-0.7
___ 08:30PM BLOOD ___ PTT-27.9 ___
___ 12:20AM BLOOD Ret Man-2.6*
___ 08:30PM BLOOD Glucose-272* UreaN-19 Creat-1.5* Na-137
K-3.5 Cl-105 HCO3-15* AnGap-21*
___ 08:30PM BLOOD ALT-8 AST-19 AlkPhos-78 TotBili-0.2
___ 08:30PM BLOOD cTropnT-0.02*
___ 08:30PM BLOOD Albumin-3.4* Calcium-8.7 Phos-3.9 Mg-2.4
___ 10:30PM BLOOD calTIBC-247* ___ Ferritn-64 TRF-190*
___ 03:47AM BLOOD %HbA1c-5.6 eAG-114
___ 10:30PM BLOOD T4-1.1* T3-30*
___ 08:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:49PM BLOOD Lactate-3.5*
Blood/Urine cultures:
CTA CHEST:
IMPRESSION:
Preliminary Report1. No acute cardiopulmonary process or
pulmonary embolism.
Preliminary Report2. Subsegmental atelectasis at the right lung
base.
Preliminary Report3. 5 mm right lower lobe pulmonary nodule for
which a followup CT is
Preliminary Reportrecommended in ___ months, if high risk
patient. If low risk patient, follow
Preliminary Reportup CT can be performed at 12 months.
CT ABDOMEN:
IMPRESSION:
No evidence of hemorrhage. No etiology for patient's symptoms
is identified.
Brief Hospital Course:
Hypotension/Sepsis due to UTI:
Presumed based on hypotension, lactic acidosis, and positive UA.
No other areas of infection found. Started on Cefepime/Vanco
empirically and given IVF with improvement in her BP. She was
transitioned to IV CTX until cultures returned. CT abd
negative. Patient discharged on a course of cefpodoxime
Anemia, NOS:
Found to have Hct 18 on presentation, no evidence of bleeding or
hemolysis. Given blood transfusion with stability in her Hct.
Could be related to severe hypothyroidism, chronic blood loss,
or nutritional. Will need treated of her hypothyroid,
nutrition, and colonoscopy as outpatient.
Hypothyroidism: Previously diagnosed, but stopped medication
years ago. TSH >100. No coma or acute decompensation. Spoke
with endocrine, and started 125mcg daily. Will need TFTs in ___
weeks and further adjustment from there
Leg swelling: Chronic and related to previous surgery? No signs
of infection. Would consider further imaging and surgical
referral as able, if patient agreeable
Lung nodules: Found incidentally on CTA. Discussed with
patient. Requires ___ month follow up if patient agreeable
Patient declined aspects of medical care and hesitant to get
care. However, she expressed understanding of the severity of
her illness, and need to follow up closely regarding all of the
issues above, and general health maintenance.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Disposition:
Home
Discharge Diagnosis:
Sepsis due to UTI
Anemia, NOS
Hypothyroidism
Right leg swelling
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 low blood pressure likely
caused by a urinary tract infection with anemia. You needed
blood transfusion and IV antibiotics. You were also found to
have very low thyroid function, and thyroid replacement was
restarted. You will need to take this medication every day,
complete your course of antibiotics, and establish care with a
doctor.
You will need your thyroid tests repeated in ___ weeks. You
will need work up of your anemia and colonoscopy. Additionally,
as we discussed, CT of the chest found incidental lung nodules.
We recommend repeating this in ___ months to make sure these
are not cancerous.
Followup Instructions:
___
|
10657677-DS-8
| 10,657,677 | 20,831,753 |
DS
| 8 |
2119-10-21 00:00:00
|
2119-10-21 17:34:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
CC: resolved diplopia, CODE STROKE
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI:
___ who presents with two episodes of vertical diplopia on a
background of Right ICA aneurysm, HTN, HL and breast CA.
She was in her usual state of health until earlier this morning.
She woke up at 6am and felt fine and went to church. However at
around 7am she noted "double vision", and patient's husband
brought patient over to ___. She underwent a
unremarkable non dilated eye / vision check there (Dr. ___. Her BP was 140's/86. Prior to her arrival at the office
her double vision dissipated and had lasted overall perhaps 1
hour. She has never had such symptoms prior to this morning.
Despite resolution of her problems though she continued to feel
that her head was "fuzzy" and that her vision was not perfectly
"focused" and had trouble reading because of this. She denied
headache at that time or other neurological symptoms. Her
husband
confirms that she was not weak and did not have facial droop.
She
did not have any changes in her speech around this time either.
The patient is followed by Dr. ___, ___ Neurology, for
possible "future ___ and by Dr. ___ at ___ for a
"tiny aneurysm" of brain. Her last MRI of brain done several
months ago did not show any changes (aneurysm was stable at
6mm).
Of note, the patient states she and her husband received
influenza vaccine yesterday at ___.
On neuro ROS, the patient endorses changes in vision but she
denies headache, blurred vision, diplopia, dysarthria,
dysphagia, lightheadedness, vertigo, tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech. Denies focal weakness, numbness, parasthesiae. No bowel
or bladder incontinence or retention. Denies difficulty with
gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
PMH:
Hypercholesterolemia
CARCINOMA IN SITU - BREAST
Hypertension, essential
CATARACT
Osteopenia
Colonic adenoma
HYPERKALEMIA
ICA aneurysm
Chronic kidney disease, stage III (moderate)
Social History:
___
Family History:
Family Hx:
CAD/PVD - Early
Father ___ at ___
Mother ___ at ___ ___ Hypertension
Physical Exam:
ADMISSION PHYSICAL EXAM:
___ Stroke Scale score was 0:
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: 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
I was present during the CT scanning and reviewed the images
instantly within 20 minutes of their completion".
Physical Exam:
Vitals: 96.6 84 138/51 16 100%
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 C/C/E bilaterally, 2+ radial, DP pulses
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 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.
-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 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 0
R 2 2 2 2 0
Plantar response was flexor bilaterally.
-Coordination: Mild bilateral intention tremor, no
dysdiadochokinesia noted. No dysmetria on FNF or HKS
bilaterally.
-Gait: deferred
Discharge Physical Exam:
A&Ox3, speech fluent, able to relate history, intact
comprehension. Conjugate gaze, PERRL, EOMI, no diplopia, face
symmetric (slight droop left eyelid). Full strength, intact
reflexes, intact sensation.
Pertinent Results:
___ 03:24PM GLUCOSE-114* NA+-138 K+-3.6 CL--101 TCO2-24
___ 03:22PM UREA N-29*
___ 03:28PM CREAT-1.3*
___ 04:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 03:22PM WBC-6.6 RBC-3.85* HGB-12.4 HCT-38.3 MCV-99*
MCH-32.1* MCHC-32.3 RDW-12.1
___ 03:22PM PLT COUNT-351
___ 03:22PM ___ PTT-32.0 ___
Radiologic Data:
NECT: No acute intracranial abnormality.
CTA: No evidence of mural irregularity, flow limiting stenosis,
or dissection. No cerebral venous thrombosis. Unremarkable
intracranial
vasculature. Notable absence of atherosclerotic disease. Final
read pending 3D reconstructions.
Echo (___): Suboptimal image quality. No intracardiac source
of embolism identified. Normal biventricular cavity size and
global/regional biventricular systolic function.
Mild-to-moderate mitral regurgitation in a structurally-normal
valve. Late bubbles after injection suggestive of intrapulmonary
shunting.
MRI brain (___): No significant abnormalities are seen on
the MRI of the brain without gadolinium.
Brief Hospital Course:
Mrs. ___ is a ___ who presents with an episode of transient
vertical diplopia on a background of HTN, HL and stable right
ICA aneurysm. Her neuro exam is currently non focal. CTA /CT of
the head/neck is unremarkable on prelim read. Overall, the cause
of her vertical diplopia is unclear but there is a concern for
transient ischemic insult to the brainstem (midbrain). As such
she will benefit from MRI to sort out this
possibility.
Other considerations for her presentation of painless transient
diplopia would include myasthenia ___, ischemia cranial nerve
injury (___) which are difficult to sort out in the absence
of current deficits.
# Neuro: Patient was started on ASA 325mg po daily (increase
from home dose). We continued her Simvastatin but increased dose
to 40mg po daily. We checked for risk factors including HgbA1C
(5.6%) and Lipid profile (LDL 80). She underwent an MRI head
which was normal.
# CV: We continued her home Enalapril and Chlorthalidone for
Hypertension. She underwent a TTE, which showed no thrombus, PFO
or ASD.
# DVT: We started her on heparin sc for DVT prophylaxis.
# Nutrition: Patient underwent a bedside swallow eval and was
started on regular diet.
# Dispo: Discharge to home.
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 - (x) No
4. LDL documented? (x) Yes (LDL = ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (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:
The Preadmission Medication list is accurate and complete.
1. coenzyme Q10 100 mg oral Daily
2. exemestane 25 mg oral Daily
3. Enalapril Maleate 60 mg PO DAILY
4. Chlorthalidone 25 mg PO DAILY
5. Simvastatin 20 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral
Daily
Discharge Medications:
1. Chlorthalidone 25 mg PO DAILY
2. Enalapril Maleate 60 mg PO DAILY
3. exemestane 25 mg oral Daily
4. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral
Daily
5. coenzyme Q10 100 mg oral Daily
6. Multivitamins 1 TAB PO DAILY
7. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
8. Simvastatin 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Transient ischemic attack
Secondary diagnosis: Hypertension, Hyperlipidemia, Stable right
internal carotid artery aneurysm, History of breast cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ admitted for an episode of transient diplopia. We
evaluated ___ for a possible transient 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:
Hypertension, Hyperlipidemia, Stable right internal carotid
artery aneurysm, History of breast cancer
Please take your medications as listed below.
Please followup with Neurology and your primary care physician
as listed below.
If ___ 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
___
- 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 ___
- 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 ___ with care during this
hospitalization.
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L femur fracture
Major Surgical or Invasive Procedure:
Let femur intramedullary nail
History of Present Illness:
___ unrestrained frontseat passenger of MVC vs pole then
tree. Injury occured at 2am on ___. Denies LOC. Presented to
outside hospital where he was placed in traction brace for
diagnosed left femur fx. Also question at OSH about possible
SDH.
Transferred to ___ ED for continued care. On presentation pt
complains of R thigh and hip pain. Denies pain in knee, lower
left extremity or ankle. On ROS denies headache, change in
vision, numbness/tingling/N/V.
Past Medical History:
None
Social History:
___
Family History:
Noncontributory
Physical Exam:
Exam on Admission
Left lower extremity:
- Skin intact
- Traction brace in place.
- Edema over mid lateral portion of thigh
- Soft, tender thigh
- Unable to assess ROM due to traction brace
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Exam on discharge
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left femur fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for left femur intramedullary nail 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
weight bearing as tolerated in the left lower extremity, and
will be discharged on lovenox for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen [Acetaminophen Pain Relief] 500 mg ___
tablet(s) by mouth q6 Disp #*150 Tablet Refills:*0
2. Bilateral Axillary Crutches for Gait Training
Diagnosis: Left femur fracture
Prognosis: Good
Duration: 14 months
Contact information: ___, MD
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*100 Capsule Refills:*0
4. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*100 Capsule Refills:*0
5. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN Pain
RX *oxycodone 5 mg ___ capsule(s) by mouth q3hrs Disp #*150
Capsule Refills:*1
6. Enoxaparin Sodium 40 mg SC QPM
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 40 mg/0.4 mL 40 mg sc QPM Disp #*30 Syringe
Refills:*0
7. QUEtiapine extended-release 150 mg PO QHS
8. Calcium Carbonate 500 mg PO TID
9. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
L femur 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:
- weight bearing as tolerated
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your surgeon's team (Dr. ___, with
___, NP in the Orthopaedic Trauma Clinic 14 days
post-operation for evaluation. Call ___ to schedule
appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Physical Therapy:
Weight bearing as tolerated left lower extremity
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Augmentin / sulfites / Penicillins
Attending: ___.
Chief Complaint:
PCP: ___
CC: Back Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: ___ G2P2 postpartum day ___ s/p uncomplicated NSVD with
epidural, GERD, anxiety/depression who presents from home with
with progressive hip pain, weakness and inability to ambulate.
Pt states since returning home from her childbirth she initially
experienced b/l hip pain with radiation to her groin and some
weakness/difficulty with ambulation in the AM which improved
throughout the day. She was alternating APAP and ibuprofen with
minimal relief. On the day prior to admission she woke up with
inability to walk d/t worsening of the samme pain and weakness
with symptoms left worse than right.
She does report "falling" on the couch onto her L hip during an
attempt to get up with subsequent worsening of her L and R hip
discomfort. There have been no fevers/chills, urinary
retention/incontinence, incontinence of bowel, saddle
anesthesia. There has been no associated ___ numbness/tingling.
She also reports tailbone pain but otherwise denies associated
back pain aside from occ "pulling" when leaning the wrong
direction.
Of note, she does report similar but more mild symptoms
following her ___ pregnancy as well.
PO intake has been normal with no n/v. No Cp, Sob, abdominal
pain, rashes. She does think her ankle and hands are slightly
more swollen than normal.
She does report intermittent stress d/t perceived lack of social
support (currently her mother and in laws are looking after her
2 children) and being separated from family.
As per GYN notes, pt underwent IOL for advanced cervical
dilation at 40+ weeks; she reports she rapidly delivered without
pushing shortly after artificial ROM. She notably did require an
epidural. She was discharged after an uneventful 2 day
postpartum course.
She initially presented to urgent care for LBP and pelvic pain
but was subsequently triaged to the ED.
ED Course:
----------
Vitals:
Exam: Mild bilateral paralumbar tenderness. No pain with hip
flexion. Difficulty standing and pivoting from wheelchair to bed
due to pain, ___ and sensation otherwise intact.
Labs:
13.0>9.7/31.3<321
INR 1.0
140 106 11 Glucose 88
4.6 22 0.7
Imaging:
MRI: No cord compression or signal abnormality on MRI.
Meds: APAP, Morhpine, Zofran, oxycodone, Toradol, ?lidoderm
Course/impression:
Code cord called. No compression on MRI. No objective weakness
on exam.
Seen by Ob/Gyn; rec'd medicine admit; suspect unrelated to
ob/gyn issues
Patient has persistent pain precluding ambulation. Will require
admission for pain control.
Upon arrival to the floor, the patient reports ongoing pain with
abduction/adduction of hips. Feels only IV morphine is helping
for hips and valium for back.
Also reporting new dysuria, UA/Ucx sent
Seen by ___ rec'd OT consult, impression is possible
Femoroacetabular impingement or labrum pathology. Also concern
for acute hip flexor spasms' rec'd mobilization, lay flat in bed
to stretch anterior hips, ice hips ___ 3x/d
REVIEW OF SYSTEMS:
General: no weight loss, fevers, sweats.
Eyes: no vision changes.
ENT: no odynophagia, dysphagia, neck stiffness.
Cardiac: no chest pain, palpitations, orthopnea.
Resp: no shortness of breath or cough.
GI: No nausea, vomiting, diarrhea.
GU: No dysuria, frequency, urgency.
Neuro: As per HPI
MSK: As per HPI
Heme: no bleeding or easy bruising.
Lymph: no swollen lymph nodes.
Integumentary: no new skin rashes or lesions.
Psych: no mood changes
Past Medical History:
Well-controlled Asthma
Obesity
?Eating d/o
GERD
Anxiety/depression
Social History:
___
Family History:
Dad: CAD
Mom: ___, Sarcoidosis (pt states she has been screened and
ruled out for this)
Physical Exam:
PHYSICAL EXAM:
VITALS:
___ 0642 Temp: 98.3 PO BP: 136/85 HR: 90 RR: 20 O2 sat: 99%
O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___
GENERAL: Obese female, laying in bed, pumping breast milk during
initial interview. Speaking in full sentences. NAD.
EYES: EOMI, PERRL.
ENT: OP clear, MMM
CV: RRR, no mrgs appreciated
RESP: LCTA, no w/r/r
GI: Abd soft, ntnd
GU: No foley
MSK: No appreciable joint swelling of legs or ankles. TTP in
paraspinal
SKIN: No rashes noted. Epidural site in mid back with tiny
well-healed area without fluctuance or erythema
NEURO: Sensation intact in ___ and sensation full in b/l UEs.
Hip flexion 4+/5 bilaterally. Resisted b/l hip abduction and
adduction limited due to pain
___ of plantar and dorsiflexion full
PSYCH: At times tearful when discussing social situation.
Otherwise appropriate with good eye contact
Pertinent Results:
DATA: I have reviewed the relevant labs, radiology studies,
tracings, medical records, and they are notable for:
Labs -
UA: Mod blood, Sm leuks, 6 WBC
13.0>9.7/31.3<321
INR 1.0
140 106 11 Glucose 88
4.6 22 0.7
Microbiology:
Ucx: Pending
Radiology -
# MRI L Spine (___) :Vertebral body height and alignment is
preserved. Intervertebral disc spaces are maintained. Bone
marrow signal intensity is within normal limits. The spinal cord
appears normal in caliber and configuration. The conus
terminates normally at the L1 level. There is no epidural
collection.
There is no evidence of cord compression, spinal canal stenosis
or neural foraminal narrowing. IMPRESSION: 1. No evidence of
epidural hematoma. 2. No evidence of cord compression, spinal
canal stenosis or neural foraminal narrowing.
# Hip XRs (___): Mild diastasis of the pubic symphysis up to
1.3 cm. Suggestion of mild sclerosis around the sacroiliac
joints bilaterally with no evidence of erosions.
# ECG/Telemetry:
NSR 70 BPM, nml axis, no Ischemic st/t wave changes. CTPT
___
___
Brief Hospital Course:
ASSESSMENT & PLAN: ___ G2P2 postpartum day ___ s/p uncomplicated
NSVD with epidural, GERD, anxiety/depression, who presents from
home with progressive radiating hip pain, weakness and inability
to ambulate. Workup thus far includes negative MRI.
ACUTE/ACTIVE PROBLEMS:
# B/l hip pain:
# Inability to ambulate:
# Possible Femoroacetabular impingement vs labrum pathology
compounded by pubic symphysis diastasis
# Likely muscle spasms
Ms. ___ presented with progressive b/l hip pain with
radiation to groin, inability to ambulate after recent
uneventful normal spont vaginal delivery. In the ED, she
obtained spine MRI which was negative for acute process. OB/Gyn
also evaluated her, and felt her symptoms were unlikely a
complication of the recent delivery.
___ eval led to the likely diagnosis of femoroacetabular
impingement vs labrum pathology as well as possible acute hip
flexor spasms c/b pubic symphysis diastasis. She was treated
with ATC APAP, Ibuprofen, Flexeril (lower dose given lethargy)
PRN along with oxycodone PRN for breakthrough. She did well
with this regimen with gradual improvement in pain - with the
ability to ambulate (with a walker) on the day of discharge.
___ consult were involved in her care and felt that she
would benefit from home ___ input. She was also given pelvic
girdle given by OB for assist with pubic symphysis diastasis.
SW consult was obtained to assess what support systems are
available when returning home.
#Leukocytosis:
#Urinary symptoms:
Suspect WBC is ___ acute rxn from pain, recent childbirth. Also
reporting some urinary symptoms of dysuria but UA not overtly
infectious. Normalized. No antibiotics were needed.
#G2P2 post partum day ___ s/p uncomplicated NSVD with epidural
Per OB/Gyn; suspect current presentation unlikely to be
complication of recent delivery. Lactation c/s, OB/GYN
following, without any additional needs. SW consulted for
multiple stressors related to new child
CHRONIC/STABLE PROBLEMS:
=======================
#Anxiety/depression: Home BuPROPion
#Asthma: No signs of exacerbation: Home albuterol prn
#GERD: Home H2 blocker BID
GENERAL/SUPPORTIVE CARE:
# Nutrition: Regular diet
# Functional status: Ambulation as tolerated
# Lines/Tubes/Drains: PIV
# VTE prophylaxis: HSQ
# Advance Care Planning:
- Surrogate/emergency contact: ___
- Code Status: Full (confirmed)
# Consulting Services: Ob/gyn, ___
# Disposition: home ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion XL (Once Daily) 150 mg PO DAILY
2. Ranitidine 75 mg PO BID
3. Albuterol Inhaler 1 PUFF IH Q6H:PRN Shortness of breath
4. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild
5. Acetaminophen Dose is Unknown PO Q6H:PRN Pain - Mild/Fever
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *bisacodyl [Biscolax] 10 mg 10 mg PR once a day Disp #*20
Suppository Refills:*0
2. Cyclobenzaprine 5 mg PO TID:PRN Muscle spasms
RX *cyclobenzaprine 5 mg 1 tablet(s) by mouth three times a day
Disp #*24 Tablet Refills:*0
3. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain -
Moderate
Please use as last resort
RX *oxycodone [Oxaydo] 5 mg 0.5 (One half) tablet(s) by mouth
every twelve (12) hours Disp #*4 Tablet Refills:*0
4. Acetaminophen 1000 mg PO Q8H
5. Albuterol Inhaler 1 PUFF IH Q6H:PRN Shortness of breath
6. BuPROPion XL (Once Daily) 150 mg PO DAILY
7. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild
8. Ranitidine 75 mg PO BID
9.Rolling Walker
Pubic symphysis diastasis
Prognosis; Good
Length of need: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
L hip pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
It was a pleasure looking after you. As you know, you were
admitted with left hip pain. Fortunately, extensive workup here
(including hip x-rays) and MRI of the spine showed no
significant neurological or skeletal problems (no fractures or
dislocations).
There was evidence of pubic symphysis widening, which can be
seen post-delivery. You were also deemed to have
ligament/musculoskeletal condition called femuloacetabular
impingement syndrome. For this, you received
anti-inflammatories, muscle relaxants, and small doses of
oxycodone for pain relief. You were evaluated and cleared by
the ___ service here and will continue to be seen by their
services as an outpatient.
As discussed, don't be afraid to ask for help when needed.
We wish you good health and quick recovery!
Your ___ Team
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Iodine / Augmentin / Minocycline
Attending: ___.
Chief Complaint:
Leg weakness and numbness
Major Surgical or Invasive Procedure:
___: T1-T3 laminectomy for evacuation of subarachnoid
hematoma
History of Present Illness:
Patient is a ___ year old woman with a h/o bullous pemphigoid on
immunosuppressant medications, peripheral neuropathy, and recent
shingles, who presents with back pain, rash, and leg weakness
and
numbness. Last week she developed back pain with associated
worsening numbness in her legs and leg weakness. Walking has
been
"terrible" since the back pain began, described as decreased
balance. This morning her legs gave out and she fell while in
the
bathtub. The fall was described as slow and graceful, but she
did
hit her bottom. She has had no other falls since her symptoms
began.
She has chronic peripheral neuropathy and lumbosacral poly
radiculopathy. She was followed in neurology clinic (last visit
___. MRI L spine at that time had bilateral neural foraminal
stenosis at L5-S1. EMG showed moderate chronic bilateral
lumbosacral polyradiculopathies, as well as evidence for a
length-dependent sensorimotor axonal polyneuropathy. Etiology
was
not discovered. At baseline she has numbness in her feet and an
unsteady gait, but for the past week the numbness has involved
the entire left leg and from the knee-down on the right. The
symptoms have been static over the past week.
___ she was diagnosed with herpes zoster by dermatology in
the
left S1-S3 dermatomes and was treated with a 7 day course of
valacyclovir (1g tid). This was complicated by post herpetic
neuralgia and she was started on gabapentin. She has had
numbness
in the genital area since the shingles began.
She denies urinary or fecal incontinence but was incontinent to
urine once in triage. She endorses urinating less frequently
than
usual this past week, but attributes it to decreased PO intake
in
the setting of malaise and anorexia.
In the ED, WBC was elevated to 20.2 and she was febrile to
101.2.
A rash was noted on her back and she was evaluated by
dermatology
who took a biopsy and are concerned for possible disseminated
herpes zoster. Neurology was consulted for concern of VZV
myelitis. Antimicrobial coverage was discussed with ID and she
was started on IV acyclovir. Urgent MRI spine revealed a
suspected T1-T3 epidural hematoma, with C7-T3 cord edema, as
well as suspected blood in the cauda equina. There was cord
compression.
Past Medical History:
- Recent zoster, dx ___ involving left S1-S3 dermatomes.
- Bullous Pemphigoid
- Mechanical valve (aortic), on Coumadin
- s/p kidney removal for infection soon after childbirth
- Lumbosacral radiculopathy
- Length-dependent polyneuropathy
- h/o lumbar diskectomy/laminectomy
Social History:
___
Family History:
- Denies neurologic disease in the family
- mother and father with cancer
Physical Exam:
On admission:
Vitals: 101.2 68 113/63 18 100%
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple.
Pulmonary: breathing comfortably on RA
Abdomen: soft, nondistended
Extremities: no edema, warm
Skin: no rashes or lesions noted.
NEUROLOGIC EXAMINATION
-Mental Status: Alert, oriented. Able to relate history without
difficulty. Language is fluent with normal prosody. There were
no paraphasic errors. Pt. was able to name both high and low
frequency objects. Speech was not dysarthric. Able to follow
both midline and appendicular commands. There was no neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm bilaterally. VFF to confrontation with
finger
wiggling.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch in all distributions
VII: No facial droop with symmetric upper and lower facial
musculature bilaterally
VIII: Hearing intact to voice.
IX, X: Palate elevates symmetrically.
XI: full strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline with full ROM right and left
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No tremor noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 4+ 5- 5 4 4
R ___ ___ ___ 5 5 5 5- 5-
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 0 0
R 2 2 2 0 0
- Toes were mute bilaterally.
-Sensory: Decreased light touch in the legs, L>R. Pin is intact
in the right leg. 50% of normal in the left thigh and almost
absent in the left lower leg (both medially and laterally, and
in
the foot). Vibration sense is decreased in the right toe and
absent in the left great toe. Position sense is intact only to
large movements in the toes bilaterally. There is a temperature
gradient in her legs. No deficits to light touch, pinprick, cold
sensation, vibratory sense, proprioception in arms. No
extinction
to DSS.
-Coordination: No dysmetria on FNF bilaterally.
-Gait: Able to stand but held onto bed and appeared unsteady.
She
was incontinent of urine upon standing. She was a 2 person
assist
to return to bed.
On discharge:
___:
oriented to person, place, time
normal sensation.
Bi Tri Grip IP Q H AT ___
R ___
L ___
incision clean/dry/intact- closed with sutures neck and left
flank
Pertinent Results:
___ CT T spine without contrast:
1. S/p T1 through T3 laminectomies with expected postsurgical
changes. No definite hyperdense blood is seen within the spinal
canal, but evaluation by CTs limited compared to MRI.
2. Partially visualized small bilateral pleural effusions with
compressive atelectasis in the lower lobes. Evaluation of the
remainder of the lungs is limited by respiratory motion, but
patchy peribronchial consolidation is noted in the left upper
lobe, and possibly also in the right upper lobe, compatible with
pulmonary edema or infection. Interstitial septal thickening at
the apices is compatible with pulmonary edema or scarring.
3. Cardiomegaly and extensive atherosclerotic disease, including
coronary
artery disease. Apparent enlargement of the main pulmonary
artery, suggesting mild pulmonary arterial hypertension.
___ MRI T spine with & without contrast:
1. Status post evacuation of the subarachnoid and possible
epidural/subdural hemorrhage in the lower cervical and upper
thoracic spine with a postoperative seroma.
2. Unchanged C7-T4 cord contusion.
___ ___ ___
Cardiovascular Report ECG Study Date of ___ 3:20:26 AM
Sinus rhythm with premature atrial contractions. Possible old
anteroseptal myocardial infarction. Diffuse non-specific ST-T
wave abnormalities. Compared to the previous tracing of ___
sinus rhythm with premature atrial contractions has replaced
atrial fibrillation. Left bundle-branch block is no longer seen.
Criteria for old anteroseptal myocardial infarction is now noted
in the absence of left bundle-branch block.
Read by: ___
Intervals Axes
Rate PR QRS QT QTc (___) P QRS T
77 188 98 426 455 48 -20 61
Radiology Report SPINAL ARTERIOGRAM Study Date of ___
7:48 AM
ReportIMPRESSION:
Preliminary ReportUnremarkable cervical and upper thoracic
spinal angiogram
Brief Hospital Course:
Mrs. ___ was admitted to the Neurosurgery service on the
day of admission. She was admitted to the ICU and emergently
taken to the operating suite for thoracic hematoma evacuation.
She tolerated the procedure well and there were no
intra-operative complications. Please see the operative report
for further details. Dermatology was consulted for a diffuse
rash. They biopsied the patient's lesion, wich was most
consistent with pre-bullous BP. Viral stains negative for VZV.
The patient was initially started on oral steroids were tapered
down to prednisone 5mg daily. Cellcept was held as advised by
dermatology. The Infectious Disease service was also consulted
and felt that the patient should remain on acyclovir.
On ___, the patient was kept on flat bedrest and her head of
bed was slowly elevated during the day. Her post-op MRI was
stable and the patient continued to recover well.
On ___, Mrs. ___ foley catheter was discontinued at
midnight. On the morning of ___, she failed to void and was
found to have approximately 800cc in her bladder. A foley
catheter was reinserted and she was given a voiding trial on
___.
On ___, The spinal angiogram was negative for vascular
malformation. The patient was screened for rehab. The foley
catheter was discontinued. Infectioous disease recommeded
thatthe acyclovir IV be discontinued and it was.
___: a routine EKG was performed and consistent with Sinus
rhythm with premature atrial contractions. Possible old
anteroseptal
myocardial infarction. Diffuse non-specific ST-T wave
abnormalities. Compared
to the previous tracing of ___ sinus rhythm with premature
atrial
contractions has replaced atrial fibrillation. Left
bundle-branch block is no
longer seen. Criteria for old anteroseptal myocardial infarction
is now noted
in the absence of left bundle-branch block. The patient was
mobilized out of bed to the chair. The patient complained of
right posterior shoulder pain and oxycodone was increased to
___ mg po q 4 . the patients neurological exam was stable.
The patient was discharged to rehab.
Medications on Admission:
- Cellcept 1500mg BID
- prednisone 2mg daily
- niacinamide
- hydroxyzine
- gabapentin 300mg TID prn zoster pain
- Clinda 300 mg 1 hour before dental procedures
- clobetasol 0.05 % topical BID prn
- Lasix 40 mg daily prn
- Proctosol HC 2.5 % rectal cream. TID
- hydroxyzine HCl q8hr ___ prn
- metoprolol tartrate 25 mg BID
- nitroglycerin 0.4 mg sublingual q 5 minutes x 3 prn
- pantoprazole 20 mg once a day
- prednisone 2 mg daily
- Zocor 40 mg tablet. 1 Tablet(s) by mouth daily
- tretinoin 0.025 % topical cream. to face at night
- Coumadin 2mg 5 days/week, 3mg 2x/wk (tues, sat)
- aspirin 81 mg (takes ___ given recent epistaxis)
- cholecalciferol (vitamin D3) 1,000 once a day
- niacinamide 500 mg BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Docusate Sodium (Liquid) 100 mg PO BID
4. Famotidine 20 mg PO Q12H
5. Heparin 5000 UNIT SC BID
6. HydrALAzine ___ mg IV Q6H:PRN SBP>160
7. Metoprolol Succinate XL 12.5 mg PO DAILY
8. Tretinoin 0.025% Cream 1 Appl TP QHS
9. Senna 8.6 mg PO BID Constipation
10. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
11. PredniSONE 2 mg PO DAILY
12. Sodium Chloride 1 gm PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
spinal subarachnoid hematoma with cord contusion
bullous pemphigoid flair
Discharge Condition:
oriented to person, place, time
normal sensation.
Bi Tri Grip IP Q H AT ___
R ___ ___- 5 5 5
L ___ ___- 5 4 5
incision clean/dry/intact- closed with sutures neck and left
flank
Discharge Instructions:
Discharge Instructions
Spinal Fusion
Surgery
Your incision is closed with sutures. You will need suture
removal.
Do not apply any lotions or creams to the site.
Please keep your incision dry until removal of your sutures.
Please avoid swimming for two weeks after suture removal.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
You must wear your cervical spine Aspen collar brace at all
times. You may remove this for showering and hygeine.
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon.
Do NOT smoke. Smoking can affect your healing and fusion.
The DERMATOLOGY service evaluated you during your hospital stay
with us and recommended the following:
DO NOT TAKE your cellecept discuss the restarting of this
medication at your follow up appointment with dermatology.
Please follow up in the ___ CLINIC in ___ weeks to see
Dr ___- ___ ___. You may call ___ to
arrange for this appointment.
You have left flank stitches that were placed by dermatology
following a skin biopsy. These need to be REMOVED on ___ and be
be removed at rehab.
Prednisone 2mg QD continue per the Dermatology service
NEUROSURGERY FOLLOW UP:
Please follow up for a wound check in ___ days from the date
of your surgery on ___, then gain to see Dr ___ in 3 months
with MRI of the thoracic spine with contrast.
You have been CLEARED to RESTART COUMADIN POD 7 ( ___ at
routine home dose- You will not be given a bolus. No continuous
heparin infusion.
You have been cleared to RESTART you home dose of Aspirin on POD
6 ( ___
Your serum sodium was low during your stay. You are taking
:Sodium Chloride 1 gm PO BID. Please have your serum sodium
rechecked in three days at rehab. Your rehabiliation/primary
care doctor ___ wean these sodium chloride tablets at their
discretion to maintain a normal serum sodium level
Medications
Please do NOT take any blood thinning medication (Ibuprofen,
Plavix) until cleared by the neurosurgeon.
Do not take any anti-inflammatory medications such as Motrin,
Advil, and Ibuprofen etc
until cleared by your neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
New weakness or changes in sensation in your arms or legs.
Followup Instructions:
___
|
10658514-DS-17
| 10,658,514 | 20,431,143 |
DS
| 17 |
2145-07-25 00:00:00
|
2145-07-25 14:55:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex / codeine / Penicillins
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with a complicated psychiatric
history, unclear primary diagnosis but history of depression,
anxiety, psychosis, trauma, personality
disorder(borderline/dependent), as well as benzodiazepine
misuse,
brain aneurysm, breast cancer in remission, HTN, COPD, and
cognitive impairment who was brought to the ED by her partner
___ after changes in behavior and declining mental status.
The patient's partner, ___, gave most of the history as patient
was not able to give a chronologic history. About 1 week ago the
patient accidentally overdosed on Ativan and was brought to the
ED and seen by psychiatry. The patient recovered and was
discharged home. ___ notes that the patient is worse in the
morning as she often times will have episodes where she appears
catatonic and will mumble or repeat phrases. She will forget
conversations as they are conversing. These episodes started in
___, but are now more frequent. This is all in the setting of
numerous psychiatric medication changes.
The patient was seen by neurologist Dr. ___ at ___ last fall
for work up of cognitive issues. The patient underwent MRI brain
and MRA head and neck, which revealed significant white matter
disease and some atrophy. Also noted to have aneurysms in her
ACA
approximately and a possible basilar tip region aneurysm. She
was
referred to Dr ___ performed a cerebral angiogram.
Currently, they are in the process of deciding on intervention
vs. watchful waiting. After diagnosis of the aneurysms a few
months ago, ___ states that he has noted even more decline. She
will talk about her father who passed
away and will ask to see him. She speaks in an infantile voice
and starts laughing or crying inappropriatley out of context. In
regards to other neurologic work up, ___ states that she also
had an EEG done with the neurologist and was not aware of any
abnormalities on the test, but is unsure when the test was done.
Of note, she had a significant decompensation back in ___ when her haldol was tapered down (patient and ___ are
unclear why she was started on haldol or how long she was taking
this medication for). He states that she becomes non functional
and stays in bed for long periods of time, and has become very
dependant on ___ for most of her activities of daily living.
On ROS, the patient has been having urinary incontinence off and
on for a few years but has worsened over the past year or so and
she at times has to wear diapers. She also has had some
increasing difficulty with gait and has started to walk slowly
due to feeling unsteady. The pt denies headache, loss of vision,
blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. ROS otherwise negative.
In the ED, initial vitals: T-99.2 HR-73 BP-120/69 RR-16
O2sat-96%
RA
Exam notable for inappropriate affect, tangential thought
process, inattention, but otherwise she was able to comply with
commands, language was fluent, and no other significant focal
findings. She did have brisk reflexes and a wide based gait.
Labs were significant for: TSH 5.2 (T3/T4 PND), Vit B12 wnl,
Non-reactive RPR, Chem7 wnl, CBC wnl, LFTs wnl, Phosphate 4.9,
Ca
and Mg wnl, Negative Urine tox screen, negative UA, lipase wnl.
Imaging showed:
CT head w/o contrast IMPRESSION: No acute hemorrhage or large
territorial infarction.
In the ED, pt received: Fluticasone-Salmeterol Diskus (250/50)
x2, Mirtazapine 30 mg, amLODIPine 10 mg, Anastrozole 1 mg,
Escitalopram Oxalate 10 mg, Metoprolol Succinate XL 25 mg
Psych and neuro saw the patient in the ED. Psych recommended
evaluation for organic etiologies of presentation, and states
that patient meets section 12a criteria. Neuro recommended broad
workup from medical, neurological and psych perspective.
Vitals prior to transfer: T 98.4, HR 68, BP 141/78, RR 18, O2
sat
95% RA
On arrival to the floor, the patient reports that she feels fine
and has no specific complaints. Does not feel like she is more
confused that usual. Does not report fevers, chills, chest pain,
shortness of breath, nausea, vomiting, abdominal pain, and
changes in bowel or bladder habits.
Past Medical History:
PAST PSYCH HISTORY:
Prior diagnoses: per patient and her partner, primary diagnosis
of depression. Per psychiatrist, unclear primary diagnosis-
symptoms of depression, anxiety, psychosis, trauma symptoms, and
personality traits (borderline, dependent)
-Hospitalizations: patient reports "a couple" with most recent
being several years ago. Per outpatient psychiatrist, multiple
and most recent was in ___ of last year- ___ with discharge diagnosis of unspecified psychosis.
-Partial hospitalizations: went to an intake appointment at
___ on ___, but did not continue with partial
-Psychiatrist: Dr. ___, ___ (___)- seen
by her for 8 months. Was seen by other providers at ___ since
___
-Therapist: ___, ___
-Medication trials: multiple including clozapine, trazodone,
clomipramine, clonazepam, olanzapine, Haldol, Lexapro, Ativan,
mirtazapine
-___ trials: denies
-Suicide attempts: cut her wrists several years ago in the ___
and overdosed on Ativan about a week ago, unclear if these were
suicide attempts
-Harm to others: denies
-Trauma: endorses sexual abuse but will not elaborate further;
denies physical abuse
PAST MEDICAL AND SURGICAL HISTORY:
-Breast cancer, s/p bilateral mastectomies, in remission
-Brain aneurysms, follows with Dr. ___ at ___
-___ instability
-HTN
-Osteoporosis
-Lung nodule
-COPD
-Denies history of seizure.
Social History:
-Born/Raised: born in ___, raised mostly in ___. Grew up with mom, dad, and two younger
brothers all of whom she says she got along with very well.
-Relationship status/Children: lives with partner ___ (been
together for 20+ years), no children
-Primary Supports: ___. He is now her primary care taker. They
have a
home health aid who comes two times a week, but patient prefers
for ___ to care for her.
-Housing: lives in a house in ___
-Education: BA and ___ degree in ___ and Literature
-Employment/Income: worked as a ___ after graduating,
including at ___ where she was promoted several times,
worked
in ___. Also worked in a ___ group at
___. Stopped working in the later ___ and hasn't
worked since. On psychiatric disability.
-Spiritual: Presbyterian but doesn't practice
-Forensic history: ___
Family History:
-Father who died of ruptured brain aneurysm, brother with
dementia (age ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 99.6 PO, BP 154 / 87, HR 75, RR 18, O2 sat 96% on RA
GEN: Pleasant elderly woman, lying down in bed, appears
comfortable and in no acute distress
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: CTAB, without wheeze, rales, or rhonchi
COR: RRR, (+)S1/S2, no m/r/g/t
ABD: Soft, non-tender, non-distended, normal bowel sounds
EXTREM: Warm, well-perfused, no edema
NEURO: A&Ox3, moving all 4 extremities with purpose, intact
sensation, CN II-XII grossly intact
MENTAL STATUS: Pseudobulbar affect, intermittent laughing and
crying during interview, emotionally labile, perseverating on
asking whether she is in a psych hospital, A&Ox3, president
"___", able to recite days of the week backwards, ___
immediate
and 5 minute recall
DISCHARGE PHYSICAL EXAM:
VS: 98.6 PO 115 / 70L Lying 65 18 94 Ra
GEN: AOx3. Pleasant woman, lying down in bed, appears
comfortable and in no acute distress
HEENT: Moist MM, anicteric sclera, no conjunctival pallor
NECK: Supple without LAD
PULM: CTAB, without wheeze, rales, or rhonchi
COR: RRR, (+)S1/S2, no m/r/g/t
ABD: Soft, non-tender, non-distended, normal bowel sounds
EXTREM: Warm, well-perfused, no edema
NEURO: A&Ox3, moving all 4 extremities with purpose, intact
sensation, CN II-XII grossly intact, ___ strength throughout
MENTAL STATUS: Pseudobulbar affect, A&Ox3, answers most
questions
appropriately, though will sometimes follow up with, "is that
the right
answer?"
Pertinent Results:
ADMISSION LAB RESULTS:
___ 12:10PM BLOOD WBC-6.8 RBC-5.27* Hgb-15.1 Hct-45.5*
MCV-86 MCH-28.7 MCHC-33.2 RDW-13.3 RDWSD-41.3 Plt ___
___ 12:10PM BLOOD Neuts-53.7 ___ Monos-8.7 Eos-0.0*
Baso-0.9 Im ___ AbsNeut-3.64 AbsLymp-2.48 AbsMono-0.59
AbsEos-0.00* AbsBaso-0.06
___ 12:10PM BLOOD Plt ___
___ 12:10PM BLOOD Glucose-97 UreaN-10 Creat-0.7 Na-138
K-8.0* Cl-101 HCO3-22 AnGap-15
___ 03:30PM BLOOD Glucose-132* UreaN-10 Creat-0.7 Na-144
K-4.1 Cl-103 HCO3-24 AnGap-17
___ 09:50PM BLOOD ALT-18 AST-19 LD(LDH)-178 CK(CPK)-49
AlkPhos-58 TotBili-0.2
___ 03:30PM BLOOD ALT-19 AST-20 AlkPhos-59 TotBili-0.2
___ 09:50PM BLOOD Lipase-31
___ 03:30PM BLOOD Lipase-25
___ 09:50PM BLOOD Albumin-4.1 Calcium-9.4 Phos-4.9* Mg-2.0
___ 03:30PM BLOOD Albumin-4.1 Calcium-9.3 Phos-4.6* Mg-1.9
___ 09:50PM BLOOD VitB12-498
___ 09:50PM BLOOD TSH-5.3*
___ 09:50PM BLOOD T4-7.0 T3-106
___ 03:12PM BLOOD K-6.2*
___ 03:37PM BLOOD K-3.7
DISCHARGE LAB RESULTS:
___ 08:50AM BLOOD WBC-6.8 RBC-5.16 Hgb-14.8 Hct-46.1*
MCV-89 MCH-28.7 MCHC-32.1 RDW-13.2 RDWSD-43.5 Plt ___
___ 08:50AM BLOOD Glucose-110* UreaN-17 Creat-0.8 Na-141
K-4.3 Cl-100 HCO3-25 AnGap-16
___ 08:50AM BLOOD Calcium-9.0 Phos-4.7* Mg-2.0
IMAGING:
___ CT HEAD W/O CONTRAST: IMPRESSION: No acute hemorrhage
or large territorial infarction.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a complicated psychiatric
history, unclear primary diagnosis but history of depression
with inpatient psychiatric hospitalization, anxiety, psychosis,
trauma, personality disorder(borderline/dependent), stable brain
aneurysm (f/u Dr. ___, breast cancer status post bilateral
mastectomies in remission, HTN, COPD/emphysema, and cognitive
impairment, who was brought to the ED by her partner ___ w/
AMS.
ACUTE ISSUES
# Altered mental status: The patient has had more frequent
episodes of catatonic behavior and pseudobulbar affect, the
differential for this patient remains broad and includes
psychiatric, neurologic, and other organic etiologies. The
patient underwent a broad workup. A primary psychiatric
diagnosis such as catatonia was favored by the psychiatry
consult service. Specific diagnoses per neurology, included:
CADASIL (white matter changes on MRI, brother with early
dementia), though her MRI findings were not entirely classic and
patient does not have any history of TIAs or stroke. Early
dementia, including frontotemporal dementia is possible, but
likely not responsible for her acute presentation. Other
diagnosis such as CNS vasculitis or cerebral lupus are quite
unlikely given lack of any associated findings. Seizures are
possible, though no seizure activity was noted and the patient
had an EEG not long ago at ___ that was normal. Neurology
recommended obtaining a re-read of her MRI head from ___ but
neuroradiology said there was no utility in rereading MRI from
___ given that their recommendation would have been to get a
CTA, which the patient already had last month. Regarding the
___ medical workup, she was RPR negative. B12 normal. CK
normal. TSH mildly elevated at 5.3 but T3/T4 WNL. Lactate wnl.
HIV negative. CRP wnl. ___ titer 1:40 which can be seen in
approximately 30 percent of the normal population. ESR 2.
Psychiatry followed along and were most concerned for catatonia
so they recommended 1mg TID Ativan which was started on ___ and
increased to 1mg Ativan QID on ___ iso good response. At that
time, mirtazapine was decreased to 15mg daily.
CHRONIC ISSUES
# HTN- Continued home amlodipine, lisinopril, and metoprolol.
# History of breast cancer - Continued home anastrozole.
# COPD - Continued Advair.
TRANSITIONAL ISSUES:
=======================
[ ] Consider MRI c-spine non-urgently for work up of cervical
spondylosis which could explain her wide based gait, and
incontinence
[ ] Continue Ativan 1mg QID, and risperidone 2mg PRN for
anxiety/agitation per psychiatry recommendations
[ ] It may be possible that there may be a component of
progressive dementia in this patient and she should, thus,
follow up with cognitive neurology unit at ___ for
neurocognitive evaluation.
[ ]Have PCP follow up with repeat TSH/T4/T3 in ___ weeks and to
follow up on positive ___ (titers 1:40)
[ ] f/u on pending dsDNA test, though it is unclear what
significance a positive result would carry
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Influenza Vaccine Quadrivalent 0.5 mL IM NOW X1
Start: ___, First Dose: Next Routine Administration Time
2. Salsalate 500 mg PO BID
3. Anastrozole 1 mg PO DAILY
4. amLODIPine 10 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Lisinopril 10 mg PO DAILY
7. Escitalopram Oxalate 10 mg PO DAILY
8. LORazepam 1 mg PO QHS
9. RisperiDONE 0.25 mg PO BID
10. Mirtazapine 30 mg PO QHS
11. Psyllium Powder 1 PKT PO TID:PRN constipation
Discharge Medications:
1. LORazepam 1 mg PO QID
2. Mirtazapine 15 mg PO QHS
3. RisperiDONE 0.25 mg PO QHS:PRN agitation
4. amLODIPine 10 mg PO DAILY
5. Anastrozole 1 mg PO DAILY
6. Escitalopram Oxalate 10 mg PO DAILY
7. Lisinopril 10 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Psyllium Powder 1 PKT PO TID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Psychosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You came because your partner, ___, brought you in because
you were confused and had difficulty taking care of yourself at
home.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- In the hospital, you underwent many lab tests to evaluate
possible reasons for your worsening confusion.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments and follow up with your PCP.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10658681-DS-25
| 10,658,681 | 20,906,584 |
DS
| 25 |
2130-09-04 00:00:00
|
2130-09-13 14:00:00
|
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:
___ exploratory laparotomy, lysis of adhesions
History of Present Illness:
___ year old female s/p RNY and history of multiple recurrent
ventral hernias, s/p repair x8, presents with abdominal pain.
His
last repair was in ___ and was with mesh placement. Since
then she reports doing well until 4 days ago when she started to
develop pain across the abdomen, bloating and constipation. She
hasn't had BM for 4 days but reports passing flatus yesterday
evening. She denies nausea, vomiting, fever or chills,
hematemesis or hematochezia.
She states that in case she requires a surgical intervention she
would like to be transferred to ___ to the
surgeon that did her last hernia repair.
ROS:
(+) per HPI
(-) Denies fevers chills, night sweats, unexplained weight
loss, fatigue/malaise/lethargy, changes in appetite, trouble
with
sleep, pruritis, jaundice, rashes, bleeding, easy bruising,
headache, dizziness, vertigo, syncope, weakness, paresthesias,
nausea, vomiting, hematemesis, melena, BRBPR,
dysphagia, chest pain, shortness of breath, cough, edema,
urinary
frequency, urgency
Past Medical History:
1. Hypertension.
2. Hyperlipidemia.
3. Asthma.
4. Osteoarthritis.
5. Prior DVT with pulmonary embolism on Coumadin.
6. DJD with chronic neck pain.
7. Low back pain.
Past Surgical History:
Status post gastric bypass.
Status post bilateral total knee replacements.
Status post ventral hernia repair x8.
Status post bilateral carpal tunnel release surgery
bilaterally
Social History:
___
Family History:
Both parents died of CA in their ___.
Physical Exam:
afebrile, VSS
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI,
PERRL.
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: soft, mildly tender to palpation incisionally,
non-distended. Incisions: clean, dry and intact, dressed.
EXTREMITIES: Warm, well perfused, pulses palpable, (-) edema
Pertinent Results:
Labs
___ 04:30PM BLOOD WBC-10.7* RBC-4.37 Hgb-13.0 Hct-40.1
MCV-92 MCH-29.7 MCHC-32.4 RDW-13.0 RDWSD-43.7 Plt ___
___ 06:25AM BLOOD WBC-16.4*# RBC-4.39 Hgb-13.2 Hct-40.8
MCV-93 MCH-30.1 MCHC-32.4 RDW-13.1 RDWSD-44.5 Plt ___
___ 05:10AM BLOOD WBC-7.9# RBC-3.76* Hgb-11.1* Hct-35.3
MCV-94 MCH-29.5 MCHC-31.4* RDW-13.3 RDWSD-45.5 Plt ___
___ 05:45AM BLOOD WBC-10.8* RBC-4.07 Hgb-12.0 Hct-37.3
MCV-92 MCH-29.5 MCHC-32.2 RDW-13.1 RDWSD-43.9 Plt ___
___ 05:40AM BLOOD WBC-12.2* RBC-3.81* Hgb-11.4 Hct-35.7
MCV-94 MCH-29.9 MCHC-31.9* RDW-13.8 RDWSD-47.3* Plt ___
___ 06:50AM BLOOD WBC-10.1* RBC-3.76* Hgb-11.1* Hct-35.2
MCV-94 MCH-29.5 MCHC-31.5* RDW-13.7 RDWSD-47.0* Plt ___
___ 04:30PM BLOOD Glucose-109* UreaN-21* Creat-1.1 Na-136
K-5.3* Cl-97 HCO3-27 AnGap-17
___ 06:50AM BLOOD Glucose-82 UreaN-26* Creat-1.0 Na-134
K-5.1 Cl-102 HCO3-24 AnGap-13
___ 04:34PM BLOOD Lactate-1.3 K-3.7
___ 10:29PM BLOOD Lactate-1.2
Imaging
___ AXR
FINDINGS:
Multiple dilated loops of small bowel are noted measuring up to
4.4 cm with differential air-fluid levels seen on the upright
view concerning for small bowel obstruction. Several clips are
noted within the right upper quadrant of the abdomen compatible
with prior cholecystectomy. There is no free intraperitoneal
air or pneumatosis. Degenerative changes are noted within the
imaged thoracolumbar spine. No concerning soft tissue
calcifications are present.
IMPRESSION:
Findings concerning for small bowel obstruction. Further
assessment with CT is recommended.
___ CT A/P
IMPRESSION:
1. Early or partial small bowel obstruction with a transition
point in the midline pelvis and small amount of free fluid. No
specific evidence for ischemia.
2. Common bile duct dilation and prominence of the main
pancreatic duct, progressed from ___. Recommend correlation
with liver function tests. If there is concern for biliary
obstruction, MRCP can be obtained for further evaluation on a
nonurgent basis.
RECOMMENDATION(S): Nonurgent MRCP for further evaluation of CBD
and
pancreatic ductal dilation.
___ CT A/P
IMPRESSION:
Further interval increase in distention of the excluded stomach,
duodenum and
proximal jejunal loops suggestive of ongoing and/or worsening
obstruction.
The remnant stomach is decompressed from the nasogastric tube.
The transition
point is again demonstrated in the midline pelvis. There is
trace free fluid.
No drainable collections pneumatosis or pneumoperitoneum.
Intra and extra hepatic biliary ductal dilatation, if concern
for obstruction
MRCP seen can be considered on nonurgent basis.
Brief Hospital Course:
___ w/ hx of morbid obesity, s/p RYB, recurrent ventral hernia
s/p 8 hernia repairs, last one on ___, p/w SBO. The patient was
initially managed nonoperatively with bowel rest and nasogastric
decompression. Despite this, she developed worsening abdominal
distention and worsened obstruction on imaging. The patient was
taken to the Operating Room on ___ for exploratory
laparotomy, Lysis of adhesions, gastrotomy with repair, Small
bowel enterotomy with repair, and reduction of internal hernia.
The procedure occured without complication. For more information
about the procedure please refer to the operative report. The
patient was transferred to the PACU in the immediate post
operative period, and when apporopriate, the patient was
transferred to the floor. Pain was initially managed with IV
pain control until the patient was tolerating PO. Diet was
advanced in a stepwise fashion after the patient had return of
bowel function until regular diet was tolerated without
difficulty. The patient was discharged home on POD5. At the time
of discharge, the patient was urinating and stooling normally,
pain was controlled with oral pain medication, and the patient
was out of bed to ambulate without assistance. The patient was
discharged home with plan to follow up with Dr. ___ in clinic
in 2 weeks
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. albuterol sulfate 90 mcg/actuation inhalation 2 PUFFS IH QID
PRN
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) inhalation ASDIR PRN
3. Amlodipine 5 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Hydrochlorothiazide 25 mg PO DAILY
6. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN pain
7. PredniSONE 10 mg PO 5 TABLETS PO DAILY TAPER AS DIRECTED BY
MD FOR ASTHMA
8. TraMADol 50 mg PO Q6H:PRN pain
9. astaxanthin 4 mg oral DAILY
10. calcium-magnesium unknown strength oral DAILY
11. Vitamin D ___ UNIT PO DAILY
12. coenzyme Q10 200 mg oral DAILY
13. Cyanocobalamin Dose is Unknown PO DAILY
14. Glucosamine (glucosamine sulfate) unknown strength oral
DAILY
15. Vitamin B Complex 1 CAP PO DAILY
16. Ferrous Sulfate 18 mg PO BID
17. lysine HCl (B
complex-C-E-FA-Zn-lysine;<br>multivitamin-iron-minerals) 1,000
mg oral DAILY
18. Multivitamins 1 TAB PO DAILY
19. Omega-3 (omega 3-dha-epa-fish oil) unknown strength oral
DAILY
20. resver-red-bfl-grpsd-pol-C-pom (resve-chrom-grn
tea-EGCG-dig#3) 40:40 tablet oral DAILY
21. Vitamin E Dose is Unknown PO DAILY
22. lutein unknown strength oral DAILY
23. Healthy Eyes (vit A,C and E-lutein-minerals) 1,000 unit-200
mg-60 unit-2 mg oral DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
3. Hydrochlorothiazide 25 mg PO DAILY
4. Acetaminophen 650 mg PO TID
RX *acetaminophen 650 mg 1 tablet(s) by mouth three times a day
Disp #*60 Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
6. Mineral Oil ___ mL PO DAILY:PRN Constipation
RX *mineral oil ___ ml by mouth daily Refills:*0
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*90 Tablet Refills:*0
8. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*60 Tablet Refills:*0
9. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 packet by mouth
daily Disp #*30 Packet Refills:*0
10. albuterol sulfate 90 mcg/actuation inhalation 2 PUFFS IH QID
PRN
11. astaxanthin 4 mg oral DAILY
12. calcium-magnesium unknown ORAL DAILY
13. coenzyme Q10 200 mg oral DAILY
14. Cyanocobalamin unknown PO DAILY
15. Ferrous Sulfate 18 mg PO BID
16. Glucosamine (glucosamine sulfate) unknown ORAL DAILY
17. Healthy Eyes (vit A,C and E-lutein-minerals) 1,000 unit-200
mg-60 unit-2 mg oral DAILY
18. lutein unknown ORAL DAILY
19. lysine HCl (B
complex-C-E-FA-Zn-lysine;<br>multivitamin-iron-minerals) 1,000
mg oral DAILY
20. Multivitamins 1 TAB PO DAILY
21. Omega-3 (omega 3-dha-epa-fish oil) unknown ORAL DAILY
22. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN pain
23. PredniSONE 10 mg PO 5 TABLETS PO DAILY TAPER AS DIRECTED BY
MD FOR ASTHMA
24. resver-red-bfl-grpsd-pol-C-pom (resve-chrom-grn
tea-EGCG-dig#3) 40:40 tablet oral DAILY
25. TraMADol 50 mg PO Q6H:PRN pain
26. Vitamin B Complex 1 CAP PO DAILY
27. Vitamin D ___ UNIT PO DAILY
28. Vitamin E unknown PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner 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:
___
|
10658987-DS-11
| 10,658,987 | 27,942,231 |
DS
| 11 |
2182-01-09 00:00:00
|
2182-01-09 12:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old female who was in the process of putting
on her seat belt in the
passenger side of the car when an oncoming car struck their car
on the drivers side, she recals hitting the rare view mirror.
She denied loss of
consiousness. The patient presents to the ED at her
neurological
baseline. She denies headache, numbness, tingling sensation,
weakness.
Past Medical History:
PMHx:DM type II, diet controlled, glaucoma, hyperlipidemia, mva
___, pancytopenia, myelodysplastic syndrome
All:NKDA
Physical Exam:
PHYSICAL EXAM:
Gen: left facial edema and eccymosis, no raccoon sign, no battle
sign. no ottorhea. no rhinorhea
HEENT: Pupils: 3-2mm bilaterally EOMs:intact
Neck: Supple.
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, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
Upon discharge:
AOx3, nonfocal, MAE full
Pertinent Results:
CT abdomen ___:
1. Subtle wedge deformity of the L1 vertebral body new from the
prior exam on
___, of indeterminate chronicity. Correlate for focal
pain.
2. 2.2 x 3.3 cm peripherally calcified lesion adjacent to the
pancreas and the
inferior vena cava which is unchanged in overall appearance from
the prior
study and may represents a calcified lymph node. Please
correlate clinically.
___. Subarachnoid hemorrhage along the left frontal and right
parietal lobes.
2. Subgaleal hematoma at the vertex with no evidence of
fracture.
___. Subarachnoid hemorrhage along the left frontal and right
parietal lobes.
2. Subgaleal hematoma at the vertex with no evidence of
fracture.
Brief Hospital Course:
Ms. ___ was admitted to the hospital for evaluation. She was
found to have bilateral intracranial hemorrhages on CT. She was
admitted to the icu for close observation and underwent a
cranial CT 24 hours after her injury which showed a stable
hermorrhage.
On ___, she was clinically stable and transferred to the floor.
She was evaluated by ___ who cleared her for home with one
additional ___ visit. On ___ she was re-evaluated by ___ and was
cleared for home. She was discharged home with follow-up.
Medications on Admission:
metformin, bentagan, travatan, lisinopril,sertraline,
multivitamin.
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN headache
2. Docusate Sodium 100 mg PO BID
3. Levobunolol 0.5% 1 DROP BOTH EYES BID
4. LeVETiracetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
5. Lisinopril 5 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN headache
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
8. Sertraline 50 mg PO DAILY
9. Travatan Z (travoprost) 0.004 % ophthalmic daily
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Traumatic SAH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Nonsurgical Brain Hemorrhage
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin prior to your injury, you may
safely resume taking this only when cleared by the Neurosurgeon.
**You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring. You only need to take this
for 7 days
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
___
|
10659135-DS-18
| 10,659,135 | 20,702,704 |
DS
| 18 |
2149-08-26 00:00:00
|
2149-08-26 15:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Mineral Oil / Castor Oil / dyes / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug) / aspirin / hydrochlorothiazide
Attending: ___.
Chief Complaint:
LLE pain
Major Surgical or Invasive Procedure:
Left acetabulum open reduction internal fixation
History of Present Illness:
___ with HTN and diabetes who was transferred to the ___ ED
from ___ s/p mechanical fall from standing while at
her assisted living facility. She was playing a game of bingo at
her community center, and when she
went to shut the door to another room where other residents were
being loud, the door swung back and knocked her off her balance.
She landed directly onto her left side. Denies HS or LOC,
remembers the entire event. Immediate left hip/groin pain and
inability to weight bear. She was taken to ___,
where she underwent a pan-scan that was notable for a left
acetabular fracture with surrounding pelvic hematoma without
active contrast extravasation. She was transferred to ___ for
further management. Denies weakness, numbness, tingling.
Comfortable at rest. Denies pain elsewhere. Denies other
complaints.
Of note, she is a community ambulator without assist device. She
is able to walk a few neighborhood blocks and around Stop N'
Shop without difficulty. She can climb up and down multiple
flights of stairs. She lives alone at her assisted living
facility.
Past Medical History:
HYPERTENSION
POOR DENTITION
DIABETES TYPE II
INSOMNIA
LUMBAR PAIN
RIGHT SIDED RIB PAIN
TINNITUS
ALLERGIC CONJUNCTIVITIS
VITAMIN D INSUFFICIENCY
CHRONIC CONSTIPATION
CATARACT
Social History:
Denies tobacco, alcohol, illicit drug use.
Physical Exam:
LLE:
Dressing c/d/I
SILT S/S/SP/DP/T
Firing ___
+2 pulses distally
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left anterior column hemitransverse acetabulum fracture
and was admitted to the orthopedic surgery service. The patient
was taken to the operating room on ___ for open reduction
internal fixation of left acetabulum, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to rehab was appropriate.
The patient's received 1 unit of pRBCS for a low hematocrit and
responded appropriately.
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
touchdown 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:
CITALOPRAM - citalopram 10 mg tablet. 1 tablet(s) by mouth daily
CLOTRIMAZOLE-BETAMETHASONE - clotrimazole-betamethasone 1 %-0.05
% topical cream. apply to affected area twice a day
FEXOFENADINE - fexofenadine 60 mg tablet. 1 tablet(s) by mouth
daily for allergies
GLYBURIDE - glyburide 5 mg tablet. 1 tablet(s) by mouth twice a
day for diabetes
INSULIN GLARGINE [LANTUS SOLOSTAR] - Lantus Solostar 100 unit/mL
(3 mL) subcutaneous insulin pen. 8 units SQ in the am 10 u in am
8 units at 2 pm after food total of 18 units
LISINOPRIL - lisinopril 30 mg tablet. 1 tablet(s) by mouth daily
for high blood pressure
LORAZEPAM - lorazepam 0.5 mg tablet. ___ tablet(s) by mouth at
bedtime as needed for anxiety wathc for drowsiness
POLYETHYLENE GLYCOL 3350 - polyethylene glycol 3350 17 gram/dose
oral powder. 1 powder(s) by mouth at bedtime for constipation
Medications - OTC
BLOOD SUGAR DIAGNOSTIC [ONETOUCH VERIO] - OneTouch Verio strips.
use to check ___
DOCUSATE SODIUM - docusate sodium 100 mg capsule. 1 capsule(s)
by
mouth twice a day as needed for constipation
LANCETS [ONETOUCH ULTRASOFT LANCETS] - OneTouch UltraSoft
Lancets. use to check BS three times a day Dx: ___
MELATONIN - melatonin 3 mg tablet. 1 tablet(s) by mouth at
bedtime - (OTC)
PEN NEEDLE, DIABETIC [NOVOFINE 30] - NovoFine 30 30 gauge x ___
needle. Use with Lantus Solostar twice a day to inject insulin
Pen needle
VIT C-VIT E-LUTEIN-MIN-OM-3 [OCUVITE] - Dosage uncertain -
(Prescribed by Other Provider)
Discharge Medications:
1. Acetaminophen 650 mg PO 5X/DAY
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Calcium Carbonate 500 mg PO QID:PRN reflux
4. Docusate Sodium 100 mg PO BID
5. Enoxaparin Sodium 30 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 30 mg/0.3 mL 30 mg subcutaneous daily Disp #*28
Syringe Refills:*0
6. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
7. Glucose Gel 15 g PO PRN hypoglycemia protocol
8. Glargine 10 Units Breakfast
Glargine 8 Units Lunch
Insulin SC Sliding Scale using REG Insulin
9. Milk of Magnesia 30 ml PO BID:PRN Constipation
10. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth .___ tablet
every 4 hours Disp #*42 Tablet Refills:*0
11. Senna 8.6 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
left anterior column hemitransverse acetabulum fracture
Discharge Condition:
AAOx3, mentating appropriately, NVI
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- touch down weight bearing
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.
Physical Therapy:
touchdown weight bearing left lower extremity
range of motion as tolerated
Treatments Frequency:
change dressing as needed when saturated or every ___ days
Followup Instructions:
___
|
10659371-DS-12
| 10,659,371 | 25,996,643 |
DS
| 12 |
2161-03-02 00:00:00
|
2161-03-02 10:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Confusion, weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ year-old lady with a history of anal cancer
in remission and metastatic neuro-endocrine tumor on
carboplatin/etoposide (___) who presents with weakness and
fever.
She was in her usual state of health until today when she came
for a staging CT chest and felt "in daze" and confused per
report. She was referred to the ED prior to clinic visit.
ED initial vitals were 101.2 78 105/56 20 100% RA
Tmax 101.3, HRmax 109
Prior to transfer vitals were 101.3 108 ___ 100% 2L NC
ED work-up significant for:
-CBC: WBC: 20.3*. HGB: 7.7*. Plt Count: 201. Neuts%: 88.0*.
-Chemistry: Na: 131*. K: 4.0 . Cl: 94*. CO2: 25. BUN: 11. Creat:
0.8.
-Lactate: 1.1
-LFTs: ALT: 10. AST: 21. Alk Phos: 82. Total Bili: 0.3.
-UA: unremarkable
-CT chest (outpt): "2 new right upper lobe pulmonary micro
nodules, given the background of the patient the nodules should
be followed in ___ month. Otherwise no evidence of new or
growing
nodules. No pleural abnormalities. No adenopathy."
-RUQ-US: "No sonographic evidence to suggest abscess formation."
ED management significant for:
-Medications: vancomycin 750mg, cefepime 2g, LR 1.5L, APAP 1g x2
On arrival to the floor, patient reports feeling much better.
She's had a chronic non productive cough which is unchanged per
husband.
Patient denies chills, night sweats, headache, vision changes,
dizziness/lightheadedness, weakness/numbnesss, shortness of
breath, hemoptysis, chest pain, palpitations, abdominal pain,
nausea/vomiting, diarrhea, hematemesis, hematochezia/melena,
dysuria, hematuria, and new rashes.
Past Medical History:
PAST ONCOLOGIC HISTORY (Per OMR, reviewed):
Anal cancer
- ___ Normal colonoscopy
- ___ Developed narrow-caliber bowel movements and then pain
on defecation. This led to a rectal exam on which she was noted
to have a mass.
- ___ CT showed a 7 cm mass narrowing the lumen of the
distal rectum with pathologically enlarged lymph nodes seen
along
the left common iliac chain and as high as the S1 vertebral
body.
There seemed to be some possible involvement of the posterior
vagina.
- ___ Colonoscopy identified a thick nodular mass was seen
at the anorectal junction and the subsequent biopsy of this mass
revealed poorly differentiated squamous carcinoma.
- ___ C1D1 concomitant ___ and mitomycin C with
radiation
therapy
- ___ C2D1 concomitant ___ and mitomycin C with
radiation
therapy
- ___ Noted as having recurrence with increased bilateral
inguinal lymphadenopathy as well as palpable anal mass within
6-weeks of completed combined modality therapy.
- ___ C1D1 cisplatin ___
- ___ C2D1 cisplatin ___
- ___ C3D1 cisplatin ___
- ___ C4D1 cisplatin ___
- ___ CT torso significant reduction in disease burden
- ___ C5D1 cisplatin ___
- ___ C6D1 cisplatin ___
- ___ C7D1 cisplatin ___
- ___ C8D1 cisplatin ___
- ___ CT torso ___
- ___ C9D1 cisplatin ___
- ___ Anoscopic biopsies negative for cancer
- ___ ___ by imaging
NEC
- ___: MR enterography shows liver lesions concerning for
metastatic disease
- ___: EGD with minimal erythema of the stomach and normal
duodenum; Bx of antrum and duodenum benign
- ___: liver Bx shows poorly differentiated carcinoma with
neuroendocrine features. Rare reactivity for chromogranin and
synaptophysin. Ki67 > 80%. Specifically compared to prior
squamous cell carcinoma, NOT similar.
- ___: C1D1 carboplatin AUC 5/etoposide 100 mg/m2 Days ___
- ___: C2D1 carboplatin AUC 5/etoposide 80 mg/m2
(etoposide
dose reduced 20% for mucositis)
- ___: CT Torso shows decrease in size of hepatic mets, no
new lesions
- ___: C3D1 carboplatin AUC 5/etoposide 80 mg/m2
(etoposide
dose reduced 20% for mucositis)
- ___: C4D1 carboplatin AUC 5/etoposide 80 mg/m2
(etoposide
dose reduced 20% for mucositis)
- ___: C5D1 carboplatin AUC 5/etoposide 80 mg/m2 (etoposide
dose reduced 20% for mucositis)
- ___: CT Torso shows further decrease in liver metastases,
recommend MRI to better visualize
- ___: C6D1 carboplatin AUC 5/etoposide 80 mg/m2 (etoposide
dose reduced 20% for mucositis)
- ___: C7D1 carboplatin AUC 5/etoposide 80 mg/m2 (etoposide
dose reduced 20% for mucositis)
- ___: C8D1 carboplatin AUC 5/etoposide 80 mg/m2 (etoposide
dose reduced 20% for mucositis)
- ___: C9D1 carboplatin AUC 5/etoposide 80 mg/m2 (etoposide
dose reduced 20% for mucositis)
- ___: RFA to 2 residual liver lesions
- ___: MRI shows progression in the liver with several new
lesions
- ___: C10D1 carboplatin AUC 5/etoposide 80 mg/m2 (etoposide
dose reduced 20% for mucositis)
PAST MEDICAL HISTORY (Per OMR, reviewed):
-Esophageal dysmotility / Dysphagia
-Urinary incontinence NOS
-GERD
-Lactose intolerance
-Rectal leakage
-Obstructive sleep apnea
-Psoriasis on MTX weekly
s/p tonsillectomy
s/p cervical laminectomy
s/p R knee replacement
s/p R hammer toe
Social History:
___
Family History:
Non-contributory
Physical Exam:
VS: ___ 2322 Temp: 99.4 PO BP: 93/54 HR: 109 RR: 20 O2 sat:
95% O2 delivery: Ra
GENERAL: Well-appearing lady, in no distress lying in bed
comfortably.
HEENT: Anicteric, PERLL, Mucous membranes dry, oropharynx clear.
CARDIAC: Regular rate and rhythm, no murmurs, rubs or gallops.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Non-distended, normal bowel sounds, soft, non-tender, no
guarding, no palpable masses, no organomegaly.
EXT: Warm, well perfused. No lower extremity edema. No erythema
or tenderness.
NEURO: Somnolent and oriented to self and hospital but not to
date, inattentive. CN II-XII intact. Strength full throughout.
Sensation to light touch intact. Negative Kernig and Brudziski.
SKIN: No significant rashes. Right chest port without erythema,
secretion, tenderness.
.
.
DISCHARGE EXAM:
Gen: NAD, says she is feeling well and ready to go home
Lungs: CTAB
Cards: RR, no m/r/g
Abd: soft, not distended, not tender to palpation, BS+
MSK: grossly normal strength in all 4 extremities
Neuro: AAOx4, clear speech, stable gait
Pertinent Results:
Admission Labs
___ 12:40PM BLOOD WBC-20.3* RBC-2.84* Hgb-7.7* Hct-24.1*
MCV-85 MCH-27.1 MCHC-32.0 RDW-17.9* RDWSD-47.8* Plt ___
___ 12:40PM BLOOD Glucose-98 UreaN-11 Creat-0.8 Na-131*
K-4.0 Cl-94* HCO3-25 AnGap-12
___ 06:01AM BLOOD Calcium-8.0* Phos-3.0 Mg-1.5*
___ 12:40PM BLOOD Albumin-3.7
Blood culture
ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES.
Daptomycin MIC OF 1 MCG/ML = SUSCEPTIBLE , test result
performed
by Etest.
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
gentamicin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECALIS
|
AMPICILLIN------------ <=2 S
DAPTOMYCIN------------ S
PENICILLIN G---------- 2 S
VANCOMYCIN------------ 1 S
___ blood cultures negative
Pelvic U/S
The uterus is anteverted and measures 7.9 x 3.9 x 3.7 cm. The
endometrial
cavity is distended with hypoechoic fluid without internal
vascularity. Not
accounting for the endometrial fluid, the endometrium is
homogeneous and
measures 4 mm. The degree of endometrial distention measures
approximately
2.4 cm.
The ovaries are not definitively seen however there are no
abnormal adnexal
masses. There is no free fluid.
IMPRESSION:
Fluid distended endometrial cavity without abnormal vascularity,
as described
above, suggesting cervical stenosis.
Brief Hospital Course:
Mrs. ___ is a ___ year-old lady with a history of anal cancer
in remission and metastatic neuro-endocrine tumor on
carboplatin/etoposide (___) who presented with weakness,
confusion and fever; found to have enterococcal sepsis, much
improved on antibiotics. Ultimately the source of her
enterococcal bacteremia was not determined. She clinically
improved/resolved with targeted abx therapy (IV ampicillin).
Transitioned to IV PCN via PORT on discharge per ID recs.
#Enterococcal sepsis: Patient demonstrated dramatic improvement
on IV ampicillin and On ampicillin, will get ampicillin locks of
port, seen by ID who recommended total of 14 days of treatment
(___). TTE showed no evidence of endocarditis. Discharged
on PCN 3 million units q4h (=continuous infusion) thru ___.
Unclear cause of enterococcal sepsis - ? bacterial gut
translocation. There was also concern that patient may have had
infectious source in uterus; she has long standing vaginal
stenosis due to XRT for prior anal cancer and has a long
standing uterine fluid collection. GYN was consulted to
determine if it was possible to sample this collection to
determine if it may have been the source of infection. Pelvic
u/s showed small amount of fluid in the uterine cavity, and
patient had substantial clinical improvement with abx, so GYN
advised against sampling this.
# Cough: improved with starting Flonase, bronchodilators, QHS
codeine.
# Anemia: Likely myelosuppression due to chemo; received 1 unit
of prbc and hematocrit increased appropriately. Stable for
several days prior to discharge.
# Metastatic NET: On carboplatin etoposide
-Further plans per Dr. ___
#Anal leakage, chronic
#Diarrhea, chronic
-C. diff was negative. Resumed home loperamide PRN.
#ACCESS: Right Chest wall port
.
.
.
Time in care:
[x] Greater than 30 minutes in discharge-related activities
today.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diphenoxylate-Atropine 1 TAB PO Q8H:PRN severe diarrhea
2. LOPERamide ___ mg PO QID:PRN diarrhea
3. Simethicone 40-80 mg PO QID
4. solifenacin 5 mg oral DAILY
5. Ranitidine 150 mg PO DAILY:PRN breakthrough reflux
6. esomeprazole magnesium 40 mg oral BID
7. Aspirin 81 mg PO DAILY
8. Citalopram 40 mg PO DAILY
Discharge Medications:
1. Ampicillin-Heparin Lock 50 mg LOCK Q4H:PRN for locks when
line not in use Duration: 8 Days
Continue during systemic antibiotic therapy.
Last dose will be on ___.
2. Fluticasone Propionate NASAL 1 SPRY NU BID
3. GuaiFENesin ___ mL PO Q6H:PRN cough
4. Penicillin G Potassium 3 Million Units IV Q4H Duration: 8
Days
Last dose will be on ___.
RX *penicillin G pot in dextrose 3 million unit/50 mL 3 million
units IV every four (4) hours Disp #*48 Intravenous Bag
Refills:*0
5. Aspirin 81 mg PO DAILY
6. Citalopram 40 mg PO DAILY
7. Diphenoxylate-Atropine 1 TAB PO Q8H:PRN severe diarrhea
8. Esomeprazole Magnesium 40 mg oral BID
9. LOPERamide ___ mg PO QID:PRN diarrhea
10. Ranitidine 150 mg PO DAILY:PRN breakthrough reflux
11. Simethicone 40-80 mg PO QID
12. solifenacin 5 mg oral DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Enterococcal Sepsis
2. Cough
3. Anemia
4. Metastatic neuroendocrine cancer on chemotherapy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. ___
___ were admitted with confusion and weakness and were found to
have a bacteria in your blood stream. This is a condition
called sepsis. ___ were treated with antibiotics and IV fluids
and ___ improved dramatically in a relatively short period of
time. ___ were evaluated by the infectious diseases doctors
and they recommended that ___ remain on the antibiotic
penicillin to be administered through your port thru ___.
It was a pleasure caring for ___ while ___ were here, and we
wish ___ the best.
Sincerely,
Dr. ___ the ___ Medicine Team
Followup Instructions:
___
|
10659371-DS-14
| 10,659,371 | 20,297,647 |
DS
| 14 |
2161-08-04 00:00:00
|
2161-08-04 16:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hyponatremia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with a remote history of anal cancer s/p chemoRT and
___ x9 (___), metastatic neuroendocrine carcinoma s/p 9
cycles carboplatin/etoposide (___) and RFA to liver
lesions (___), recurrent disease leading to reinitation of 3
cycles of carboplatin/etoposide (___) with
progression, recently found to have brain mets s/p SBRT
(___), s/p 3 cycles capecitabine/temozolamide
(___) with progression, now switched to FOLFIRI
(___) who presents following allergic reaction during
chemo with hyponatremia believed to be ___ SIADH.
On day of admission, patient presented to the infusion clinic
for
chemo. She was pre-medicated with standard medications (Ativan,
PO dexamethasone) and was started on ___ and leucovorin
infusions. Towards the end of their infusion, she developed
generalized SOB, wheezing, coughing and nausea consistent with
an
allergic reaction. She received Benadryl, dexamethasone and
famotidine and was sent to the ER. She did not require
epinephrine. On arrival, she was noted to be sleepy. The
patient's husband also recalled her tripping, falling and
striking her knee earlier in the day but denies head strike or
LOC.
Over the past several weeks, patient has been feeling
intermittently sluggish and somewhat confused. She complains of
worsening lower extremity edema. She notes her appetite is good
but does complain of intermittent nausea and dry heaves which
resolve with zofran. Over the past few days, she has had a cough
productive of clear sputum. Her husband notes restless upper and
lower extremity movements. She also complains of healing oral
lesions that were extremely painful. She has been strictly
adhering to her 1L fluid restriction ever since discharge in
___.
Of note, patient was recently admitted in ___ for
hyponatremia in the setting of progression of NEC with new brain
metastasis. At that admission, hyponatremia was felt to be
consistent with SIADH, patient was placed on 1L fluid
restriction
and daily salt tabs.
In the ED,
- Initial Vitals: temp 98.6, HR 99, BP 166/99, RR 20, 100% 2L NC
- Exam: normal inspiratory effort, no wheezing, no urticarial,
somewhat sleepy.
- Labs: notable for Na 124->119, WBC 3.8, Hg 7.3, AST/ALT 60/23,
AP 182, serum osm 249. Urine lytes: Na 165, Osmolality 486
- Imaging: CT Head with no evidence of acute intracranial
abnormality, known left cerebellar lesion. CXR with pulmonary
congestion and mild edema, known pulmonary nodules.
- Consults: none
- Interventions: Treated with Benadryl 25mg IV, dexamethasone
20mg IV, and famotidine 20mg IV. This was in addition to
standard
chemo premedication (Ativan, PO dexamethasone).
Past Medical History:
PAST ONCOLOGIC HISTORY (Per OMR, reviewed):
Anal cancer
- ___ Normal colonoscopy
- ___ Developed narrow-caliber bowel movements and then pain
on defecation. This led to a rectal exam on which she was noted
to have a mass.
- ___ CT showed a 7 cm mass narrowing the lumen of the
distal rectum with pathologically enlarged lymph nodes seen
along
the left common iliac chain and as high as the S1 vertebral
body.
There seemed to be some possible involvement of the posterior
vagina.
- ___ Colonoscopy identified a thick nodular mass was seen
at the anorectal junction and the subsequent biopsy of this mass
revealed poorly differentiated squamous carcinoma.
- ___ C1D1 concomitant ___ and mitomycin C with
radiation
therapy
- ___ C2D1 concomitant ___ and mitomycin C with
radiation
therapy
- ___ Noted as having recurrence with increased bilateral
inguinal lymphadenopathy as well as palpable anal mass within
6-weeks of completed combined modality therapy.
- ___ C1D1 cisplatin ___
- ___ C2D1 cisplatin ___
- ___ C3D1 cisplatin ___
- ___ C4D1 cisplatin ___
- ___ CT torso significant reduction in disease burden
- ___ C5D1 cisplatin ___
- ___ C6D1 cisplatin ___
- ___ C7D1 cisplatin ___
- ___ C8D1 cisplatin ___
- ___ CT torso ___
- ___ C9D1 cisplatin ___
- ___ Anoscopic biopsies negative for cancer
- ___ ___ by imaging
NEC
- ___: MR enterography shows liver lesions concerning for
metastatic disease
- ___: EGD with minimal erythema of the stomach and normal
duodenum; Bx of antrum and duodenum benign
- ___: liver Bx shows poorly differentiated carcinoma with
neuroendocrine features. Rare reactivity for chromogranin and
synaptophysin. Ki67 > 80%. Specifically compared to prior
squamous cell carcinoma, NOT similar.
- ___: C1D1 carboplatin AUC 5/etoposide 100 mg/m2 Days ___
- ___: C2D1 carboplatin AUC 5/etoposide 80 mg/m2
(etoposide
dose reduced 20% for mucositis)
- ___: CT Torso shows decrease in size of hepatic mets, no
new lesions
- ___: C3D1 carboplatin AUC 5/etoposide 80 mg/m2
(etoposide
dose reduced 20% for mucositis)
- ___: C4D1 carboplatin AUC 5/etoposide 80 mg/m2
(etoposide
dose reduced 20% for mucositis)
- ___: C5D1 carboplatin AUC 5/etoposide 80 mg/m2 (etoposide
dose reduced 20% for mucositis)
- ___: CT Torso shows further decrease in liver metastases,
recommend MRI to better visualize
- ___: C6D1 carboplatin AUC 5/etoposide 80 mg/m2 (etoposide
dose reduced 20% for mucositis)
- ___: C7D1 carboplatin AUC 5/etoposide 80 mg/m2 (etoposide
dose reduced 20% for mucositis)
- ___: C8D1 carboplatin AUC 5/etoposide 80 mg/m2 (etoposide
dose reduced 20% for mucositis)
- ___: C9D1 carboplatin AUC 5/etoposide 80 mg/m2 (etoposide
dose reduced 20% for mucositis)
- ___: RFA to 2 residual liver lesions
- ___: MRI shows progression in the liver with several new
lesions
- ___: C10D1 carboplatin AUC 5/etoposide 80 mg/m2 (etoposide
dose reduced 20% for mucositis)
PAST MEDICAL HISTORY (Per OMR, reviewed):
-Esophageal dysmotility / Dysphagia
-Urinary incontinence NOS
-GERD
-Lactose intolerance
-Rectal leakage
-Obstructive sleep apnea
-Psoriasis on MTX weekly
s/p tonsillectomy
s/p cervical laminectomy
s/p R knee replacement
s/p R hammer toe
Social History:
___
Family History:
Non-contributory to this hospital admission.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: temp 97.9, HR 90, BP 185/163, RR 21, 90% on RA
GEN: NAD, alert and oriented
EYES: pupils equal and reactive to light, anicteric sclera
HENNT: MMM, neck supple, no mucosal lesions.
CV: RRR, normal S1, S2. no murmurs, rubs, gallops.
RESP: crackles at the lung bases bilaterally. no wheezes, rales,
normal inspiratory effort.
GI: soft, nontender, nondistended, +BS
MSK: moving all extremities symmetrically
SKIN: no lesions or rashes.
NEURO: CNs grossly intact.
PSYCH: normal mood, affect.
DISCHARGE PHYSICAL EXAM
========================
24 HR Data (last updated ___ @ 016)
Temp: 97.7 (Tm 98.2), BP: 113/62 (91-134/53-69), HR: 88
(85-93), RR: 18 (___), O2 sat: 100% (98-100), O2 delivery: Ra
GENERAL: Sitting up in bed, NAD
CV: RRR, no m/r/g
PULM: LCTAB, R chest wall port without surrounding erythema
ABD: Soft, NT, ND
EXT: WWP, no ___ edema
NEURO: A&Ox3, CN II-XI grossly intact. Moving all four
extremities spontaneously, independently ambulating.
Pertinent Results:
ADMISSION LABS:
===============
___ 07:45AM BLOOD WBC-3.8* RBC-2.60* Hgb-7.3* Hct-22.6*
MCV-87 MCH-28.1 MCHC-32.3 RDW-19.9* RDWSD-58.0* Plt ___
___ 03:48AM BLOOD ___ PTT-27.1 ___
___ 07:45AM BLOOD UreaN-13 Creat-0.7 Na-124* K-4.2 Cl-88*
HCO3-25 AnGap-10
___ 07:45AM BLOOD ALT-23 AST-60* AlkPhos-182* TotBili-0.3
___ 07:45AM BLOOD Albumin-3.4* Calcium-8.5 Phos-3.3 Mg-1.6
___ 05:30PM BLOOD Osmolal-249*
___ 06:24AM BLOOD Na-116*
INTERVAL LABS:
==============
___ 10:07AM BLOOD Na-117*
___ 12:35PM BLOOD Na-117*
___ 02:16PM BLOOD Na-116*
___ 04:14PM BLOOD Na-116*
___ 06:24PM BLOOD Na-118*
___ 08:04PM BLOOD Na-117*
___ 09:54PM BLOOD Na-118*
___ 12:06AM BLOOD Na-117*
___ 01:56AM BLOOD Na-118*
___ 03:54AM BLOOD Na-118*
___ 06:17AM BLOOD Na-117*
___ 09:34AM BLOOD Na-117*
___ 11:45AM BLOOD Na-119*
___ 02:53PM BLOOD Na-118*
___ 05:20PM BLOOD Na-119*
___ 07:24PM BLOOD Na-120*
___ 09:32PM BLOOD Na-121*
___ 11:28PM BLOOD Na-120*
___ 03:50AM BLOOD Na-121*
___ 07:30AM BLOOD Na-120*
___ 12:01PM BLOOD Na-115*
___ 12:10PM BLOOD Na-120*
___ 03:14PM BLOOD Na-121*
___ 07:30AM BLOOD Na-120*
___ 12:01PM BLOOD Na-115*
___ 12:10PM BLOOD Na-120*
___ 03:14PM BLOOD Na-121*
___ 04:20PM BLOOD Na-121*
___ 08:02PM BLOOD Na-122*
___ 08:17PM BLOOD Na-121*
___ 01:08AM BLOOD Na-122*
___ 04:36AM BLOOD Na-124*
___ 08:45AM BLOOD Na-123*
___ 03:23PM BLOOD Na-123*
___ 06:25AM BLOOD Na-126*
___ 03:07PM BLOOD Na-126*
___ 06:10AM BLOOD Na-127*
___ 06:25PM BLOOD Na-128*
___ 06:26AM BLOOD Na-139
___ 07:43AM BLOOD Na-137
___ 10:06AM BLOOD Na-136
___ 12:20PM BLOOD Na-136
___ 02:25PM BLOOD Na-134
___ 09:00PM BLOOD Na-137
___ 05:33AM BLOOD Na-138
LABS AT DISCHARGE
=================
___ 05:01AM BLOOD WBC-2.8* RBC-2.63* Hgb-7.3* Hct-23.4*
MCV-89 MCH-27.8 MCHC-31.2* RDW-19.2* RDWSD-58.4* Plt ___
___ 05:01AM BLOOD Glucose-94 UreaN-14 Creat-0.8 Na-139
K-4.3 Cl-101 HCO3-25 AnGap-13
___ 03:33AM BLOOD ALT-21 AST-64* LD(LDH)-593* AlkPhos-162*
TotBili-0.7
IMAGING:
========
BILATERAL LOWER EXT VEINS - ___:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
TTE - ___:
The left atrium is mildly dilated. There is no evidence for an
atrial septal defect by 2D/color Doppler. The estimated right
atrial pressure is ___ mmHg. There is normal left ventricular
wall thickness with a normal
cavity size. There is normal regional and global left
ventricular systolic function. Quantitative biplane left
ventricular ejection fraction is 55 %. Global longitudinal
strain is depressed (-19.4 %; normal less than -20%) There is no
resting left ventricular outflow tract gradient. There is normal
diastolic function. Normal right ventricular cavity size with
normal free wall motion. The aortic sinus diameter is normal for
gender. The aortic arch diameter is normal. There is no evidence
for an aortic arch coarctation. The aortic valve leaflets (3)
are mildly thickened. There is no aortic valve stenosis. There
is no aortic regurgitation. The mitral valve leaflets are mildly
thickened with no mitral valve prolapse. There is trivial mitral
regurgitation. The tricuspid valve leaflets appear structurally
normal. There is physiologic tricuspid regurgitation. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
IMPRESSION: Normal left ventricular wall thickness, cavity size,
and regional/global systolic function. No valvular pathology or
pathologic flow identified.
Compared with the prior TTE ___, the findings are
similar.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
====================
___ with a remote history of anal cancer s/p chemoradiation and
metastatic neuroendocrine carcinoma s/p 9 cycles
carboplatin/etoposide, RFA to liver lesions, with recurrent
disease leading to re-initiation of 3 cycles of
carboplatin/etoposide with progression, now on
capecitabine/temozolamide, who presented with hyponatremia
believed to be ___ SIADH, possibly exacerbated by home SSRI, in
the setting of neuroendocrine carcinoma with brain metastasis.
ACUTE ISSUES
===========
#Hyponatremia: acute on chronic
Patient has known hyponatremia believed to be secondary to
SIADH. Was recently hospitalized with hyponatremia and told to
continue fluid restriction and daily salt tabs on discharge. She
presented this time with sodium to 119. The current decline in
her sodium was felt to be due to fluids from recent chemotherapy
and her SSRI (citalopram). She was initially admitted to the ICU
for management of severe hyponatremia, and nephrology was
consulted. She was initially managed with hypertonic saline.
Once her sodium improved to > 120, citalopram was stopped and
she was managed with free water restriction to 750 mL. Salt tabs
were held in the setting of volume overload. At this point, it
was felt that her strict fluid restriction would impair her
quality of life too much and that her SIADH was too severe, so
she was started on tolvaptam, which increased her sodium from
128 to 135-140. Upon starting tolvaptam, her fluid restriction
was stopped. She received two days of tolvaptam 15 mg inpatient,
which she tolerated well. She will be discharged on tolvaptam 15
mg daily and NO fluid restriction. She should drink to thirst.
The medication has been delivered to her home. She will
follow-up with nephrology as an outpatient and have labs checked
the day after discharge. Her sodium on discharge was 138.
#Metastatic neuroendocrine carcinoma with brain metastasis
#Concern for allergic reaction during chemotherapy
Most recently started on FOLFIRI (___) on day of
admission. Had episode of SOB, wheezing and nausea concerning
for allergic reaction towards the end of chemo. Resolved with
Benadryl and did not require epinephrine. Has been stable since
and shown no allergic symptoms since arrival to ER. MRI head
from ___ showed interval decrease in cerebellar lesions and no
new lesions. Patient was monitored with serial neuro exams given
known brain involvement and recurrence of allergic symptoms in
the first 24 hrs after initial reaction without positive
findings. Pain was controlled with acetaminophen and oxycodone.
Dronabinol was continued for appetite. Patient was briefly
trialed on mirtazapine, but she had confusion and too much
lethargy, so this was stopped. Zofran was continued for nausea.
She will follow-up with allergy as an outpatient.
CHRONIC ISSUES
=============
#Diarrhea
Patient without complaints of diarrhea on admission. Continued
on home loperamide.
#Mucosal lesions
Continued home Maalox/Diphenhydramine/Lidocaine as needed.
#Mood:
Citalopram was stopped due to concern for exacerbating SIADH.
Transitional Issues:
- STOPPED citalopram due to concern for SIADH.
- STARTED tolvaptam 15 mg daily. Patient should no longer be on
a fluid restriction and should drink to thirst.
[] Please check chemistry panel (chem-7) on ___ and fax
results to Dr. ___ ___.
CORE MEASURES
=============
# Code Status: FULL CODE (confirmed)
# Emergency Contact:
#HCP/CONTACT: ___
Phone number: ___
Cell phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
2. Benzonatate 100 mg PO TID:PRN cough, ___ line
3. Citalopram 40 mg PO DAILY
4. Guaifenesin-CODEINE Phosphate 15 mL PO Q6H:PRN severe cough,
___ line
5. DICYCLOMine 10 mg PO QID
6. Diphenoxylate-Atropine 1 TAB PO Q8H:PRN severe diarrhea
7. Dronabinol 2.5 mg PO BID
8. Esomeprazole 40 mg Other BID
9. estradiol 10 mcg vaginal 2X/WEEK
10. Hydrocortisone Cream 1% 1 Appl TP TID vaginal area
11. Lidocaine 5% Patch 1 PTCH TD QAM low back pain
12. Lidocaine-Prilocaine 1 Appl TP PRN over port 1 hour prior to
port access
13. LORazepam 0.5 mg PO Q8H:PRN anxiety
14. Maalox/Diphenhydramine/Lidocaine 30 mL PO QID:PRN mouth
sores
15. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
16. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
17. Pegfilgrastim 6 mg SC AFTER CHEMO
18. Ranitidine 150 mg PO DAILY
19. solifenacin 5 mg oral DAILY
20. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
21. Aspirin 81 mg PO DAILY
22. Cyanocobalamin 1000 mcg PO DAILY
23. Ferrous Sulfate 325 mg PO DAILY
24. LOPERamide ___ mg PO QID:PRN diarrhea
25. Multivitamins 1 TAB PO DAILY
26. Pyridoxine 100 mg PO DAILY
27. Simethicone 125 mg PO QID:PRN gas, bloating
28. Thiamine 100 mg PO DAILY
29. Vitamin A 8000 UNIT PO DAILY
30. Vitamin B Complex 1 CAP PO DAILY
31. Zinc Sulfate 50 mg PO DAILY
32. Sodium Chloride 2 gm PO TID
33. Magnesium Oxide 800 mg PO DAILY
34. potassium gluconate 550 mg (90 mg) oral DAILY
35. Saccharomyces boulardii 250 mg oral DAILY
36. glucosamine-chondroitin (glucosamine-chondroit-vit C-Mn)
250-200 mg oral DAILY
37. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Multivitamins W/minerals 1 TAB PO DAILY
2. Tolvaptan 15 mg PO DAILY
Monitor serum sodium closely, contact MD prior to administration
if increase > 8 in past 24h
RX *tolvaptan [Samsca] 15 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
4. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
5. Aspirin 81 mg PO DAILY
6. Benzonatate 100 mg PO TID:PRN cough, ___ line
7. Cyanocobalamin 1000 mcg PO DAILY
8. DICYCLOMine 10 mg PO QID
9. Diphenoxylate-Atropine 1 TAB PO Q8H:PRN severe diarrhea
10. Dronabinol 2.5 mg PO BID
11. Esomeprazole 40 mg Other BID
12. estradiol 10 mcg vaginal 2X/WEEK
13. Ferrous Sulfate 325 mg PO DAILY
14. glucosamine-chondroitin (glucosamine-chondroit-vit C-Mn)
250-200 mg oral DAILY
15. Guaifenesin-CODEINE Phosphate 15 mL PO Q6H:PRN severe
cough, ___ line
RX *codeine-guaifenesin 10 mg-100 mg/5 mL 15 mL by mouth EVERY 6
HOURS AS NEEDED Refills:*0
16. Hydrocortisone Cream 1% 1 Appl TP TID vaginal area
17. Lidocaine 5% Patch 1 PTCH TD QAM low back pain
18. Lidocaine-Prilocaine 1 Appl TP PRN over port 1 hour prior
to port access
19. LOPERamide ___ mg PO QID:PRN diarrhea
20. LORazepam 0.5 mg PO Q8H:PRN anxiety
21. Maalox/Diphenhydramine/Lidocaine 30 mL PO QID:PRN mouth
sores
22. Magnesium Oxide 800 mg PO DAILY
23. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
24. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
25. Pegfilgrastim 6 mg SC AFTER CHEMO
26. potassium gluconate 550 mg (90 mg) oral DAILY
27. Pyridoxine 100 mg PO DAILY
28. Ranitidine 150 mg PO DAILY
29. Saccharomyces boulardii 250 mg oral DAILY
30. Simethicone 125 mg PO QID:PRN gas, bloating
31. solifenacin 5 mg oral DAILY
32. Thiamine 100 mg PO DAILY
33. Vitamin A 8000 UNIT PO DAILY
34. Vitamin B Complex 1 CAP PO DAILY
35. Vitamin D 1000 UNIT PO DAILY
36. Zinc Sulfate 50 mg PO DAILY
37.Outpatient Lab Work
Chemistry 7
ICD 9 Code Hyponatremia ___
Fax results to: ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Hyponatremia
Syndrome of Inappropriate ADH
SECONDARY DIAGNOSIS
==================
Metastatic neuroendocrine carcinoma with brain metastasis
Depression
Anemia of Chronic Disease
GERD
History of anal cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted because you were feeling weak and were
found to have very low sodium levels
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were treated in the ICU because of your very low sodium
levels. We restricted the amount of fluid you drank to help
bring the sodium levels back to normal.
- We started you on a new medication called Tolvaptan which
should help keep your sodium level normal
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:
___
|
10659847-DS-14
| 10,659,847 | 20,568,853 |
DS
| 14 |
2129-03-18 00:00:00
|
2129-03-18 10:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Neck pain with right arm and leg weakness
Major Surgical or Invasive Procedure:
Anterior/Posterior cervical fusion with instrumentation C4-5
History of Present Illness:
___ transfer from OSH after C4-5 injury. He was participating
in a "mud run" on ___, when he dove/fell head-first into a mud
hole. He complained only of left shoulder pain and a "twinge" of
spinal pain. He was moving his upper/low left extremities, but
had weakness of upper and lower right extremities.
Past Medical History:
hyperlipidemia
Social History:
___
Family History:
N/C
Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
LUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - ___, reflexes
symmetric at biceps, triceps and brachioradialis
RUE- weakness at biceps, triceps and wrist extension
LLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
___ sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles
RLE- weakness at quads and anterior tibialis
Pertinent Results:
___ 06:10AM BLOOD WBC-11.3* RBC-4.05* Hgb-12.5* Hct-37.8*
MCV-93 MCH-30.9 MCHC-33.1 RDW-13.1 Plt ___
___ 04:00AM BLOOD WBC-9.2 RBC-4.24* Hgb-12.8* Hct-38.8*
MCV-92 MCH-30.3 MCHC-33.1 RDW-13.1 Plt ___
___ 04:05PM BLOOD WBC-14.8* RBC-4.66 Hgb-13.8* Hct-42.2
MCV-91 MCH-29.6 MCHC-32.7 RDW-12.8 Plt ___
___ 04:00AM BLOOD Glucose-176* UreaN-24* Creat-0.9 Na-138
K-4.5 Cl-103 HCO3-23 AnGap-17
___ 04:05PM BLOOD Glucose-112* UreaN-28* Creat-1.0 Na-142
K-4.3 Cl-105 HCO3-22 AnGap-19
___ 04:00AM BLOOD Calcium-8.5 Phos-4.1 Mg-2.0
___ 10:30PM BLOOD Calcium-8.5 Phos-4.5 Mg-2.0
Brief Hospital Course:
Mr. ___ was admitted to the ___ Spine Surgery Service and
emergently taken to the Operating Room for C4-5 anterior fusion.
Please refer to the dictated operative note for further details.
The surgery was without complication and the patient was
transferred to the T/ICU in a stable condition. TEDs/pnemoboots
were used for postoperative DVT prophylaxis. Intravenous
antibiotics were given per standard protocol. Initial postop
pain was controlled with a PCA. Function of his right upper and
lower extremities improved. On HD#3 he returned to the operating
room for a scheduled C4-5 decompression with PSIF as part of a
staged 2-part procedure. Please refer to the dictated operative
note for further details. The second surgery was also without
complication and the patient was transferred to the PACU in a
stable condition. Postoperative HCT was stable. He was kept NPO
until bowel function returned then diet was advanced as
tolerated. The patient was transitioned to oral pain medication
when tolerating PO diet. Foley was removed on POD#2 from the
second procedure. He was fitted with a cervical collar when out
of bed. Physical therapy was consulted for mobilization OOB to
ambulate. Hospital course was otherwise unremarkable. On the day
of discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet
Medications on Admission:
simvastatin
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Fracture/dislocation C4-5
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: ANTERIOR/POSTERIOR
Cervical Decompression With Fusion
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for ___ minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a collar. This is to be worn for
comfort when you are walking. You may take it off when sitting
in a chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually ___ days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
___ 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Followup Instructions:
___
|
10660019-DS-8
| 10,660,019 | 27,575,081 |
DS
| 8 |
2184-05-06 00:00:00
|
2184-05-07 17:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Barbiturates / Garlic Oil / Lactose
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female with GERD, hyperlipidemia, hypertension,
depression, glaucoma, anxiety, vitamin D deficiency, and
hyperparathyroidism, who presents with concern for AMS in the
setting of multiple recent falls. The patient's daughter, who
was initially with her mother in the ___, reported that she has
had multiple falls from both the standing and sitting positions
(obtained from ___ history as daughter not available on the
floor). The patient herself states that she has not fallen in
several days but does report that she falls often. She denies
any preceding dizziness, curtain coming down over her vision,
chest pain or SOB prior to these episodes. She states that she
is always surprised to find herself on the ground and does not
remember ever being able to even attempt to catch herself. She
also does not remember ever tripping. She denies any recent
fevers, chills, nausea, vomiting diarrhea, dysuria, urinary
frequency, bowel or bladder incontinence but does report
intermittent BRBPR. She does not that she has multiple bruises
from falling. She also states that she had LLE cellulitis
several months ago and has been left with swelling of her LLE.
.
In the ___, initial VS: 97.8 80 163/54 16 100%. The patient was
complaining of neck pain, headache, and bilateral wrist pain. An
EKG revealed sinus arrhythmia. A UA was grossly positive for a
UTI so the patient was given Ceftriaxone 1 gm IV once. Given her
report of BRBPR and hematocrit slightly lower than baseline, a
stool guaiac was performed which was negative. A non-contrast
head CT was performed that revealed no intracranial process.
C-spine CT revealed degenerative changes with impingement of the
thecal sac and MR was recommended for further evaluation. The
patient had been placed in a C-collar but removed it herself.
She was also given one dose of Metoprolol tartrate 50 mg PO once
for her known atrial fibrillation prior to transfer. Transfer
Vitals: Temp: 97.7. HR: 81. BP: 164/72. O2: 97% ra. RR 18.
Past Medical History:
Hypertension
Depression
Atrial fibrillation
GERD
Vitamin D deficiency
Hyperparathyroidism
Glaucoma
History of syncope
Social History:
___
Family History:
Father with pericardial injury secondary to car accident,
otherwise NC
Physical Exam:
ADMISSION PHYSICAL:
VS - 98.9, 160/98, 78, 18, 95% RA
GENERAL - well-appearing in NAD, comfortable, appropriate
HEENT - scab over right forehead, PERRLA, EOMI, sclerae
anicteric, no JVD
LUNGS - easy respiratory effor, CTAB
HEART - irregularly irregular, normal S1 and S2, II/VI SM
loudest at LLSB
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, 2+ LLE edema and mild erythema, trace RLE
edema
SKIN - diffuse ecchymotic lesions in various stages
NEURO - awake, A&Ox3, CNs II-XII intact, sensation acutely
intact, walks unsteadily with assist, immediate and remote
memory intact
.
DISCHARGE PHYSICAL: unchanged
Pertinent Results:
ADMISSION LABS:
___ 05:45PM BLOOD WBC-5.2 RBC-2.68* Hgb-8.4* Hct-25.8*
MCV-97 MCH-31.4 MCHC-32.5 RDW-18.1* Plt ___
___ 05:45PM BLOOD Neuts-67 Bands-1 Lymphs-17* Monos-15*
Eos-0 Baso-0 ___ Myelos-0
___ 05:45PM BLOOD Plt Smr-LOW Plt ___
___ 05:45PM BLOOD Glucose-184* UreaN-26* Creat-0.9 Na-138
K-3.3 Cl-100 HCO3-28 AnGap-13
___ 06:15AM BLOOD Calcium-9.6 Phos-3.0 Mg-1.7
___ 05:45PM BLOOD VitB12-___ Folate-15.1
___ 05:45PM BLOOD TSH-2.4
___ 11:20PM BLOOD Lactate-1.1
.
PERTINENT IMAGING:
___: Head CT w/o Contrast:
FINDINGS:
.
There is no evidence of acute intracranial hemorrhage, mass
effect, or shift of normally midline structures. There is no
cerebral edema or loss of gray-white matter differentiation to
suggest an acute ischemic event. The sulci and ventricles are
prominent, suggestive of age-related involutional changes.
Basilar cisterns are patent. Paranasal sinuses and mastoid air
cells appear well aerated.
.
IMPRESSION:
No evidence of acute intracranial process.
.
___: CT C-Spine w/o Contrast:
FINDINGS:
There is no acute traumatic injury. Extensive degenerative disc
changes
involving the cervical spine is present, which appears to have
progressed from ___ exam. There is loss of intervertebral
disc height involving
multiple levels. Disc osteophyte complex formations are seen
predominantly at C4-C5, C5-C6, and C6-C7 levels which appear to
impinge on the thecal sac. Similarly, there are anterior
osteophytes, most pronounced at C5-C6 with some fragmentation.
There is no evidence of critical central canal stenosis. There
is loss of normal cervical lordosis. There is no evidence of
prevertebral hematoma. The airway is patent.
.
Numerous lymph nodes are seen throughout all cervical stations,
which do not appear pathologically enlarged. Imaged lung apices
are clear. There is no pneumothorax.
.
IMPRESSION: No evidence of acute traumatic injury. Multilevel
degenerative
joint changes involving the entire cervical spine appear
longstanding and
progressed from ___ exam. Posterior disc osteophyte
complex formations are seen at multiple levels, most pronounced
at C4-C5, C5-C6, and C6-C7 with impingement on the thecal sac.
These above findings predispose the patient to ligamentous and
cord injury in the setting of trauma. If high clinical suspicion
remains for such injuries, MR may be considered for further
assessment.
Brief Hospital Course:
Brief Course:
___ y/o female AF (not on anti-coagulation, not currently in
afib), HTN, anemia, depression, intermittent delirium and h/o
syncope who presents s/p fall in setting of multiple recent
falls and found to have a UTI. She was evaluated by physical
therapy in the hospital. She was stable during her entire
hospital stay, but developed occassional episodes of agitation
and was upset about remaining in the hospital. Geriatric team
felt that she would do better in her home environment and was
discharged home with ___ services. Her daughter was aware and
felt comfortable with this plan.
Active issues:
.
#. s/p Multiple Falls: Patient has no noted history of baseline
dementia (has had repeated cognitive testing) but does have
recurrent/intermittent delirium per review of notes/records.
Patient also has h/o syncope and has had multiple recent falls
per patient/daughter/PCP ___. Unsure what formal evaluation
was performed for syncope in the past. Patient may have
underlying arrhythmia (cardiogenic syncope) in addition to
atrial fibrillation. History is inconsistent with orthostatic
hypotension (neurocardiogenic). Also does not sound consistent
with situational/vasovagal. The patient was monitored on
telemetry and did have 2 episodes of paroxysmal atrial
fibrillation with no sinus conversion pauses and was
asymptomatic at the time, while seated. It is conceivable that
these were the cause of previous episodes, she'll be evaluated
as an outpatient by her current cardiologist. Physical therapy
evaluated her and determined she was safe to go home with a
walker.
.
#. AMS: Patient without obvious evidence of delirium on arrival
to the floor but more formal testing not peformed though did
test immediate and remote memory. Has had a gradual decline per
PCP, but MMS exams have all been excellent. Patient with
grossly positive UA in ___ in the setting of AMS and inability to
give adequate history of symptoms. Patient received Ceftriaxone
1 gm IV in ___. The patient was switched to Bactrim DS, which
she has been tolerating well. The patient's baseline cognitive
decline is in the setting of multiple situational stressors,
thus it is most likely that these changes in mental status over
the long-term which are not explained by the acute UTI are
directly related to changes in living situation, loss of
caregiver responsibilities, husband's illness. She had a
documented episode of confusion several months that was thought
to be explained by her husband's absence. She will likely need
geriatric psychiatry at some point in the near future and to
stabilize a therapy and medication regimen to off set these
responses. She will follow up with cognitive therapy as an
outpatient
.
Inactive issues:
.
#. Hypertension: Patient hypertensive on arrival to the floor.
Continuing her medication regimen, can follow with cardiology or
her primary care physician should the need arise.
.
#. Normocytic Anemia: Patient has had colonoscopy in ___ and
negative FOBT in ___ (per Gerontology notes). Admission
hematocrit 25.8 with baseline hematocrit of ___ over recent
months. Low suspicion for ongoing bleed. She is somewhat
amenable to having further workup for this anemia, this can be
arranged as outpatient. She was guaiac negative while inpatient.
Will follow up with PCP as an outpatient.
.
#. Depression: Citalopram was previously decreased to 10 mg in
setting of confusion but was recently increased to 20 mg out of
concern for worsening depression. Patient will be discharged on
home citalopram. Will follow up with PCP.
#. Stable Angina: Patient currently chest pain free. Patient is
not on a long-acting nitrate and takes Nitroglycerin PRN.
Recent echo without CHF, significant for pulm art htn.
.
#. Atrial Fibrillation: current sinus with PACs. The patient
had no sustained rhythm changes, but she did have 2 episodes of
paroxysmal atrial fibrillation with a heart rate into the 130s
and 140s. These were isolated event, but will need further
workup as an outpatient with her cardiologist.
.
#. Vitamin D Deficiency/Hyperparathyroidism: Lab values stable,
we'll continue current outpatient regimen
.
#. GERD:
- Continue Omeprazole 20 mg PO daily
.
Transitional care:
1. CODE: DNR/DNI
2. Medication changes: stop citalopram, start/continue Bactrim
DS
3. Follow-up: PCP, ___, podiatry
4. Contact: Daughter
5. Pending studies/labs: Blood Cx x2, NGTD ___
Medications on Admission:
1. CITALOPRAM 20 mg PO daily
2. HYDROCHLOROTHIAZIDE 25 mg PO daily
3. LISINOPRIL 30 mg PO daily
4. METOPROLOL TARTRATE 50 mg PO BID
5. NITROGLYCERIN 0.4 mg SL Q5 minutes PRN chest pain
6. OMEPRAZOLE 20 mg PO once a day
7. ROSUVASTATIN 5 mg PO daily
8. ACETAMINOPHEN 500 mg PO BID PRN pain
9. ASPIRIN 81 mg PO QOD
10. CALCIUM CARBONATE-VITAMIN D3 [CALTRATE-600 PLUS VITAMIN D3]
600 mg calcium (1,500 mg)-400 unit PO BID
Discharge Medications:
1. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
2. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day.
4. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO every other day.
7. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit
Capsule Sig: One (1) Capsule PO twice a day.
8. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO twice a
day as needed for pain or fever.
9. citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual once a day: as directed.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
1) urinary tract infection
2) altered mental status
3) paroxysmal atrial fibrillation
Secondary:
1) high blood pressure
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 ___:
It was a pleasure taking care of you in the hospital; you were
seen due to a change in your mental status which was determined
to be a urinary tract infection on laboratory results. During
your stay you were evaluated by a team of primary medical
doctors and physical ___. Your started on an antibiotic
and your urinary symptoms improved. Please be sure to walk with
your walker at home because you have fallen at home before.
There were no changes to your medications.
Please be sure to keep your primary care appointment this week.
Followup Instructions:
___
|
10660679-DS-7
| 10,660,679 | 25,423,116 |
DS
| 7 |
2189-01-02 00:00:00
|
2189-01-03 13:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Subdural hematoma
Major Surgical or Invasive Procedure:
IVC Filter placement
History of Present Illness:
This is an ___ gentleman with a history of Afib on
Coumadin, recent b/l PE on Lovenox bridging to Coumadin,
Alzheimer's dementia, and unsteady gait who presents s/p fall
with OSH head CT showing 4mm SDH. Patient reports slipping in
the bathroom the night prior to admission, falling and hitting
his head. He was brought to ___ where a head CT was
done, showing a R SDH, 10 of Vit K was administered for an INR
2.2 and then he was transferred to ___ for further management.
.
Patient reports that he does fall but cannot say exactly how
often. He denies symptoms of dizziness, lightheadedness, vision
changes, palpatations or other symptoms prior to fall. He denies
LOC, loss of bladder or bowel control. Patient denies fevers,
chills, dysuria, hematuria, diarrhea, cough, SOB, N/V, recentl
immobility or chest pain.
.
Of note, patient was recently admitted on ___ for
bilateral PE's, aspiration PNA, and COPD exacerbation. He was
discharged on Vancomycin and Ceftriaxone (7 day course) and
Lovenox ___ QD with Coumadin bridge. (goal for 6 months)
.
Initial VS in the ED: 98.1 81 155/78 15 100%RA Exam notable for
R eye ecchymosis. Labs notable for WBC 17.2 (87.6% Polys), INR
1.8. UA negative. Patient was given 1 Unit of FFP. FAST exam
negative for occult bleeds. Patient was seen by neurosurgery who
determined that the subdural hemorrhage seen on CT is most
likely subacute and would recommended holding anticoagulation
for 1 month before f/u in clinic.
Past Medical History:
1. H/O sepsis with aspiration pneumonia (one in ___ and then
in ___ and hypoxia.
2. H/O Afib
3. H/O metabolic encephalopathy
4. COPD
5. Facial fracture post syncopal event
6. Alzheimer's dementia
7. Unsteady gait
8. Spinal stenosis
9. Arthritis
10. CHF
11. Hypertension
12. Chronic mastoiditis
Social History:
___
Family History:
Sister had cancer, family not sure what kind.
Physical Exam:
Admission Physical Exam:
Vitals: T:97.4 BP:134/68 P:64 R:17 O2: 96%RA
General: Patient was lying in bed, appeared tired, NAD
SKIN:ecchymosis over right forehead, swelling over right
eyebrow.
HEENT: dried blood around nares, not actively bleeding, no blood
noted in ear canals. No battle sign or racoon eyes. Sclera
anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: cool, no clubbing 2+ pulses.
Neuro:
CNII: PERRL, visual fields intact
CNIII, IV, VI: EOMI
CNV: intact
CNVII: right facial droop (unclear if chronic or acute)
CNVIII: decreased hearing bilaterally, chronic
CNIX-CNX: intact
CNXI: SCM ___
CNXII: tongue midline
Motor: atrophic throughout. Upper extremities: Left- biceps,
triceps, intrinsics ___. Right-unable to abduct arm, but
strength intact after passive motion. biceps, triceps,
intrinsics ___.
Sensation: decreased proprioception of lower extremities
Reflex: 1+ throughout.
Gait: unbalanced
MSK: decreased AROM about right shoulder (pt has history of
rotator cuff tear)
Discharge physical exam:
Vitals: T:98.9 BP:124/73 P:80 R:20 O2: 98% RA
General: Patient was lying in bed, appeared tired, NAD
SKIN:ecchymosis over right forehead, swelling over right
eyebrow.
HEENT: dried blood around nares, not actively bleeding, no blood
noted in ear canals. No battle sign or racoon eyes. Sclera
anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: WWP, no clubbing 2+ pulses.
Neuro:
CNII: PERRL, visual fields intact
CNIII, IV, VI: EOMI
CNV: intact
CNVII: right facial droop (unclear if chronic or acute)
CNVIII: decreased hearing bilaterally, chronic
CNIX-CNX: intact
CNXI: SCM ___
CNXII: tongue midline
Motor: atrophic throughout. Upper extremities: Left- biceps,
triceps, intrinsics ___. Right-unable to abduct arm, but
strength intact after passive motion. biceps, triceps,
intrinsics ___.
Sensation: decreased proprioception of lower extremities
Reflex: 1+ throughout.
MSK: decreased AROM about right shoulder (pt has history of
rotator cuff tear)
Pertinent Results:
___ 09:20AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 05:55AM GLUCOSE-89 UREA N-20 CREAT-0.9 SODIUM-140
POTASSIUM-5.0 CHLORIDE-104 TOTAL CO2-24 ANION GAP-17
___ 05:55AM WBC-17.2* RBC-4.18* HGB-11.6* HCT-38.5*
MCV-92 MCH-27.8 MCHC-30.2* RDW-16.0*
___ 05:55AM NEUTS-87.6* LYMPHS-7.8* MONOS-2.5 EOS-1.8
BASOS-0.3
___ 05:55AM PLT COUNT-219
___ 05:55AM ___ PTT-29.5 ___
___ 06:49AM BLOOD WBC-8.1 RBC-3.59* Hgb-10.2* Hct-34.0*
MCV-95 MCH-28.5 MCHC-30.0* RDW-16.2* Plt ___
___ 06:49AM BLOOD Glucose-132* UreaN-29* Creat-0.8 Na-140
K-4.6 Cl-104 HCO3-23 AnGap-18
___ 06:49AM BLOOD Calcium-8.2* Phos-3.5 Mg-2.1
___: Video Oropharyngeal swallow: One episode of
penetration and trace aspiration with consecutive thin liquids
which the patient self cleared. Please see the speech and
swallow note in OMR for further details.
___: Bilateral Lower Extremities Dopplers: Nonocclusive
thrombus is seen at the confluence of the left deep femoral vein
and femoral vein. No DVT is seen in the left common femoral
vein. No DVT is seen in the veins of the right leg.
___: IVC Gram/Filter placement: Patent IVC without
evidence of thrombosis. Optease permanent IVC filter placement
infrarenally.
___: Head CT
Unchanged size of right subdural hematoma, but increased
attenuation
concerning for acuity. A repeat head CT is recommended in six
hours given the patient's change in mental status.
___: Repeat head CT in 6 hours
IMPRESSION: Stable appearance of right frontal subdural
hematoma. Continued follow-up imaging to be predicated on
clinical status.
NOTE ADDED IN ATTENDING REVIEW: The small right frontovertex
subdural hematoma is not significantly changed in size over the
intervening more than 2 days, with no change in the slight
degree of mass effect. The increase in attenuation may simply
reflect further organization, as the original hematoma
demonstrated a blood/fluid level. There is no new hemorrhage.
Brief Hospital Course:
This is a ___ gentleman with hx of Alzheimer's dementia,
unsteady gait, AFib on Coumadin, recent bilaterally PE on
Lovenox, and CHF who presents s/p fall with leukocytosis of 17.8
and head CT showing 4mm subdural hemorrhage.
.
ACUTE ISSUES
# Fall, Ataxic gait: The patient's fall was most likely
mechanical given history and his risk factors including
Alzheimer's and unsteady gait. However, given patient's
extensive history of aspiration PNA c/b sepsis, Afib, and CHF,
other causes for syncope needed to be ruled out. Patient did
have a leukocytosis of 17.8 with (87.6% polys). Patient's CXR
does not show evidence of acute process and UA was negative for
infection. Blood and urine culture were sent to rule out
systemic infection but are negative to date. Patient's
leukocytosis was likely a result of his recent high dose steroid
use and recent c.diff infection. His WBC trended down toward
normal during hospitalization. Patient had no evidence of
orthostatic hypotension and no evidence of ischemia on EKG. He
was seen by physical therapy who recommended rehab after
discharge to balance and mobility issues.
.
# SUBDURAL HEMATOMA: It is unclear whether the subdural
hemorrhage is from the patient's most recent fall or prior
injuries. Patient was seen by neurosurgery in the ED and the
___ was thought to be subacute on imaging. Patient's INR on
admission was 2.8 and he was given 2 doses of Vitamin K and one
unit of FFP. Patient's anticoagulation was held as well and his
INR decreased to 1.0 at discharge. On ___, the family
noticed increased slurred speech. Two head CTs done 6 hours
apart on ___ showed a stable (if not improving) bleed. His
slurred speech subsuquently improved. Patient's mental status
remained stable during hospitalization. He will follow up with
neurosurgery in 1 month.
.
# RECENT BILATERAL PULMONARY EMBOLISM: Given patient's recent
history of bilateral pulmonary embolism during his admission on
___, a lower extremity doppler was done to evaluate for
the presence of DVT. He was found to have a thrombus at the
confluence of the left deep femoral vein and femoral vein. A
permanent IVC filter was placed due to contraindications to
anticoagulation. Please follow up with neurosurgery in 1 month
regarding restarting your anticoagulation.
.
# RIGHT FACIAL DROOP: The patient's facial droop was new
according to his wife. It is possible that his lack of ability
to lift his lips and eyebrows on the right side is due to the
swelling of his right face after the fall. There was no evidence
of intraparenchymal hemorrhage in CT. Patient's right facial
droop improved throughout hospitalization as the swelling
decreased.
.
# ATRIAL FIBRILLATION: Patient was on Coumadin on admission,
which was held due to the presence of the subdural hemorrhage.
Patient was monitored on telemetry and was discovered to be
intermittently in and out of AFib. He was asymptomatic and was
well rate controlled.
.
CHRONIC ISSUES:
# ALZHEIMER'S DEMENTIA: Patient's mental status is at baseline.
He was continued on home Memantine.
.
# COPD: Patient satting 100% on RA. Continued on home regimen
of Spiriva and Advair. Was continued on Albuterol/Ipratropirum
albuterol Q6H PRN and Prednisone taper from prior admission.
TRANSITIONAL ISSUES:
Subdural hematoma. Will have follow up with neurosurgery as
scheduled in 3 weeks to assess stability of fluid collection,
and assessability to restart anticoagulation.
Medications on Admission:
- Prednisone 60mg taper, currently 30mg
- Albuterol/Ipratropium nebs Q6H PRN
- Bactracin 500U BID
- Carvedilol 3.125mg BID
- Fluticasone BID
- Simvastatin 10mg QD
- Gabapentin 100mg QD
- Aspirin 81mg QD
- Memantine 10mg BID
- Multivitamins 1 Tab QD
- Vitamin D 1000 U QD
- Magnesium Hydroxide 10mL QD
- Lactobacillus 2Tabs Daily
- Lovenox ___ SC QD
- Oyster Shell Calcium 500mg BID
- Spiriva 1 puff QD
- Warfarin 5mg PO QD
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
3. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. memantine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
10. ipratropium-albuterol ___ mcg/actuation Aerosol Sig: ___
Puffs Inhalation Q6H (every 6 hours) as needed for SOB.
11. magnesium hydroxide 2,400 mg/10 mL Suspension Sig: One (1)
PO once a day.
12. lactobacillus acidoph & bulgar 1 million cell Tablet Sig:
Two (2) Tablet PO once a day.
13. prednisone 10 mg Tablet Sig: As directed Tablet PO once a
day for 4 days: Prednisone taper for COPD. Take 20mg on ___
and ___. Take 10mg on ___ and ___.
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
--Subdural Hemorrhage
--Deep Venous Thrombosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure being involved in your care. You were
admitted because of a fall. You had a CT scan of your head at
___, which showed a small amount of bleeding in your
brain. You were evaluated by neurosurgeons at ___
___ and it was determined that the bleed is most
likely not an acute process. Repeat CT scans of your head
showed that the bleeding was stable. Your blood thinning
medications were stopped to prevent further bleeding. You will
need to follow up with the neurosurgeons in 1 month.
.
You had an image of your legs done to look for any clots given
your recent hospitalization for clots in your lungs. You were
found to have a clot in the left leg. You underwent a procedure
where a filter is placed in the large vein that drains into your
heart to prevent the clot from traveling to your lungs.
.
Please continue your home medications with the following
changes:
--STOP Coumadin 5mg
--STOP Lovenox ___
--STOP Aspirin 81mg
--Increase gabapentin to 100mg three times a day for pain
Followup Instructions:
___
|
10660679-DS-8
| 10,660,679 | 20,291,739 |
DS
| 8 |
2191-08-29 00:00:00
|
2191-08-30 06:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fall, hip fracture
Major Surgical or Invasive Procedure:
Intertrochanteric Hip Fracture s/p R TFN ___
Intubation/Extubation
History of Present Illness:
HISTORY OF PRESENT ILLNESS: ___ with Alzheimer's, HTN, COPD, a
fib (no anticoag), CHF, who is transferred from OSH with right
hip fracture, per report. Per transferring hospital ___),
patient had fall at nursing facility last night. Circumstances
surrounding the fall are unclear; no documented history provided
by nursing facility, and patient unable to give history. Initial
evaluation at ___ revealed right hip fracture and right middle
and lower lobe
pneumonias, and patient was transferred to ___. CT head and neck
at OSH were negative.
In the ED initial vitals were: 98.6 88 132/61 14 96% 4L
- Labs were significant for Trop-T: <0.01, Lactate:1.5, h/h
12.9, 38.8, ___ ct 11
- Patient was given CeftriaXONE 1 gm
Vitals prior to transfer were: 104 111/60 19 95% Nasal Cannula
Past Medical History:
1. H/O sepsis with aspiration pneumonia (one in ___ and then
in ___ and hypoxia.
2. H/O Afib
3. H/O metabolic encephalopathy
4. COPD
5. Facial fracture post syncopal event
6. Alzheimer's dementia
7. Unsteady gait
8. Spinal stenosis
9. Arthritis
10. CHF
11. Hypertension
12. Chronic mastoiditis
Social History:
___
Family History:
Sister had cancer, family not sure what kind.
Physical Exam:
Admission PHYSICAL EXAM:
Vitals - 97.3 125/72 91 18 97% 3L
GENERAL: NAD, hard of hearing, Oriented to name; thought he was
in ___, and the date was ___
HEENT: AT/NC, EOMI, PERRL, anicteric sclera
NECK: no JVD elevation
CARDIAC: soft heart sounds, RRR, S1/S2, no m/r/g
LUNG: crackles heard at lower ___ lungspaces bilaterally,
breathing comfortably without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no pitting edema in extremities bilaterally, moving
all 4 extremities with purpose
PULSES: ___ pulses heard well on Doppler
NEURO: CN II-XII intact, full strength in LUE/RUE/LLE, unable to
move hip flexors in RLE but full strength otherwise distally,
sensation intact bilaterally
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge Physical Exam:
Vitals- 97.8 (97.9) 115/54 (115-125/54-61) 74 (74-76) 19
96% RA
General- NAD, frail, Alert and oriented to self and place
(hospital), does not know what year it is.
HEENT- MMM
Lungs- Clear lungs, no prolonged expiratory phase, slight
decreased breath sounds in left lung base. No accessory muscle
use or tachypnea.
CV- RRR, no m/r/g
Abdomen- Soft, NT/ND
GU- Condom cath draining yellow urine
Ext- WWP, no edema, decreased ROM of right shoulder
Right Hip: Unable to elevate thigh off of bed, but strength ___
in lower leg, incision c/d/i, staples in place, well
approximated
Neuro- Moving all extremities, speaking in full sentences, not
oriented to time/date but oriented to place (hospital). Long
term memory and attention intact. Pleasant, Fluent speech, but
does not speak much unless asked discrete questions
necessitating long answer.
Pertinent Results:
Labs On Admission:
==============
___ 05:07AM LACTATE-1.5 K+-4.5
___ 05:00AM GLUCOSE-147* UREA N-23* CREAT-0.9 SODIUM-135
POTASSIUM-7.9* CHLORIDE-104 TOTAL CO2-24 ANION GAP-15
___ 05:00AM cTropnT-<0.01
___ 05:00AM WBC-11.0 RBC-4.46* HGB-12.9*# HCT-38.8*
MCV-87# MCH-29.0 MCHC-33.3# RDW-15.4
___ 05:00AM NEUTS-89.8* LYMPHS-5.6* MONOS-4.0 EOS-0.5
BASOS-0.1
___ 05:00AM ___ PTT-28.7 ___
___ 05:00AM PLT COUNT-160
Discharge Labs:
=================================
___ 06:23AM BLOOD WBC-8.7# RBC-4.07* Hgb-11.8* Hct-36.2*
MCV-89 MCH-29.0 MCHC-32.5 RDW-15.1 Plt ___
___ 06:23AM BLOOD Glucose-86 UreaN-21* Creat-0.7 Na-139
K-3.4 Cl-99 HCO3-32 AnGap-11
___ 06:23AM BLOOD Calcium-7.9* Phos-2.6* Mg-1.9
MICROBIOLOGY:
==============
___ 5:00 am BLOOD CULTURE NEGATIVE
___ 5:00 am BLOOD CULTURE NEGATIVe
___ 6:57 am URINE CULTURE NEGATIVE
STUDIES:
==============
HIP 1 VIEW Study Date of ___ 5:27 AM
IMPRESSION:
Improved positioning right proximal femoral intertrochanteric
fracture with traction
CHEST (PORTABLE AP) Study Date of ___ 10:21 AM
IMPRESSION:
No significant interval change in right middle lobe airspace
opacity which could be compatible with pneumonia in the
appropriate clinical setting.
ABDOMEN (SUPINE & ERECT) PORT Study Date of ___ 2:59 ___
IMPRESSION:
1. No evidence of obstruction or perforation.
2. Severe degenerative changes of the lumbar and thoracic spine.
LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R. Study Date of
___ 1:55 ___
FINDINGS:
6 fluoroscopic spot views, obtained without a radiologist
present, demonstrate placement of a gamma nail construct at the
proximal right femur, fixating the intertrochanteric fracture.
Surgical clips are seen in the right hemipelvis. The total
fluoroscopic time was 74 seconds. For further details, please
see the operative report in the ___ medical record.
HIP UNILAT MIN 2 VIEWS IN O.R. RIGHT Study Date of ___
1:55 ___
FINDINGS:
6 fluoroscopic spot views, obtained without a radiologist
present, demonstrate placement of a gamma nail construct at the
proximal right femur, fixating the intertrochanteric fracture.
Surgical clips are seen in the right hemipelvis. The total
fluoroscopic time was 74 seconds. For further details, please
see the operative report in the ___ medical record.
CHEST (PORTABLE AP) Study Date of ___ 10:10 ___
IMPRESSION:
Mild pulmonary edema is new. Heterogeneous consolidation in the
right lung is concerning for concurrent pneumonia. Pleural
effusions are small. Heart size is normal. Mediastinal
vascular congestion is mild.
Portable TTE (Complete) Done ___ at 10:51:40 AM FINAL
Non-diagnostic study due to very poor image quality. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function appears normal (LVEF>55%). The right ventricular cavity
is dilated but funciton cannot be assessed. The aortic valve is
not well seen. The mitral valve leaflets are not well seen.
There is no pericardial effusion.
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of ___
5:02 AM
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Small bilateral pleural effusions. Ground-glass opacities in
the lungs bilaterally may represent mild pulmonary edema however
some of this is explained by breathing artifact.
3. Bilateral atelectasis, please note that superinfection
cannot be excluded
4. Pleural thickening on the right with calcifications are
suggestive of a benign etiology such as a sequela of prior are
inflammation, infection or hemothorax
5. Pulmonary artery hypertension
6. 11 mm left thyroid nodule. Further evaluation with ultrasound
could be
considered
7. Small hiatal hernia with esophageal wall thickening likely
due to
esophagitis. This could be further evaluated with barium swallow
if clinically indicated
CXR ___:
Heart size and mediastinum are unchanged in appearance.
Bilateral, right more than left pleural effusion is noted. There
is interval resolution of
interstitial pulmonary edema. No increase in pleural effusion or
evelopment of pneumothorax or new consolidations demonstrated
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
===================================================
___ with Alzheimer's, HTN, COPD, afib (not on anticoagulation
___nd prior SDH), ___, who was transferred
from OSH with right intertrochanteric hip fracture and HCAP
pneumonia. Orthopedics peformed operative repair w/ trochanteric
nail on ___, was started on lovenox post procedure (for ___nding ___. He will need to attend outpatient
appt on ___ to have staples removed and hip examined. Until
then, was rec'd to be weight bearing as tolerated w/ physical
therapy. Post-operatively, pt desaturated so was re-intubated,
then had brief MICU course, where hypoxia was felt to be ___
pulmonary edema ___ decompensated dCHF) and COPD exacerbation.
He was then diuresed and treated w/ 5 day course of steroids,
which allowed him to breathe comfortably on room air. He also
completed course of antibiotics for HCAP. Hospitalization also
complicated by pAFIB w/ RVR, treated briefly w/ Digoxin given
hypotension to SBP of ___, then transitioned to metoprolol when
he converted back into sinus rhythm. Coreg was held given soft
pressures when rates were fast. Pt's
seroquel/sertraline/trazodone were held and patient remained
euthymic during hospitalization. Pt was discharged in stable
condition, asymptomatic.
#AFib: Known history. Had been in SR until transfer to MICU. C/b
hypotension. Suspect this was in the setting of ongoing volume
overload. He converted to sinus after being loaded with digoxin.
Since he does not have sCHF and due to his age predisposing him
to high risk for toxicity, digoxin was discontinued, and patient
was continued on low dose BB. His home carvedilol, which would
predispose him to hypotension, was replaced by low dose
metoprolol, which can be titrated as needed for rate control
with less effect on BPs. CHADS2 =3 but previously had a subdural
hematoma, so currently not on anticoagulation. As per
cardiology, Aspirin 325 mg qd was started. Aspirin may increase
toxicity of Depakote, so please look out for ataxia, drowsiness,
nystagmus, tremor, and decrease depakote if such reactions
occur.
# Hypoxemia: Admitted at baseline home oxygen requirement. CTA
negative for PE. Admission complicated by possible pna, COPD
exacerbation, and volume overload. See management of various
problems as below. Upon discharge, after completion of 5-day
steroid course and diuresis, patient breathing comfortably on
room air.
# COPD exacerbation: History of COPD with home O2 requirement of
___ L via nasal cannula. Increase in O2 requirement and
wheezing found on ___ AM, thought to be COPD exacerbation.
Treated with a 5-day steroid course (finished on ___, and
given albuterol nebulizers and ipratropium nebs.
# Consolidations on CXR: Patient noted to have question of
pneumonia on CXR. Has been afebrile, no leukocytosis. Initially
treated with flagyl/levaquin (also protecting for aspiration),
but then in ICU, treated with vancomycin and zosyn, then
transitioned to levaquin. CTA from ___ showed focal areas of
consolidation in the dependent portions of the left upper lobe,
right upper lobe and the lower lobes bilaterally, suggestive of
atelectasis - less likely infection. Levaquin stopped on ___
after 7d of total treatment.
# Diastolic heart failure: TTE poor study, EF 55%. With new
pleural effusions on CXR and on exam. Although he is on his home
O2 requirement, suspect that he remains volume overloaded, 7 kg
above admission weight in the setting of volume resuscitation
post-op and when transferred to the MICU for AF and hypotension.
After receiving diuresis with iv lasix, patient's hypoxia
improved remarkably as he was found to be satting well on room
air.
# s/p ORIF and intertrochanteric nail on ___. Pain well
controlled with APAP. Will avoid giving narcotic medication to
avoid depression respiratory effort/delirium. Per Ortho, weight
bearing as tolerated. Enoxaparin for DVT prophylaxis x2 weeks
(ending ___ until ortho f/u. Pt will need to be seen by
orthopedics on ___ to have hip examined and staples removed,
and will need to continue physical therapy, weight bearing as
tolerated in order to regain his functional status.
# Alzheimers dementia: polypharmacy may have contributed to his
fall. Seroquel/sertraline/trazodone stopped, while
memantine/depakote/donepezil continued. Will defer additional
adjustments to his outpt dementia providers.
# Hyperlipidemia: continued on home statin.
Transitional Issues:
=========================================
1. CTA showed 11 mm left thyroid nodule. Further evaluation with
ultrasound could be considered. CTA also showed small hiatal
hernia with esophageal wall thickening likely due to
esophagitis. This could be further evaluated with barium swallow
if clinically indicated
2. Pt will need to continue lovenox for DVT prophylaxis for ___nding ___.
3. Pt will need to be seen by orthopedics on ___ to have hip
examined and staples removed.
4. Pt will need to continue physical therapy, weight bearing as
tolerated in order to regain his functional status.
5. Pt was started on full dose ASA as stroke ppx given pAFIB.
Aspirin may increase toxicity of Depakote, so please look out
for ataxia, drowsiness, nystagmus, tremor, and decrease depakote
if such reactions occur.
6. Pt was switched from carvedilol to metoprolol to prevent
hypotension.
7. Seroquel, sertraline, and trazodone were held during
hospitalization and patient remained euthymic. Accordingly,
would not recommend that they be restarted.
# Communication: HCP: ___, daughter (___)
# Code: DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral twice daily
2. Memantine 10 mg PO BID
3. Tiotropium Bromide 1 CAP IH DAILY
4. Multivitamins 1 TAB PO DAILY
5. Carvedilol 3.125 mg PO BID
6. Vitamin D 1000 UNIT PO DAILY
7. Donepezil 10 mg PO QHS
8. Simvastatin 10 mg PO QPM
9. Acetaminophen 650 mg PO Q4-6:PRN pain/fever
10. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB/wheezing
11. Bisacodyl ___AILY:PRN constipation
12. Fleet Enema ___AILY:PRN constipation
13. Milk of Magnesia 30 mL PO QHS:PRN constipation
14. vitamin A and D 1 PAK TOP topical three times daily
15. Furosemide 20 mg PO DAILY
16. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation twice daily
17. Divalproex (DELayed Release) 250 mg PO BID
18. Potassium Chloride 10 mEq PO DAILY
19. TraZODone 50 mg PO Q4H:PRN agitation
20. Sertraline 25 mg PO DAILY
21. QUEtiapine Fumarate 25 mg PO BID
22. Guaifenesin-Dextromethorphan 10 mL PO Q4H:PRN cough
Discharge Medications:
1. Acetaminophen 650 mg PO Q4-6:PRN pain/fever
2. Bisacodyl ___AILY:PRN constipation
3. Donepezil 10 mg PO QHS
4. Fleet Enema ___AILY:PRN constipation
5. Furosemide 20 mg PO DAILY
6. Guaifenesin-Dextromethorphan 10 mL PO Q4H:PRN cough
7. Memantine 10 mg PO BID
8. Milk of Magnesia 30 mL PO QHS:PRN constipation
9. Multivitamins 1 TAB PO DAILY
10. Potassium Chloride 10 mEq PO DAILY
11. Simvastatin 10 mg PO QPM
12. Vitamin D 1000 UNIT PO DAILY
13. Divalproex (DELayed Release) 250 mg PO BID
14. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION TWICE DAILY
15. Tiotropium Bromide 1 CAP IH DAILY
16. vitamin A and D 1 PAK TOP topical three times daily
17. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB/wheezing
18. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral twice daily
19. Docusate Sodium 100 mg PO BID
20. Senna 17.2 mg PO HS
21. Aspirin 325 mg PO DAILY
22. Metoprolol Succinate XL 25 mg PO DAILY
23. Enoxaparin Sodium 40 mg SC QHS
Start: Today - ___, First Dose: Next Routine Administration
Time
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Intertrochanteric Hip Fracture s/p R TFN ___
COPD exacerbation
HCAP Pneumonia
Pasroxysmal Atrial Fibrillation w/ RVR
Pulmonary Edema
Discharge Condition:
Discharge Condition: Stable/improved
Mental Status: Intact attention, long term memory, poor short
term recall, unable to correctly identify date/time. At baseline
as per discussion w. daugther and trending over several days.
Ambulatory Status at Discharge: Requires assistance for bed
mobility, transfers
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you while you were hospitalized
at ___. As you know, you were
admitted after a fall and were found to have a hip fracture.
Fortunately, you had a successful surgery to fix it. You will
need to be on blood thinning medication for several more days
and will need to be seen by orthopedics in 1 more week to ensure
you are healing appropriately.
During your hospitalization, your breathing worsened for some
time, which was likely due to your asbestos exposure in the
past. Fortunately, you responded well to treatment and were
weaned off of oxygen.
We wish you a speedy recovery!!!
Followup Instructions:
___
|
10661182-DS-7
| 10,661,182 | 20,942,024 |
DS
| 7 |
2178-02-11 00:00:00
|
2178-02-12 22:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Compazine / Topamax / Latex
Attending: ___.
Chief Complaint:
Epigastric pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Briefly, this is ___ year old female with history of radiologic
SMA syndrome and uncontrolled esophageal reflux/GERD presenting
with 72 hours of constant epigastric pain. She is followed by
Dr. ___ at ___. She had previously been well-controlled
with her outpt med regimen for past 6 months (nexium, nifedipine
and zantac). She reports to the ___ after trying her usual
treatment for epigastric pain consisting of nifedipine + nitro
without any success. This episode is reportedly different than
prior episodes as she has no nausea or vomiting. She describes
the epigastric pain as "squeezing" and non-radiating. She had
called Dr. ___ advised ___ for symptom control. Last EGD
showed a small hiatal hernia and colonoscopy was normal in ___,
while barium swallow with small bowel follow through was
negative in ___.
she was last seen by her PCP ___ ___ and complained of
continued weight loss and migraines c/b increased stress
surrounding her ex-husband and issues of child support. She
reports that for about 10 days a month around her menses she has
decreased po intake.
In the ___, initial VS: 97.7 74 125/56 16 100% RA. He was given
ondansetron 4mg, morphine 5 mg x4, ASA 325mg, Aluminum-Magnesium
Hydrox.-Simethicone 30 mL + Lidocaine Viscous 2% with minimal
improvement of pain. Troponin negative and EKG was unreamrkable.
On the floor, she contniues to have ___ epigastric pain.
Otherwise she appears comfortable
Past Medical History:
- Superior mesenteric artery syndrome, diagnosed in ___
in ___, has since had several attacks requiring
hospitalization (most recently ___, improved w/ bowel
rest). Followed by Dr. ___.
- GERD with esophageal spasm
- Hyperthyroidism now resolved. U/S ___ showed no significant
change of bilateral thyroid nodules.
- Anxiety; sees psychologist weekly
- migraine HAs sincs childhood
- G4P1, NSVD no pregnancy problems with son
- h/o dysmenorrhea, menorrhagia
- h/o abnormal pap smear, last pap in ___ normal
- IBS
- fibroids
- ankle reconstruction surgery age ___
- surgery for hammer toe
- laparoscopic appendectomy ___
Social History:
___
Family History:
-Father ___ D2M, hyperlipidemia, htn, nephrolithiasis, OA, elev
PSA.
-Mother ___ thyroid Hurthle cell tumor, htn, hyperlipidemia,
IBS, GERD, anxiety, osteoporosis, COPD, sleep apnea, RLS,
obesity, migraines, melanoma.
-GMs - heart disease (PGM had breast CA when elderly)
-MGF died of MI in ___. EtOH, head/neck cancer.
-PGF died @ ___ from multiply myeloma, blind, osteoporosis
-sister: ___ abuse
Physical Exam:
Physical Exam on admission and discharge:
GENERAL - well-appearing in NAD, thin appearing, comfortable
HEENT - sclerae anicteric, dry mucous memebranes, OP clear
NECK - supple, no thyromegaly appreciated
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, tenderness to palpation in the epigastric
region, no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, muscle strength ___ throughout
Pertinent Results:
Labs on admission:
___ 10:48PM BLOOD WBC-7.3 RBC-4.03* Hgb-12.4 Hct-37.0
MCV-92 MCH-30.8 MCHC-33.6 RDW-13.3 Plt ___
___ 10:48PM BLOOD Neuts-49.2* Lymphs-44.7* Monos-3.5
Eos-1.6 Baso-1.1
___ 10:48PM BLOOD Glucose-94 UreaN-17 Creat-0.7 Na-138
K-3.8 Cl-102 HCO3-30 AnGap-10
___ 10:48PM BLOOD ALT-16 AST-13 LD(LDH)-161 AlkPhos-59
TotBili-0.1
___ 10:30AM BLOOD cTropnT-<0.01
___ 10:48PM BLOOD cTropnT-<0.01
___ 05:52PM URINE UCG-NEGATIVE
Labs on discharge:
none
Imaging:
CXR ___:
IMPRESSION:
1. The lungs remain well inflated without evidence of focal
airspace
consolidation, pleural effusions, pneumothorax, or pulmonary
edema. Overall, the cardiac and mediastinal contours appear
stable.
Brief Hospital Course:
___ year old female with history of SMA syndrome and GERD c/b
esophageal spasms who presents with 3 days of intermittent
epigastric pain not resolved with nifedipine and nitroglycerin.
Active Issues:
# Epigastric pain: The location of the pain (epigastric) was
similar in location to prior episodes, although she notes that
there is no nausea or vomiting with this presentation.
Differential included uncontrolled GERD, esophageal spasm,
recurrence of SMA syndrome, pulmonary processes or cadiac
ischemia. Cardiac causes of the pain were felt to be unlikely
given negative troponin x 2, normal EKG and lack of improvement
with morphine/nitro. CXR was clear making a pulmonary process
less likely. The fact that she had no nausea or vomiting makes
SMA syndrome unlikely. Previous EGD, colonoscopy and barium
swallow with follow through were all non-conclusive.
Pt was trialed on diltiazem on the first day of
hospitalization. Pt was extremely frustrated with the lack of
improvement of the epigastric pain after two doses of diltiazem.
Pt was then given 1 gm of IV tylenol without relief of her
pain. She was then started on po morphine with a reduction in
her pain scale from an 8 to a 3. At the time of the discharge
the following day her pain was much better controlled and she
was discharged witohut any narcotics.
Inactive Issues:
# Migraines: Recent headaches likely exacerbated by stress. No
concern for neurologic causes of headache. she was continued on
Fioricet prn.
# Anxiety/depression: continued lexapro.
Transitional Issues:
-Pt would likely benefit from esophageal manometry as an
outpatient to investigate esophageal dysmotility syndromes as a
cause of her epigastric pain
-she will follow-up with Gyn as an outpatient as previously
scheduled to investigate if a gynecological process could be the
underlying etiology of her pain, such as endometriosis.
-Pt was full code for this admission
Medications on Admission:
FIORICET 50 mg-325 mg-40 mg, ___ Tablet(s) q6h PRN
ESCITALOPRAM [LEXAPRO] 10 mg daily
ESOMEPRAZOLE MAGNESIUM [NEXIUM] 80 mg BID
HYOSCYAMINE SULFATE [HYOMAX-SL] 0.125 mg daily
NIFEDIPINE 10 mg Ccpsule - 6 drops sl PRN abdominal pain
PROMETHAZINE 6.25 mg TID PRN nausea
RANITIDINE HCL 150 mg Tablet - 3 Tablet(s) by mouth q AM, 4 q ___
SUCRALFATE 1 gram/10 mL Suspension - 2 tsp by mouth QID PRN
SUMATRIPTAN SUCCINATE 50 mg PRN
TRETINOIN 0.025 % Cream PRN acne
Discharge Medications:
1. Fioricet 50-325-40 mg Tablet Sig: ___ Tablets PO every six
(6) hours as needed for headache.
2. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. esomeprazole magnesium 40 mg Capsule, Delayed Release(E.C.)
Sig: Two (2) Capsule, Delayed Release(E.C.) PO twice a day.
4. hyoscyamine sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual DAILY (Daily).
5. nifedipine 10 mg Capsule Sig: Six (6) drops PO sl as needed
for abdominal pain.
6. promethazine 12.5 mg Tablet Sig: ___ Tablet PO every six (6)
hours as needed for nausea.
7. ranitidine HCl 150 mg Tablet Sig: 1.5 Tablets PO QAM (once a
day (in the morning)).
8. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
9. sucralfate 1 gram Tablet Sig: Two (2) tbsp PO QID (4 times a
day) as needed for indigestion.
10. sumatriptan succinate 50 mg Tablet Sig: One (1) Tablet PO
once a day as needed for nausea.
11. tretinoin 0.025 % Cream Sig: One (1) Topical once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Abdominal Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was a pleasure taking care of you during your
hospitalization at ___. You
were admitted with abdominal pain. We are not sure what causes
this pain, but it may be related to an esophageal spasm that is
best treated with your home medications nifedipine and
nitroglycerin.
We also gave you a few doses of morphine that was helpful to
bring the pain under control, but generally this medication does
not treat this type of pain well in the long-term.
You should follow up with Dr. ___ your primary care
physician ___ the next two weeks
NO MEDICATIONS WERE CHANGED DURING THIS ADMISSION
Followup Instructions:
___
|
10661237-DS-35
| 10,661,237 | 22,879,807 |
DS
| 35 |
2131-06-28 00:00:00
|
2131-06-28 20:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Keflex / Oxycodone / morphine / vancomycin / vitamin B12 /
ceftriaxone
Attending: ___.
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
Femoral central line placement on ___
Femoral central line removal on ___
History of Present Illness:
Ms. ___ is an ___ with PMH of ESRD on HD with LUE fistula
since ___, history of HTN, AF, GERD, RA, C diff colitis ___
who presents with weakness and hypotension. Patient was at an
appointment today for routine fistula evaluation. She was found
to be hypotensive to the ___ at that appointment, associated
with some generalized weakness and lightheadedness. The patient
did complain, per report of chest pain and palpitations. She
denied headache, LOC, abdominal pain, flank pain, melena,
hemotochezia. She denies cough, diarrhea. She only makes scant
amount of urine, has noted some hematuria. She was referred to
___ ED for further evaluation. Per her husband's report,
patient is usually aware of her surroundings and names, but not
aware of date. Her husband notes no other new symptoms other
than lightheadedness, apparently felt as though she would pass
out at breakfast on the AM of presentation.
In the ED, initial vitals: 97.1 73 61/36 18 98% RA
- Exam notable for: speaks in full sentence , saying she feels
she will pass out, HEENT: moist mucous membranes, Lung: cta,
___: rrr, no murmur, Abdomen: obese, soft, non tender, normal
bowel sounds, LL: no ankle edema or calf swelling or tenderness
- Labs notable for: K 5.4, Cr 6.2, normal CBC, LFTs, lipase 94,
trop 0.05, lactate 2.6 -> 1.4
- Imaging notable for: CTA chest with no e/o PE or acute aortic
abnormality, no PNA, obstruction in scattered RLL ___ mucus
plugging vs. aspiration
- Patient given: levofloxacin 750mg, 500cc IV NS x2,
diphenhydramine 25mg IV, vancomycin 1g IV. Central line was
placed due to initial hypotension for consideration of levophed,
but BP stabilized after IVF.
- Vitals prior to transfer: 98.2 67 140/95 20 95% Nasal Cannula
On arrival to the floor, pt reports feeling well. She denies
further lightheadedness, dizziness. She endorses chest pain
occasionally, but none currently. She denies cough, NVD, ___
edema.
REVIEW OF SYSTEMS: (+) per HPI, all other ROS otherwise negative
Past Medical History:
ESRD status post left upper arm fistula placement, on dialysis
since the ___.
H/o HTN
Paroxysmal Afib, not anticoagulated
Abscess/complex cyst of left liver lobe s/p IV oxacillin,
minocycline, IV nafcillin -> daptomycin -> nafcillin ->
ceftriaxone (MSSA)
Thoracic aortic aneurysm
Gallstones
Lactose intolerance
IBS (last colonoscopy ___
GERD
HTN
RA
Patent foramen ovale
Complex ovarian cyst on R ovary
C diff colitis (___)
Prior Surgical History:
1. Cholecystectomy.
2. Pelvic surgery of unknown type
3. Sigmoid resection ___ for diverticulitis
4. Right salpingo-oophorectomy
5. Papillary stenosis status post papillotomy ___
6. Tubal ligation
7. S/p L4-L5 laminectomy and fusion
Social History:
___
Family History:
No family history of renal disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: 97.9 PO 177 / 85 R Sitting 69 18 94 ra
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: RRR, normal S1 S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
Ext: Warm, well perfused, no cyanosis or edema
Skin: Without rashes or lesions
Neuro: A&Ox2. Grossly intact.
DISCHARGE PHYSICAL EXAM:
========================
PHYSICAL EXAM:
Vitals: 98.5PO 163/85 72 18 93 RA
General: No acute distress. Oriented x2.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally. Mild decrease breath
sounds at the bases, no wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: No focal neurological deficits, AOx2 (hospital) apparent
baseline
Pertinent Results:
ADMISSION LABS:
===============
___ 07:40PM ___
___ 07:40PM LACTATE-1.4
___ 04:56PM ___ PO2-39* PCO2-52* PH-7.37 TOTAL
CO2-31* BASE XS-2
___ 04:56PM O2 SAT-66
___ 02:11PM ___ PO2-22* PCO2-60* PH-7.36 TOTAL
CO2-35* BASE XS-4
___ 02:11PM LACTATE-2.6* K+-4.7
___ 02:11PM O2 SAT-23
___ 01:38PM GLUCOSE-106* UREA N-30* CREAT-6.2*#
SODIUM-139 POTASSIUM-5.4* CHLORIDE-93* TOTAL CO2-28 ANION
GAP-23*
___ 01:38PM estGFR-Using this
___ 01:38PM ALT(SGPT)-23 AST(SGOT)-32 ALK PHOS-89 TOT
BILI-0.3
___ 01:38PM LIPASE-94*
___ 01:38PM CK-MB-1 cTropnT-0.05*
___ 01:38PM ALBUMIN-3.9 CALCIUM-10.0 MAGNESIUM-2.4
___ 01:38PM WBC-8.1 RBC-4.59# HGB-12.8# HCT-42.2# MCV-92
MCH-27.9 MCHC-30.3* RDW-18.3* RDWSD-60.2*
___ 01:38PM NEUTS-69.9 ___ MONOS-7.0 EOS-0.9*
BASOS-0.6 IM ___ AbsNeut-5.65 AbsLymp-1.71 AbsMono-0.57
AbsEos-0.07 AbsBaso-0.05
___ 01:38PM PLT COUNT-237
___ 01:38PM ___ PTT-28.7 ___
DISCHARGE LABS:
===============
___ 06:44AM BLOOD WBC-7.9 RBC-3.79* Hgb-10.1* Hct-34.0
MCV-90 MCH-26.6 MCHC-29.7* RDW-17.7* RDWSD-57.1* Plt ___
___ 06:44AM BLOOD Glucose-91 UreaN-37* Creat-7.0* Na-135
K-5.2* Cl-94* HCO3-25 AnGap-21*
___ 06:44AM BLOOD Calcium-9.5 Phos-5.5* Mg-2.2
___ 07:40PM BLOOD Lactate-1.4
IMAGING:
========
___ CTA
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. No focal pneumonia.
3. Obstruction in scattered subsegmental right lower lobe
airways could be due to mucous plugging or aspiration.
___ CXR
IMPRESSION:
Moderate to severe cardiomegaly. Patchy bibasilar opacities may
reflect atelectasis. Similar appearance of widened superior
mediastinal contour due to known thoracic aortic aneurysm and
thyroid goiter.
MICRO:
======
BCx pending at discharge
Brief Hospital Course:
Ms. ___ is an ___ with underlying dementia, PMH of ESRD on
HD with LUE fistula since ___, history of HTN, thoracic aortic
aneurysm, paroxysmal AF on aspirin, C diff colitis ___,
diverticulitis, who presents with weakness and hypotension, now
resolved with IVF.
#Hypotension: Patient p/w marked hypotension with symptomatic
lightheadedness, some chest pain, and elevated lactate, now with
full resolution with fluids. Presentation most consistent with
blood pressure lability in the setting of ESRD and recent
hemodialsysis on ___ where 2.6L of fluid was removed and she
was ultra-filtrated below her dry weight to 94.1kg. Differential
includes cardiac given +risk factors, occasional chest pain,
cardiomegaly, and hx of CHF and Afib. However, initial trops
0.05 now back to baseline of 0.03 consistent with hx of ESRD,
normal CKMB, no ischemic changes or arrhythmia on EKG. Negative
CTA w/o PE or aortic abnormality. Limited echo in ED, but with
normal LV function. Sepsis/occult infection also a
consideration; however, low suspicion given pt is afebrile
without leukocytosis or evidence of PNA. Antibiotics (zosyn and
levofloxacin) were initially started in ED, but quickly were
discontinued. Patient remained asymptomatic after receiving
fluids in ED and after her HD session.
---------------
CHRONIC ISSUES:
---------------
# ESRD on HD: MWF. Conintued HD while in the hospital- patient
able to tolerate has had full rebound of blood pressure up to
160s/80s post fluids in the ED. Continued renal meds.
#Dementia: Progressive dementia over last several years that has
been evaluated as an outpatient. Patient A&Ox1-2, able to state
name and "hospital". At baseline mental status.
# Paroxysmal Afib: History of pAF, but normal sinus rhythm
throughout hospitalization. CHADS2 score of 3. Currently treated
only with aspirin and beta-blocker per records w/ outpatient
providers. Continue metoprolol and ASA during hospitalization.
# HLD: continued home pravastatin
# Dilated ascending thoracic aorta noted to be 4.6 cm in
diameter similar to ___. This should continued to be monitored
per Cardiology.
TRANSTIIONAL ISSUES:
=====================
# NO medication changes were made this hospitalization
[] ongoing monitoring of dilated ascending thoracic aorta per
cardiology. On imaging this hospitalization noted to be stable
in diameter from ___ without change.
[] BCx pending at discharge
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
3. Cholestyramine 4 gm PO BID
4. Pravastatin 10 mg PO QPM
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Triphrocaps (B complex with C#20-folic acid) 1 mg oral DAILY
7. Vitron-C (iron-vitamin C) 65 mg iron- 125 mg oral DAILY
8. Aspirin 81 mg PO DAILY
9. Calcium Acetate 667 mg PO TID W/MEALS
10. Cinacalcet 30 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
3. Calcium Acetate 667 mg PO TID W/MEALS
4. Cholestyramine 4 gm PO BID
5. Cinacalcet 30 mg PO DAILY
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Pravastatin 10 mg PO QPM
9. Triphrocaps (B complex with C#20-folic acid) 1 mg oral DAILY
10. Vitron-C (iron-vitamin C) 65 mg iron- 125 mg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Hypotension
ESRD on dialysis
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You came to the hospital after feeling unwell and being found to
have low blood pressure. We evaluated you for causes of blood
pressure and we ruled out infection as well as blood clot in
your lungs.
Your blood pressure normalized before you left the hospital.
Please continue to take your medications and follow up with your
primary care physician in the next week.
Name: ___
Location: ___ MEDICAL GROUP
Address: ___
Phone: ___
Fax: ___
It was a pleasure being involved in your care.
Your ___ Team
Followup Instructions:
___
|
10661896-DS-5
| 10,661,896 | 24,972,422 |
DS
| 5 |
2149-06-27 00:00:00
|
2149-06-27 14:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Major Surgical or Invasive Procedure:
Dual chamber PPM placement ___
attach
Pertinent Results:
ADMISSION LABS:
===============
___ 11:45AM BLOOD WBC-7.1 RBC-4.05* Hgb-12.9* Hct-39.3*
MCV-97 MCH-31.9 MCHC-32.8 RDW-14.4 RDWSD-51.0* Plt ___
___ 11:45AM BLOOD Neuts-74.1* Lymphs-14.9* Monos-9.4
Eos-0.3* Baso-0.7 Im ___ AbsNeut-5.28 AbsLymp-1.06*
AbsMono-0.67 AbsEos-0.02* AbsBaso-0.05
___ 11:45AM BLOOD ___ PTT-28.4 ___
___ 11:45AM BLOOD Glucose-105* UreaN-13 Creat-1.2 Na-136
K-4.3 Cl-96 HCO3-23 AnGap-17
___ 11:45AM BLOOD ALT-22 AST-19 AlkPhos-110 TotBili-0.3
___ 11:45AM BLOOD Lipase-18
___ 11:45AM BLOOD proBNP-2655*
___ 11:45AM BLOOD cTropnT-<0.01
___ 11:45AM BLOOD Albumin-4.1 Calcium-9.5 Phos-4.4 Mg-2.2
___ 11:56AM BLOOD Glucose-104 Lactate-2.0 Creat-1.2 Na-136
K-3.9 Cl-100 calHCO3-26
___ 11:56AM BLOOD Hgb-13.9* calcHCT-42
PERTINENT LABS:
===============
___ 11:45AM BLOOD TSH-5.8*
IMAGING:
========
CXR, ___:
Congestion with mild interstitial pulmonary edema.
TTE, ___:
IMPRESSION: Normal left ventricular wall thickness and
biventricular cavity sizes and regional/global biventricular
systolic function. Mild aortic regurgitation. Mild tricuspid
regurgitation. LVEF 55-60%.
CXR, ___:
Lungs are well expanded and clear. Left-sided pacemaker leads
project to the right atrium and right ventricle.
Cardiomediastinal silhouette is stable. No pneumothorax. Small
bilateral effusions right greater than left.
DISCHARGE LABS:
===============
___ 06:38AM BLOOD WBC-5.7 RBC-3.63* Hgb-11.6* Hct-35.2*
MCV-97 MCH-32.0 MCHC-33.0 RDW-14.6 RDWSD-51.0* Plt ___
___ 06:38AM BLOOD ___ PTT-23.0* ___
___ 06:38AM BLOOD Glucose-76 UreaN-11 Creat-0.9 Na-136
K-4.0 Cl-102 HCO3-24 AnGap-10
Brief Hospital Course:
TRANSITIONAL ISSUES:
====================
[] Please follow up Lyme serologies
[] Repeat TFTs in 6 weeks, patient's TSH elevated to 5.8 during
this admission
DISCHARGE WEIGHT: 179.67 lbs
DISCHARGE Cr: 0.9
CODE: Full
CONTACT: ___ (HCP)
Relationship: Sister, ___
Phone number: ___
BRIEF HOSPITAL SUMMARY:
=======================
___ year old male with medical history significant for Down's
syndrome, hypothyroidism and seizure disorder, presented from
PCP with bradycardia, found to be in complete heart block.
Patient received dual chamber PPM on ___ with subsequent return
of normal HRs A-sensed, V-paced primarily.
ACUTE ISSUES:
=============
# ___ Deg Heart Block
Patient with no known cardiac history who presented with
bradycardia and found to be in third degree heart block.
Patient's siser and ___ remarked that over the past few
days that the patient had been seemingly more lethargic and not
at baseline. For this they presented to their PCP who found the
patient to be significantly bradycardic and were then referred
to the ED. In the ED patient found to be in third degree heart
block. Otherwise without ischemic changes, troponin x1 negative.
BNP elevated to 2600. Patient underwent placement of dual
chamber PPM. Subsequently patient is primarily a-sensed, v-paced
with HRs in the ___. Following PPM placement, patient had return
of his baseline energy. Planned to follow up in device clinic
within a week and subsequently follow with Dr. ___ in EP.
CHRONIC ISSUES:
===============
# Down's syndrome
Patient lives with sister, ___, who is also his ___. She
was present throughout his admission and helped provide much of
the history.
# Epilepsy
Continued with Carbamazepine 300 mg PO BID.
# Hypothyroidism
TSH noted to be elevated at 5.8. Continued with Levothyroxine
100 mcg PO QD.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. CarBAMazepine 300 mg PO BID
2. Levothyroxine Sodium 100 mcg PO DAILY
Discharge Medications:
1. CarBAMazepine 300 mg PO BID
2. Levothyroxine Sodium 100 mcg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
==================
Complete (third degree) Heart Block
SECONDARY DIAGNOSES:
====================
Down's Syndrome
Seizure disorder
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because your heart rate was found to be
slow.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- Your slow heart rate was found to be due to a condition called
heart block. You were treated for this by placing a pacemaker.
- You tolerated this procedure well and your heart rates have
improved to a normal rate.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
10662181-DS-14
| 10,662,181 | 22,607,104 |
DS
| 14 |
2167-10-24 00:00:00
|
2167-10-25 19:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
weakness, shortness of breath, abdominal distension
Major Surgical or Invasive Procedure:
___: ___ temporary dialysis line placement
History of Present Illness:
Mr. ___ is a ___ with PMH of HTN, HLD, CKD (baseline 1.2),
CAD, right and left heart failure, Afib on warfarin, AV nodal
disease s/p single lead PPM in ___, severe pulmonary
hypertension, OSA, and copd (on 2L home o2) who presented to the
ED from his PCP's office for weakness, worsening SOB and
abdominal distention.
The patient and his family state that he was admitted in
___ to the ___ for these same symptoms. At
that time he underwent aggressive diuresis with improvement. He
was discharged to ___ for ___ and ongoing diuresis. Per
his wife he lost 70 lbs during his admission and rehab. Since
his discharge from ___ in ___ the patient has had
progressive abdominal distention, lethargy and ___ edema. He has
also had 3 falls without LOC or head strike. Over the last week
he has had cough productive of yellow sputum, severe abdominal
distention and very poor urine output. His wife noticed that he
can no longer lie flat comfortably and sleeps in his recliner.
He has also had a loss of apatite and increasing somnolence and
confusion. Patient uses ___ L home oxygen intermittently but has
been requiring it more lately.
He presented to his PCP ___ ___ for SOB, found to have
significant abdominal distension, labs showing BNP 12000 with
creatinine >4 in setting of lactic acidosis. He was referred to
the ED.
In the ED he was admitted to the ET service for presumptive
cirrhosis per the hepatology fellow. On the floor he triggered
overnight for decreased urine output and marked nursing concern.
The renal fellow was notified and recommended Lasix trial. On
review, there was no history of cirrhosis and the patient was
transferred to ___ with concern for worsening right heart
failure. By morning his lactate had risen to 7 and the attending
transferred him to the CCU for cardiogenic shock and acute on
chronic renal failure.
On evaluation the patient is weak and somewhat confused. He
endorses mild SOB. He denies chest pain and abdominal pain, he
confirms the above story.
Past Medical History:
DM Type II
HYPERTENSION
HYPERLIPIDEMIA
SMOKER, quit in ___
CHRONIC KIDNEY DISEASE (baseline 1.2)
AV NODE DISEASE s/p PACEMAKER PLACEMENT ___
CORONARY ARTERY DISEASE
ATRIAL FIBRILLATION
BASAL CELL CARCINOMA
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (uses 2L home O2
intermittently)
ACTINIC KERATOSIS
SQUAMOUS CELL CARCINOMA
PULMONARY HYPERTENSION (follows w/ Dr. ___
GOUT
OBSTRUCTIVE SLEEP APNEA on CPAP
PERIPHERAL VENOUS STASIS
RIGHT AND LEFT HEART FAILURE
Social History:
___
Family History:
Mother with MI in her ___, ETOH and obesity.
1 brother, 1 sister and 2 half sisters. Brother's health is also
failing but unknown conditions.
No known family history of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.0, 95/70, 61, 18, 92% 4L O2
GENERAL: obese cyanotic appearing man lying in bed.
HEENT: NCAT, MMM with poor dentition,
NECK: Supple short neck. JVP of 14 cm.
CARDIAC: heart sounds distant, RRR, ___ holosystolic murmur
appreciated best at ___.
LUNGS: lung sounds distant with mild bibasilar crackles, no
wheezing, not using accessory muscles to breath
ABDOMEN: obese, distended, not tense, non-tender, unable to
appreciate organomegaly.
EXTREMITIES: bilateral venous stasis changes with 2+ pitting
edema bilaterally.
SKIN: Multiple ecchymosis bilaterally
PULSES: Distal pulses faint
DISCHARGE PHYSICAL EXAM:
VITALS 99 PO 98/55 61 22 98 4L
I/O: +400 since midnight, no urine outs recorded since midnight
GENERAL: obese man sitting comfortably in bedside chair,
responding appropriately to all questions
HEENT: NCAT, MMM with poor dentition. noted to have baseline
anisocoria with R>L pupil
NECK: Supple short neck.
CARDIAC: heart sounds distant, RRR, ___ holosystolic murmur
appreciated best at LSB.
LUNGS: R>L crackles at the bases bilaterally.
ABDOMEN: obese, non-tender, and soft. No longer with tense
abdomen.
EXTREMITIES: bilateral venous stasis changes, did not observe
pitting edema
SKIN: Multiple ecchymosis bilaterally
PULSES: Distal pulses faint
Pertinent Results:
Admission labs:
---------------
___ 03:10PM ___
___ 03:10PM TSH-3.2
___ 03:10PM WBC-6.5 RBC-4.53* HGB-12.1* HCT-41.3 MCV-91
MCH-26.7 MCHC-29.3* RDW-17.8* RDWSD-59.1*
___ 03:10PM PLT COUNT-326#
___ 03:10PM PSA-0.5
___ 03:10PM CHOLEST-84
___ 03:10PM TRIGLYCER-75 HDL CHOL-30* CHOL/HDL-2.8
LDL(CALC)-39
___ 03:10PM %HbA1c-6.7* eAG-146*
___ 03:10PM ALT(SGPT)-38 AST(SGOT)-72* ALK PHOS-110 TOT
BILI-0.6
___ 03:10PM CREAT-3.3*# SODIUM-138 POTASSIUM-4.9
Pertinent labs:
---------------
___ 03:54PM BLOOD Glucose-140* UreaN-101* Creat-4.9* Na-141
K-5.9* Cl-96 HCO3-19* AnGap-26*
___ 02:38PM BLOOD Glucose-173* UreaN-46* Creat-2.7* Na-137
K-5.0 Cl-92* HCO3-21* AnGap-24*
___ 06:30AM BLOOD Glucose-133* UreaN-12 Creat-1.3* Na-140
K-4.0 Cl-101 HCO3-22 AnGap-17*
___ 04:12PM BLOOD Glucose-211* UreaN-15 Creat-1.2 Na-137
K-4.1 Cl-100 HCO3-21* AnGap-16
___ 06:00AM BLOOD Glucose-158* UreaN-65* Creat-3.8* Na-135
K-5.1 Cl-96 HCO3-22 AnGap-17*
___ 07:05AM BLOOD Glucose-192* UreaN-49* Creat-3.5* Na-138
K-5.0 Cl-98 HCO3-23 AnGap-17*
___ 10:40AM BLOOD ___
___ 04:00AM BLOOD ___ PTT-31.3 ___
___ 05:40PM BLOOD ___ PTT-72.8* ___
___ 04:44PM BLOOD ___ PTT-33.0 ___
___ 07:05AM BLOOD ___ PTT-29.5 ___
Discharge labs:
---------------
___ 06:50AM BLOOD WBC-11.3* RBC-3.74* Hgb-9.9* Hct-32.4*
MCV-87 MCH-26.5 MCHC-30.6* RDW-19.9* RDWSD-60.7* Plt ___
___ 06:50AM BLOOD ___ PTT-31.8 ___
___ 06:50AM BLOOD Glucose-111* UreaN-80* Creat-5.4* Na-135
K-5.4* Cl-94* HCO3-19* AnGap-22*
___ 04:04AM BLOOD ALT-30 AST-35 LD(LDH)-248 AlkPhos-119
TotBili-1.0
___ 06:50AM BLOOD Calcium-8.3* Phos-6.2* Mg-3.0*
Pertinent Imaging/Studies:
___ Abd US:
1. Suboptimal study secondary to poor acoustic windows. No
gross abnormality of the liver where visualized.
2. Moderate ascites, most pronounced in the left upper and
lower quadrants.
___ CXR:
1. Suboptimal study secondary to poor acoustic windows. No
gross abnormality of the liver where visualized.
2. Moderate ascites, most pronounced in the left upper and
lower quadrants.
___ CT Head:
No acute intracranial process.
___ Echo:
The left atrium is moderately dilated. The right atrium is
markedly dilated. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is mildly
depressed (LVEF= 45 %). There is no ventricular septal defect.
The right ventricular cavity is moderately dilated with
depressed free wall contractility. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. The ascending aorta 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
tricuspid valve leaflets are mildly thickened. Severe [4+]
tricuspid regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of ___, no
clear change.
___ CXR:
Continued bilateral pleural effusions with compressive
atelectasis, more
prominent on the left.
Brief Hospital Course:
Mr. ___ is a ___ with PMH of HTN, HLD, CKD (baseline 1.2),
CAD, right and left heart failure, Afib on warfarin, AV nodal
disease s/p single lead PPM in ___, severe pulmonary
hypertension, OSA, and copd (on 2L home o2) who presented to the
ED from his PCP's office for weakness, worsening SOB and
abdominal distention.
Acute Issues:
-------------
# RIGHT AND LEFT HEART FAILURE
# ASCITES, PULM EDEMA
Patient had ascites and pulmonary edema secondary to heart
failure. He has had known right heart failure since at least ___. It is likely that he was not adequately diuresed since
discharge from rehab, since he has been in and out of hospital
for the last several months. Etiology of decompensation thought
to be a combination of pneumonia, worsening renal failure
secondary to right heart failure, and metformin use. An ischemic
event was unlikely given negative cardiac enzymes and
asymptomatic. He required dobutamine pressors for one day, and
he was started on CRRT with goal ___ output. He was
transitioned to intermittent hemodialysis on ___. He was
maintained on home metoprolol but home amlodipine was held. Of
note, he had several episodes of hypotension requiring 250-500cc
boluses of fluids.
# ANURIC RENAL FAILURE
# ___ ON CKD
Patient presented with significant hypervolemia and oliguria
which was unresponsive to Lasix drip. Baseline creatinine is 1.5
but his admission creatinine was 4.5. He also triggered
overnight on ___ for oliguria and lactic acidosis resulting in
metabolic encephalopathy. The etiology of his renal failure was
likely poor perfusion in the setting of worsening right heart
failure, possibly with contribution from metformin. Since he
failed to respond to diuresis, he was started on CRRT on ___
with return of Cr back to baseline. On ___, his CRRT was
discontinued, and a tunneled line was placed on ___ for
hemodialysis. He will continue on a MWF schedule.
#Thrombocytopenia: Patient had new thrombocytopenia with
platelet 111 from 139. It was not likely HIT given low T4 score,
so it was attributed to ongoing CRRT which can cause platelet
counts to drop. Follow up platelet as outpatient.
# AFIB WITH ELEVATED INR
# RV paced (AV node disease s/p PPM): Home dose of warfarin is
alternating ___. Of note, patient presented with elevated
INR to 5.2, but he was given vitamin K IV 5mg once and FFP prior
to a line insertion. As a result, his INR dropped to
subtherapeutic levels. His discharge INR was 2.1 and he was
discharged on dose of warfarin 4mg.
# Community acquired pneumonia
Patient presented with productive cough for 3 days prior to
admission. He had no fever or leukocytosis, but it is possible
that he is unable to mount an adequate immune response at this
time. He completed a 5-day empiric course of azithromycin and
ceftriaxone. Infectious workup was negative.
# UTI
Patient had fever ___ and pan-culturing showed a UA concerning
for infection. He was started empirically on ceftriaxone 1g
q24, planned 7-day course of abx. Once speciation/sensitivities
return, CCU team will call discharge facility with results.
# AG METABOLIC ACIDOSIS W/ CONCURENT RESPIRATORY ACIDOSIS:
Patient presented with lactic acidosis to 5.1 secondary to right
heart failure, renal failure, and obstructive pulmonary disease.
Improved with CRRT and remained within normal limits off CRRT.
Chronic Issues:
---------------
# PULMONARY HTN
Patient with long standing pulmonary HTN likely secondary to
COPD, OSA and left heart failure. Maintained on home CPAP.
# ANEMIA: Likely secondary to renal failure and acute on chronic
illness. Stable
#DM2: Held metformin and briefly held gabapentin (restarted
___. Maintained on ISS.
#HLD: Maintained on Pravastatin 40 mg PO QPM, trend LFTs
#GOUT: Held Colchicine 0.6 mg PO DAILY given renal failure
#DEPRESSION: Started on fluoxetine 20 mg PO DAILY
#ALTERED MENTAL STATUS: Delirious but not confused. Not agitated
and does not require any medications.
#MALNUTRITION: Given Nepro TID with meals
Transitional Issues:
--------------------
[]Please continue ceftriaxone 1g daily through ___ for UTI
unless otherwise informed by ___ CCU team
[]Stopped home Lasix, spironolactone as patient no longer making
urine
[]Decreased gabapentin from 600 bid to ___ daily due to
worsening renal disease
[]Discontinued colchicine due to worsening renal disease
[]Metoprolol succinate decreased from 50 mg to 25 mg due to
issues with hypotension during HD; if issues with rate control,
please consider increasing
#Contact: ___ (wife) ___
#Code: Full (confirmed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Colchicine 0.6 mg PO DAILY
2. FLUoxetine 20 mg PO DAILY
3. Furosemide 80 mg PO BID
4. Gabapentin 600 mg PO BID
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Pravastatin 40 mg PO QPM
8. Spironolactone 12.5 mg PO DAILY
9. Warfarin 3 mg PO QOD
10. Warfarin 3.5 mg PO QOD
11. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
12. Multivitamins 1 TAB PO DAILY
13. Senna 8.6 mg PO BID:PRN constipation
14. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
2. CefTRIAXone 1 gm IV Q24H
last day ___ unless otherwise informed by ___ CCU team
3. Gabapentin 300 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. ___ MD to order daily dose PO DAILY16
6. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
7. FLUoxetine 20 mg PO DAILY
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. Multivitamins 1 TAB PO DAILY
10. Pravastatin 40 mg PO QPM
11. Senna 8.6 mg PO BID:PRN constipation
12. Thiamine 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
--------
Decompensated heart failure
Anuric renal failure
Secondary:
---------
Community-acquired pneumonia
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. ___,
WHY WERE YOU ADMITTED?
- You had worsening shortness of breath and enlarging belly
WHAT HAPPENED IN THE HOSPITAL?
- Your heart was not pumping properly, which was causing fluid
to build up in your body
- You were started on dialysis to help with removing fluid
- We also treated you for pneumonia
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
-If you gain more than 3 pounds in 2 days, please call your
doctor or go to the ED
It was a pleasure to take care you! We wish you the best.
-Your ___ Team
Followup Instructions:
___
|
10662181-DS-16
| 10,662,181 | 28,363,624 |
DS
| 16 |
2168-05-23 00:00:00
|
2168-05-23 17:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Slurred speech, fevers, chills
Major Surgical or Invasive Procedure:
HD line extraction
Temporary HD line placement
Tunnel HD line placement
Permanent pacemaker explant
Temporary pacer wire placement
***Permanent pacemaker placement?
History of Present Illness:
Mr. ___ is a ___ y/o gentleman with PMH notable for CAD, ESRD
___ T2DM and HTN on HD via HD catheter, AF on warfarin, AV nodal
disease s/p PPM, COPD on intermittent home O2, HFrEF (40-45%)
with severe TR/moderate AS, and moderate pHTN, admitted for
stuttering speech and shaking (acute on chronic).
History is completely gathered from chart as patient refuses to
engage in history and exam. As per ED history, the patient's
symptoms of stuttering speech began day PTA with some worsening
of his baseline shaking. His wife does state that this has
occurred in the past. He was found to be febrile to 103 today,
not improved with Tylenol and had a worsening O2 requirement,
prompting transfer to ED for further assessment.
In the ED , the patient initially denied any chest pain or
shortness of breath and could not recall feeling warm for the
last couple of days. He otherwise had no abdominal pain, no
nausea, no vomiting, no diarrhea.
In the ED, initial VS were:
-98.3 116 138/81 20 90% Nasal Cannula
Exam notable for:
"Lungs are clear to auscultation bilaterally, abdomen is soft
and
nondistended. Cardiac exam is unremarkable. There is a
well-healed ulcer to the heel of the left foot. No lower
extremity edema."
Labs showed:
-WBC 19.1 (87.6% PMNs), Hgb 12.1, normal plt
-Chem10 showing BUN/Cr 40/3.6, K 5.1, Phos 4.9
-initial VBG 7.34/51, lactate 2.2
-flu A/B negative
-U/A with 12 epis, >182 WBC, 49 RBC, negative nitrite, 100
protein, moderate blood, large ___, cloudy appering
-Urine culture drawn pending
-Blood culture x2 drawn pending
Imaging showed:
-CXR showing: Congestion with mild edema with pleural effusions
and lower lung atelectasis, difficult to exclude a superimposed
pneumonia.
-ECG per my read showing ?sinus rhythm vs. AF with ventricular
rate of 61 bpm with significant 1st degree AV delay as well as
LBBB (V-paced); non-specific ST-TW changes compared with prior
on
___
Consults: None
Patient received:
-Vancomycin 1g IV x1
-Sarna
-NS x500cc
On arrival to the floor, patient refuses to answer any questions
as he is unhappy he was awoken at night. Furthermore, he refuses
to answer questions or participate in exam "without my lawyer
present." He even refuses to answer orientation questions.
REVIEW OF SYSTEMS: Limited as above
Past Medical History:
ESRD ON HD
HEART FAILURE WITH REDUCED EJECTION FRACTION
DM Type II
HYPERTENSION
HYPERLIPIDEMIA
SMOKER, quit in ___
AV NODE DISEASE s/p PACEMAKER PLACEMENT ___, s/p temp wire
placement ___
CORONARY ARTERY DISEASE
ATRIAL FIBRILLATION
BASAL CELL CARCINOMA
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (uses 2L home O2
intermittently)
ACTINIC KERATOSIS
SQUAMOUS CELL CARCINOMA
PULMONARY HYPERTENSION
GOUT
OBSTRUCTIVE SLEEP APNEA on CPAP
PERIPHERAL VENOUS STASIS
RIGHT HEART FAILURE
Social History:
___
Family History:
Mother with MI in her ___, ETOH and obesity.
1 brother, 1 sister and 2 half sisters. Brother's health is also
failing but unknown conditions.
No known family history of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.3 102/62 58 17 95 2L
GENERAL: NAD, sitting up in bed
PULM: no increased use of accessory muscles, breathing
comfortably
NEURO: moving all extremities spontaneously and able to respond
to questions with "not without a lawyer present"
Rest of exam deferred as patient unwilling to participate
DISCHARGE PHYSICAL EXAM
Temp: 98.8 (Tm 99.3), BP: 103/63 (95-126/60-77), HR: 79 (79-81),
RR: 20 (___), O2 sat: 93% (85-94), O2 delivery: Ra, Wt: 175.71
lb/79.7 kg
GENERAL: NAD, alert, oriented
HEENT: NCAT, Sclera anicteric, EOMI, MMM
CHEST: mild erythema around tunneled HD line insertion site,
stable compared to prior days. Site non-tender to palpation.
normal respiratory effort, CTAB.
HEART: RRR, S1/S2, III/VI systolic murmur at left sternal border
ABDOMEN: Obese, soft, non-tender, non-distended
EXTREMITIES: R groin vascular access site w/o bleeding /
discharge. No hematoma or bruit. lower extremities warm
NEURO: AAOx3, moving all extremities with purpose, speech
normal.
Pertinent Results:
ADMISSION LABS:
===============
___ 09:34PM BLOOD WBC-19.1* RBC-3.97* Hgb-12.1* Hct-38.4*
MCV-97 MCH-30.5 MCHC-31.5* RDW-16.5* RDWSD-58.2* Plt ___
___ 09:34PM BLOOD Neuts-87.6* Lymphs-3.1* Monos-7.9
Eos-0.3* Baso-0.3 Im ___ AbsNeut-16.75* AbsLymp-0.59*
AbsMono-1.52* AbsEos-0.05 AbsBaso-0.06
___ 06:50AM BLOOD ___ PTT-35.8 ___
___ 09:34PM BLOOD Glucose-182* UreaN-40* Creat-3.6*# Na-137
K-5.1 Cl-95* HCO3-26 AnGap-16
___ 06:50AM BLOOD ALT-9 AST-19 LD(LDH)-217 AlkPhos-103
TotBili-0.8
___ 09:34PM BLOOD Calcium-8.9 Phos-4.9* Mg-2.1
PERTINENT LABS:
===============
___ 09:41PM BLOOD ___ pO2-65* pCO2-51* pH-7.34*
calTCO2-29 Base XS-0
___ 07:00AM BLOOD FreeKap-270.6* FreeLam-246.6* Fr K/L-1.1
___ 08:45AM BLOOD CRP-94*
___ 05:10PM BLOOD CRP-6.0*
___ 11:23AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 07:00AM BLOOD TSH-0.80
___ 07:00AM BLOOD calTIBC-178* Ferritn-348 TRF-137*
___ 05:10PM BLOOD Lipase-95*
___ 07:20AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
MICROBIOLOGY:
=============
___ 11:50 am BLOOD CULTURE #1.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 7:30 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:10 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 3:45 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 3:58 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 6:05 pm BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:45 am BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
SENSITIVITIES PERFORMED ON CULTURE # ___
(___).
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
___ 9:45 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
RIFAMPIN should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ (___) AT 2:51
___ ___.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
RELEVANT IMAGING:
=================
___ CXR:
IMPRESSION:
Congestion with mild edema with pleural effusions and lower lung
atelectasis,
difficult to exclude a superimposed pneumonia.
___ ECHO:
The left atrial volume index is severely increased. The right
atrium is moderately dilated. Left ventricular wall thicknesses
are normal. Overall left ventricular systolic function is
severely depressed (LVEF = 25%) secondary to direct ventricular
interaction with a pressure and volume overloaded right
ventricle, pacing-induced dyssynchrony, and contractile
dysfunction (inferior and posterior walls). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The right ventricular free wall is hypertrophied.
The right ventricular cavity is markedly dilated with severe
global free wall hypokinesis. There are focal calcifications in
the aortic arch. There are three aortic valve leaflets. The
aortic valve leaflets are severely thickened/deformed. There is
severe low-flow/low-gradient aortic valve stenosis (valve area
<1.0cm2). The mitral valve leaflets are mildly thickened. The
left ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. Severe [4+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. [In the setting of at least
moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] There is no pericardial
effusion. A right pleural effusion is present.
No obious vegetations seen.
Compared with the prior study (images reviewed) of ___,
multiple major abnormalities as described above persist without
major change.
___ Upper extremity US
IMPRESSION:
1. No evidence of deep vein thrombosis in the right upper
extremity.
2. Minimally visualized right IJ dialysis catheter due to
overlying bandage
without surrounding thrombus.
___ KUB
IMPRESSION:
Nonspecific bowel gas pattern. Air seen throughout the colon
and within the rectum.
___ TEE
Mild spontaneous echo contrast is seen in the body of the left
atrium. Mild spontaneous echo contrast is present in the left
atrial appendage. Left ventricular wall thicknesses are normal.
The left ventricular cavity is moderately dilated. The right
ventricular cavity is moderately dilated with severe global free
wall hypokinesis. The ascending, transverse and descending
thoracic aorta are normal in diameter and free of
atherosclerotic plaque to XX cm from the incisors. No masses or
vegetations are seen on the aortic valve. There is moderate
aortic valve stenosis (valve area 1.0-1.2cm2). Trace aortic
regurgitation is seen. No mass or vegetation is seen on the
mitral valve. Moderate (2+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is a
moderate sized pericardial effusion. There are no
echocardiographic signs of tamponade.
___ CXR
IMPRESSION:
Cardiac pacemaker device projects over the left lateral chest
wall with pacer lead terminating within the right ventricle.
Otherwise, there is no
significant interval change from prior day's radiograph.
___ RUQUS
IMPRESSION:
1. No ascites or evidence of focal liver lesions.
2. Left pleural effusion.
3. Cholelithiasis.
4. No splenomegaly.
DISCHARGE LABS:
===============
___ 06:16AM BLOOD WBC-7.6 RBC-3.43* Hgb-10.6* Hct-33.4*
MCV-97 MCH-30.9 MCHC-31.7* RDW-15.4 RDWSD-55.7* Plt ___
___ 07:55AM BLOOD ___ PTT-29.1 ___
___ 06:16AM BLOOD Glucose-184* UreaN-45* Creat-4.4* Na-137
K-4.5 Cl-94* HCO3-25 AnGap-18
___ 06:16AM BLOOD Calcium-8.8 Phos-6.1* Mg-2.2
Brief Hospital Course:
Mr. ___ is a ___ man w/ h/o CAD, ESRD ___ T2DM and HTN on
HD s/p HD catheter, AF on warfarin, AV nodal disease s/p
pacemaker placement, cor pulmonale ___ COPD, chronic RV failure,
HFrEF (40-45%) with severe TR/moderate AS, and moderate pHTN who
presented with stuttering speech, shaking, fever, and
tachycardia found to have MRSA sepsis. Now with acutely reduced
EF and s/p new HD line replacement, PPM explant, and temporary
pacer wire placement.
=============
ACUTE ISSUES:
=============
# MRSA Sepsis:
Likely source is HD line that had frank pus, removed ___.
New tunneled line inserted ___. Concern for involvement of
PPM, removed ___. Temporary pacer placed until permanent
leadless (intracardiac) pacemaker placeed after completion of
full four-week vancomycin antibiotic course. Vancomycin course
completed ___. TEE negative for vegetations. Last
positive blood culture ___. Repeat blood cultures following
completion of antibiotic course remained negative.
# High-degree AV block:
# Atrial fibrillation (?permanent) c/b AV nodal disease:
# Status post PPM placement ___:
Status post removal of prior ___ PPM (sterile explant by time
of removal with temporary external pacemaker placed until
leadless pacemaker placed on ___. Electrophysiology to implant
new pacer (not ICD) once antibiotic course is complete on
___. ICD not indicated for ESRD patients due to no proven
benefit in outcomes. During this hospital stay, warfarin was
temporarily held for procedure, than restarted without heparin
bridge (given ESRD on HD and not believed to meet criteria
necessitating bridging). Home dose warfarin 3 mg w/ INR goal
___. PPM was replaced on ___ without complications. The
patient will follow up in the EP device clinic one week after
discharge. Metoprolol was adjusted as below.
# ESRD on HD:
ESRD is likely secondary to HTN and T2DM (on HD T, Th, ___. The
patient's home vitamin supplementation was continued. Transplant
surgery was consulted and recommended an outpatient appointment
for AVF/AVG placement.
# HFrEF (EF 40-45% in ___:
# Severely depressed LVEF (25%):
# Hypervolemia:
Likely multifactorial with CAD, HTN, and pulmonary disease.
Acute worsening of LVEF this admission in the setting of sepsis
and hypervolemia. Workup showed TSH within normal limits, TIBC
and TRF low (in the setting of ongoing sepsis at that time), and
free Kappa and Lambda elevated but ratio within normal limits.
Volume was removed during hemodialysis. Per discussion with his
outpatient cardiologist Dr. ___ therapy was not
initiated. Metoprolol was continued and uptitrated to 12.5 mg
once per day. Atorvastatin was increased to 80 mg per day.
Lisinopril was started at 2.5 mg PO per day. Both metoprolol and
lisinopril can be up-titrated as an outpatient.
# Depression:
Patient broke out in tears on ___, relating how difficult
it has been for him lately. His wife reinforced that he has been
having a hard time with his medical issues being exacerbated
since ___. Fluoxetine was uptitrated to 40 mg daily.
Patient could benefit from outpatient psychiatric follow up.
# Anemia:
Likely secondary to renal failure and acute on chronic illness.
CBCs were monitored with minimal change in Hgb. The patient's
outpatient regimen of Epo 3200u QHd and Venofer 50mcg IV ___
was held due to his active infection.
# Diffuse abdominal pain, greatest at LUQ:
# Constipation:
Patient was constipated initially, but began stooling w/
intensive bowel regimen. He developed abdominal distention and
tenderness in LUQ upon palpation that persisted. LFTs were
unremarkable. KUB was unremarkable as well. Liver/GB U/S shows
no ascites or focal liver lesions. His lactate was elevated to
2.5, but exam remained stable/improved. Lipase elevated in
setting of CKD. Amylase normal. Stable at discharge.
==================
CHRONIC PROBLEMS:
==================
# DM Type II:
Discontinued insulin and fingersticks while inpatient. Did not
restart insulin at discharge. Further follow-up of diabetes is
deferred to the patient's outpatient providers.
# Hypertension:
Metoprolol was uptitrated as above.
# CAD:
# Hyperlipidemia:
Atorvastatin was increased to 80mg from 10mg (home dose).
# OSA on CPAP:
Patient has been refusing CPAP in hospital; reportedly poorly
compliant with CPAP at home. He was seen by respiratory therapy
for evaluation and recommendations on CPAP use and correcting
his mask for comfort.
# COPD:
Patient's home Flovent and home nebs were continued and PRN nebs
were made available.
# GERD:
Patient's home famotidine was continued.
====================
TRANSITIONAL ISSUES:
====================
[ ] Patient restarted on Warfarin (3mg daily, home dose)
following his permanent pacemaker placement (so far has received
two doses: on ___ and ___. Please obtain daily INR until
stable and adjust Warfarin accordingly
[ ] Please ensure patient follows up with device clinic one week
after discharge (On ___
[ ] Set up outpatient appointment with transplant surgery for
AVF/AVG placement.
[ ] In the setting of admission for ADHF, the following
medication changes were made: Metoprolol was uptitrated to 12.5
mg once per day. Atorvastatin was increased to 80 mg per day.
Lisinopril was started at 2.5 mg PO per day.
[ ] Consider uptitration of metoprolol succinate to 50 mg daily
as tolerated.
[ ] Consider uptitration lisinopril as tolerated to goal 20 mg.
Give after HD on HD days. Monitor BP.
[ ] Consider repeat ECHO once euvolemic to evaluate for EF
improvement
[ ] F/u depression: Fluoxetine was uptitrated to 40 mg daily.
Consider optimizing SSRI dosage and patient would benefit from
psychiatry/CBT
[ ] Follow-up glycemic control as outpatient.
Discharge weight: 79.7 kg (175.71 lb)
HCP: ___ ___
Code Status: Full (confirmed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Gabapentin 100 mg PO BID
3. Metoprolol Succinate XL 12.5 mg PO 4X/WEEK (___)
4. Senna 8.6 mg PO BID
5. Warfarin 3 mg PO DAILY
6. Famotidine 20 mg PO DAILY
7. Atorvastatin 10 mg PO QHS
8. Ferrous Sulfate 325 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain -
Moderate
11. Fluticasone Propionate 110mcg 2 PUFF IH BID
12. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
13. FLUoxetine 30 mg PO DAILY
14. Thiamine 100 mg PO DAILY
15. Bisacodyl ___AILY:PRN if no BM
16. Fleet Enema (Mineral Oil) ___AILY:PRN if bisacodyl
suppository ineffective
17. lactulose 20 gram/30 mL oral DAILY:PRN
18. OxyCODONE (Immediate Release) 10 mg PO DAILY
19. sevelamer CARBONATE 800 mg PO TID W/MEALS
20. Nepro Carb Steady (nut.___.imp.renal fxn,lac-reduc) 0.08
gram-1.8 kcal/mL oral TID W/MEALS
21. ProMod Protein (protein supplement) 30 mL oral BID
Discharge Medications:
1. Heparin IV per Weight-Based Dosing Protocol
Indication: Atrial Fibrillation
Continue existing infusion at 1400 units/hr
Therapeutic/Target PTT Range: 60 - 99.9 seconds
2. Ipratropium-Albuterol Neb 1 NEB NEB Q12H
3. Lisinopril 2.5 mg PO DAILY
4. Nephrocaps 1 CAP PO DAILY
5. Polyethylene Glycol 17 g PO DAILY
6. ___ MD to order daily dose IV HD PROTOCOL
7. Atorvastatin 80 mg PO QPM
8. FLUoxetine 40 mg PO DAILY
9. Gabapentin 100 mg PO AFTER HD
10. Metoprolol Succinate XL 12.5 mg PO DAILY
Please take after HD on HD days
11. Senna 17.2 mg PO BID
12. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
13. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
14. Bisacodyl ___AILY:PRN if no BM
15. Famotidine 20 mg PO DAILY
16. Ferrous Sulfate 325 mg PO DAILY
17. Fleet Enema (Mineral Oil) ___AILY:PRN if bisacodyl
suppository ineffective
18. Fluticasone Propionate 110mcg 2 PUFF IH BID
19. lactulose 20 gram/30 mL oral DAILY:PRN
20. Multivitamins 1 TAB PO DAILY
21. Nepro Carb Steady (nut.___.imp.renal fxn,lac-reduc) 0.08
gram-1.8 kcal/mL oral TID W/MEALS
22. ProMod Protein (protein supplement) 30 mL oral BID
23. sevelamer CARBONATE 800 mg PO TID W/MEALS
24. Thiamine 100 mg PO DAILY
25. Warfarin 3 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Methicillin Resistant Staphylococcus Bacteremia
SECONDARY DIAGNOSES:
High-degree AV block
Atrial fibrillation (?permanent) c/b AV nodal disease
Status post PPM placement ___
Acute on chronic heart failure exacerbation
End stage renal disease on hemodialysis
Chronic obstructive pulmonary disease
Abdominal pain
Depression
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___!
WHY WERE YOU ADMITTED?
- You came to the hospital because you had stuttering speech,
fevers, and a fast heart rate
WHAT HAPPENED IN THE HOSPITAL?
- You were diagnosed with an infection in your blood.
- You had tests that showed that there was no bacterial
infection in your heart.
- You were given antibiotics and your symptoms improved.
- You had your dialysis catheter replaced and a temporary
pacemaker placed.
- You continued on ___ dialysis.
- You had your pacemaker replaced once antibiotics were complete
and there was no longer bacteria in your blood.
WHAT SHOULD YOU DO AT HOME?
- You should follow-up with your cardiologists, nephrologists,
surgeons, and your PCP. Specifically, please follow up with the
cardiac device clinic on ___ as detailed below.
We wish you all the best,
Your ___ Care Team
Followup Instructions:
___
|
10662181-DS-17
| 10,662,181 | 29,664,739 |
DS
| 17 |
2168-06-08 00:00:00
|
2168-06-08 22:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Bradycardia
Major Surgical or Invasive Procedure:
Successful single lead PPM via L axillary generator (___)
History of Present Illness:
___ year old male with CAD, T2DM,
HTN, HFrEF (___), atrial fibrillation, AV nodal disease s/p
PPM, COPD on intermittent home O2, severe TR/moderate AS,
moderate pHTN, and ESRD (HD TTS) with recent admission to ___
for atrial fibrillation with complete heart block who presented
from nursing home this evening with lethargy, weakness, and
sleepiness and was found to be bradycardic to the ___ and
hypotensive to ___. Interrogation of his pacer showed
evidence of failure of his Micra to capture.
The patient was recently admitted to ___ from ___ for
MRSA sepsis requiring explantation of his PPM (previous placed
for atrial fibrillation with high degree AV block). On ___ the
patient underwent placement of a Micra pacemaker by EP without
complication.
Prior to his current presentation, the patient was increasingly
lethargic and falling asleep more frequently. He endorses
generalized weakness but denies any other complaints. He was
found to be bradycardic at his nursing home and was brought to
___ for further evaluation.
In the ED, he was noted to be bradycardic to the ___ with EKG
consistent with atrial fibrillation with complete heart block.
His Micra PPM was not capturing. EP interrogated the Micra,
which
showed that the pacer was not capturing with increasing
threshold, concerning for dislodging of the device. The rate was
increased to 80 with appropriate capture. He was admitted to the
CCU with plans for a procedure in the AM with EP.
On arrival to the CCU, patient was noncompliant with interview
and exam. Would not answer questions and insisted that I leave
the room.
Past Medical History:
ESRD ON HD
HEART FAILURE WITH REDUCED EJECTION FRACTION
DM Type II
HYPERTENSION
HYPERLIPIDEMIA
SMOKER, quit in ___
AV NODE DISEASE s/p PACEMAKER PLACEMENT ___, s/p temp wire
placement ___
CORONARY ARTERY DISEASE
ATRIAL FIBRILLATION
BASAL CELL CARCINOMA
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (uses 2L home O2
intermittently)
ACTINIC KERATOSIS
SQUAMOUS CELL CARCINOMA
PULMONARY HYPERTENSION
GOUT
OBSTRUCTIVE SLEEP APNEA on CPAP
PERIPHERAL VENOUS STASIS
RIGHT HEART FAILURE
Social History:
___
Family History:
Mother with MI in her ___, ETOH and obesity.
1 brother, 1 sister and 2 half sisters. Brother's health is also
failing but unknown conditions.
No known family history of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: HR 80, BP 88/50, RR 24, SpO2 95% on RA, T pt refused
GENERAL: Elderly male laying comfortably in bed.
HEENT: Normocephalic, atraumatic. Patient opening eyes to
commands though would not allow full exam.
NECK: Supple. No JVD appreciable.
CARDIAC: Normal rate, regular rhythm. ___ systolic murmur at
apex. No rubs or gallops.
LUNGS: CTAB when auscultated on anterior surface. Respiration is
unlabored with no accessory muscle use.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
DISCHARGE PHYSICAL EXAM:
========================
GENERAL: Elderly male laying comfortably in bed.
HEENT: Normocephalic, atraumatic. PERRLA EOMI. Sclera anicteric.
NECK: Supple. No JVD appreciable.
CARDIAC: Regular rate and rhythm. ___ systolic murmur at apex.
No
rubs or gallops.
LUNGS: CTAB, no wheezes, rales, or rhonchi. Respiration is
unlabored with no accessory muscle use.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
Pertinent Results:
===============
ADMISSION LABS:
===============
___ 07:57PM BLOOD WBC-10.2* RBC-3.38* Hgb-10.8* Hct-33.2*
MCV-98 MCH-32.0 MCHC-32.5 RDW-17.4* RDWSD-58.8* Plt ___
___ 07:57PM BLOOD ___ PTT-54.1* ___
___ 07:57PM BLOOD Glucose-122* UreaN-40* Creat-5.6*# Na-138
K-4.5 Cl-98 HCO3-23 AnGap-17
___ 07:57PM BLOOD CK(CPK)-42*
___ 07:57PM BLOOD CK-MB-3
___ 07:57PM BLOOD cTropnT-0.22*
___ 06:30AM BLOOD CK-MB-2 cTropnT-0.21*
___ 07:57PM BLOOD Calcium-8.7 Phos-4.9* Mg-2.1
___ 06:45AM BLOOD %HbA1c-5.6 eAG-114
___ 07:57PM BLOOD TSH-0.65
___ 06:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 09:41PM BLOOD Type-ART pO2-78* pCO2-47* pH-7.38
calTCO2-29 Base XS-1
___ 09:41PM BLOOD Lactate-1.8
===============
DISCHARGE LABS:
===============
___ 04:50AM BLOOD WBC-9.1 RBC-3.40* Hgb-10.8* Hct-34.0*
MCV-100* MCH-31.8 MCHC-31.8* RDW-18.4* RDWSD-62.7* Plt ___
___ 04:50AM BLOOD ___ PTT-29.5 ___
___ 04:50AM BLOOD Glucose-96 UreaN-20 Creat-3.3*# Na-141
K-3.9 Cl-100 HCO3-28 AnGap-13
___ 04:50AM BLOOD Calcium-8.5 Phos-3.8 Mg-2.3
================
IMAGING STUDIES:
================
TTE (___):
The left atrial volume index is severely increased. The right
atrium is moderately dilated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is ___
mmHg. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is moderately depressed (LVEF= 30 %). The
right ventricular cavity is moderately dilated with moderate
global free wall hypokinesis. Tricuspid annular plane systolic
excursion is depressed (8 cm) consistent with right ventricular
systolic dysfunction. [Intrinsic right ventricular systolic
function is likely more depressed given the severity of
tricuspid regurgitation.] There is abnormal diastolic septal
motion/position consistent with right ventricular volume
overload. There is a mass in the right ventricle, likely
representing a leadless pacemaker. There are three aortic valve
leaflets. The aortic valve leaflets are moderately thickened.
There is severe aortic valve stenosis (valve area 0.6cm2). No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
tricuspid valve leaflets fail to fully coapt. Severe [4+]
tricuspid regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Moderate-severe global LV systolic dysfunction in
the setting of pacing-induced dyssynchrony. Dilated right
ventricle with severe RV systolic dysfunction. Severe aortic
stenosis. Severe functional tricuspid regurgitation. Leadless
pacemaker present in the RV.
Compared with the prior study (images reviewed) of ___,
biventricular function and degree of tricuspid regurgitation are
similar. Aortic stenosis has worsened and there is no longer a
pacing wire. A leadless pacemaker is now present.
___ CXR
Small left pleural effusion with left basilar atelectasis and
trace right
pleural effusion are unchanged. Left-sided pacemaker and
right-sided 8
minutes catheter also unchanged. Moderate cardiomegaly is
stable. There is evidence of stable pulmonary arterial
hypertension, unchanged. No
pneumothorax is seen
=============
MICROBIOLOGY:
=============
Blood cultures NGTD x2
Brief Hospital Course:
Summary
___ with CAD, HFrEF, ESRD on HD TTS, and atrial fibrillation
with complete heart block s/p recent PPM explantation in the
setting of bacteremia and Micra PPM
implantationon ___ presents with bradycardia likely secondary
to Micra malfunction (possible dislodgement).
#CORONARIES: Unknown
#PUMP: EF ___
#RHYTHM: Regularized atrial fibrillation, ventricular rate 34
# Hypotension
Patient was intermittently hypotensive since admission requiring
low dose phenylephrine. Weaned off pressors slowly with normal
mentation and lactate. Unclear exactly what caused this but
likely severe aortic stenosis and CHF. Lisinopril and Metoprolol
were held and should only be restarted carefully as an
outpatient.
# Bradycardia
# Atrial fibrillation with complete heart block
Patient with history of atrial fibrillation with complete heart
block s/p PPM implantation with recent explantation in the
setting of MRSA bacteremia. Underwent placement of Micra PPM on
___ with device check 1 week later that showed acceptable
function. On presentation, was found to have bradycardia in the
setting of device not capturing initially, although it began
capturing when the rate was increased to 80. He underwent single
lead PPM placement on ___ with good results. He was
continued on outpatient warfarin.
# HFrEF
# Pulmonary hypertension complicated by cor pulmonale
TTE on ___ with EF 30% with moderate global RV free wall
hypokinesis. Severe AS and severe TR. Mild pulmonary artery
systolic hypertension. As above, held his Metoprolol and
lisinopril on discharge.
# Severe AS
Noted on echo with a valve area ~0.6 and high valve gradient
(mean 49). Should follow with ___ cardiology as outpatient for
consideration of TAVR.
# ESRD on HD TTS
Receives HD on TTS via right tunneled dialysis catheter.
Continued HD TTS per renal,
nephrocaps, sevelamer.
# CAD
Continued atorvastatin 80mg daily.
# OSA on BiPAP
On BiPAP per nursing home records, though on previous
hospitalization notes appears to be on CPAP (and consistently
refusing). Will defer BiPAP at this time and readdress if
necessary.
# COPD
On intermittent home O2. Satting well on room air on discharge.
Continued ipratropium/albuterol
# GERD
Continued famotidine 20mg PO daily.
# Anemia
Thought to be secondary to CKD. Continued ferrous sulfate 325mg
PO daily.
# Depression
Continued fluoxetine 40mg PO daily.
Transitional issues
- Will follow-up with Dr. ___ in 4 weeks for PPM followup.
- Should follow with BI cardiology for evaluation of TAVR
placement for severe aortic stenosis.
- Metoprolol and ACEi where held on discharge. Could be
restarted carefully as outpatient if blood pressures stable.
- Patient reported ride from his nursing facility to HD unit is
painful on his back. He reports better when he is able to go in
a wheelchair. I also gave him a short script of oxycodone 5mg to
be used prior to transportation for the pain.
Code: DNR/DNI (has MOLST form)
Name of health care proxy: ___
Relationship: Spouse
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Atorvastatin 80 mg PO QPM
3. Ferrous Sulfate 325 mg PO DAILY
4. FLUoxetine 40 mg PO DAILY
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Metoprolol Succinate XL 12.5 mg PO 4X/WEEK (___)
7. Senna 17.2 mg PO BID
8. sevelamer CARBONATE 800 mg PO TID W/MEALS
9. Thiamine 100 mg PO DAILY
10. Ipratropium-Albuterol Neb 1 NEB NEB Q12H
11. Lisinopril 2.5 mg PO DAILY
12. Nephrocaps 1 CAP PO DAILY
13. Polyethylene Glycol 17 g PO DAILY
14. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
15. Fleet Enema (Mineral Oil) ___AILY:PRN if bisacodyl
suppository ineffective
16. Multivitamins 1 TAB PO DAILY
17. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08
gram-1.8 kcal/mL oral TID W/MEALS
18. ProMod Protein (protein supplement) 30 mL oral BID
19. lactulose 20 gram/30 mL oral DAILY:PRN
20. Famotidine 20 mg PO DAILY
21. Gabapentin 100 mg PO AFTER HD
22. Bisacodyl ___AILY:PRN if no BM
23. Warfarin 3 mg PO DAILY
24. Docusate Sodium 100 mg PO BID:PRN constipation
25. Heparin 5000 UNIT SC BID
26. TraZODone 25 mg PO QHS:PRN insomnia/agitation
27. Ramelteon 8 mg PO QHS:PRN insomnia
Discharge Medications:
1. Lidocaine 5% Patch 1 PTCH TD QAM
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
4. Atorvastatin 80 mg PO QPM
5. Bisacodyl ___AILY:PRN if no BM
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Famotidine 20 mg PO DAILY
8. Ferrous Sulfate 325 mg PO DAILY
9. Fleet Enema (Mineral Oil) ___AILY:PRN if bisacodyl
suppository ineffective
10. FLUoxetine 40 mg PO DAILY
11. Fluticasone Propionate 110mcg 2 PUFF IH BID
12. Gabapentin 100 mg PO AFTER HD
13. Heparin 5000 UNIT SC BID
14. Ipratropium-Albuterol Neb 1 NEB NEB Q12H
15. lactulose 20 gram/30 mL oral DAILY:PRN
16. Multivitamins 1 TAB PO DAILY
17. Nephrocaps 1 CAP PO DAILY
18. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08
gram-1.8 kcal/mL oral TID W/MEALS
19. Polyethylene Glycol 17 g PO DAILY
20. ProMod Protein (protein supplement) 30 mL oral BID
21. Ramelteon 8 mg PO QHS:PRN insomnia
22. Senna 17.2 mg PO BID
23. sevelamer CARBONATE 800 mg PO TID W/MEALS
24. Thiamine 100 mg PO DAILY
25. TraZODone 25 mg PO QHS:PRN insomnia/agitation
26. Warfarin 3 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis
Complete heart block
Severe aortic stenosis
Secondary diagnosis
ESRD
CAD
Chronic dCHF
OSA
COPD
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 came to ___ with weakness due to a problem with your
pacemaker. We did a procedure to place a new pacemaker which
went very well. Please continue to follow with your outpatient
doctors.
It was a pleasure taking care of you, best of luck.
Your ___ medical team
Followup Instructions:
___
|
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|
2169-02-20 15:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dislodged HD catheter
Major Surgical or Invasive Procedure:
___ - tunneled HD line placement
History of Present Illness:
Patient is a ___ male with a history of atrial
fibrillation on systemic anticoagulation, s/p PPM placement iso
AV nodal disease, COPD with 2L home oxygen requirement, T2DM,
and
ESRD on HD (TTS) who presents as a transfer from his nursing
home
given concern for a dislodged dialysis catheter from his right
chest.
Patient reportedly underwent dialysis on ___ without any
complications. His HD line was noted to be dislodged evening
___, no significant bleeding. Site was covered with a
sterile dressing and decision was made to transfer patient to
___ emergency department for
evaluation/management. Patient was found to be hypotensive by
EMS, he was given 250 cc IVS prior to arrival.
Of note, patient was previously seen in our ED ___, similarly
presenting after his HD line became dislodged. Potassium
increased slowly prior to a new tunneled line was placed by ___
___. Patient subsequently was able to undergo dialysis
without complication, he was ultimately discharged home from the
ED without need for admission.
Past Medical History:
T2DM
HFrEF
HTN
HLD
CAD
Pacemaker placement ___ due to AV nodal disease
ESRD on HD
Atrial fibrillation
COPD (home 2L O2)
Skin cancer
OSA on CPAP
Pulmonary HTN
GOUT
Social History:
___
Family History:
Both parents died of heart failure
Son with HTN
Physical Exam:
ADMISSION EXAM:
===============
VITALS: 97.5 102/67 70 18 100 2.5L
General: Easily awoken from sleep, pleasant conversation.
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: No appreciable JVP elevation beyond 2 cm above the
clavicle
with head of bed at 60 degrees.
CV: Distant heart sounds. Regular rate and rhythm with left ear
murmur at the right upper sternal border.
Lungs: Clear to auscultation bilaterally over the anterior lung
fields.
Abdomen: Obese abdomen. Soft, non-tender, non-distended, bowel
sounds present, no organomegaly, no rebound or guarding
Ext: Warm, well perfused. No clubbing, cyanosis or edema.
Skin: Warm, dry, no rashes or notable lesions. Prior tunneled
HD
catheter site is mildly erythematous and there is slight
tenderness to palpation, no palpable abscess/fluid collection,
no
drainage.
DISCHARGE EXAM:
===============
VITALS: 24 HR Data (last updated ___ @ 2351)
Temp: 99.6 (Tm 99.6), BP: 96/59 (96-109/59-74), HR: 70
(68-71), RR: 18, O2 sat: 98% (92-100), O2 delivery: 2 L Nc
General: Lying comfortably in bed in no acute distress.
HEENT: Sclerae anicteric
Neck: JVP not elevated, difficult to assess secondary to body
habitus
CV: Normal rate and rhythm. Grade ___ systolic murmur heard
loudest at base. No rubs or gallops.
Lungs: Clear to auscultation bilaterally without wheezes,
rhonchi, or rales.
Abdomen: Soft, non-tender, non-distended. Normal bowel sounds.
Ext: Lukewarm. No edema.
Skin: HD catheter site is nontender to palpation, nonfluctuant,
nonindurated. Clean dressing overlying line.
Pertinent Results:
ADMISSION LABS:
===============
___ 10:01PM WBC-12.2* RBC-3.13* HGB-10.2* HCT-32.1*
MCV-103* MCH-32.6* MCHC-31.8* RDW-16.9* RDWSD-63.6*
___ 10:01PM NEUTS-62.6 LYMPHS-16.0* MONOS-18.1* EOS-2.0
BASOS-0.6 IM ___ AbsNeut-7.63* AbsLymp-1.95 AbsMono-2.21*
AbsEos-0.24 AbsBaso-0.07
___ 10:01PM ___ PTT-33.2 ___
___ 10:01PM PLT SMR-NORMAL PLT COUNT-180
___ 08:26PM LACTATE-1.7
___ 08:15PM GLUCOSE-155* UREA N-38* CREAT-5.6*#
SODIUM-134* POTASSIUM-4.5 CHLORIDE-95* TOTAL CO2-23 ANION GAP-16
___ 08:15PM ALT(SGPT)-20 AST(SGOT)-26 CK(CPK)-29* ALK
PHOS-179* TOT BILI-0.3
___ 08:15PM LIPASE-42
___ 08:15PM CK-MB-3 cTropnT-0.15* ___
___ 08:15PM ALBUMIN-3.5 CALCIUM-8.5 PHOSPHATE-3.5
MAGNESIUM-2.5
DISCHARGE LABS:
(NOTE: LABS DRAWN PRIOR TO DIALYSIS, PATIENT REFUSED AM LABS ON
DAY OF DISCHARGE)
===============
___ 06:25AM BLOOD WBC-10.2* RBC-3.21* Hgb-10.3* Hct-32.8*
MCV-102* MCH-32.1* MCHC-31.4* RDW-16.5* RDWSD-62.9* Plt ___
___ 06:25AM BLOOD Glucose-176* UreaN-67* Creat-7.7* Na-137
K-4.9 Cl-98 HCO3-19* AnGap-20*
___ 06:25AM BLOOD Calcium-8.7 Phos-3.9 Mg-2.8*
MICROBIOLOGY:
=============
__________________________________________________________
___ 8:32 pm URINE Source: ___.
URINE CULTURE (Pending):
__________________________________________________________
___ 10:10 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 10:03 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 8:55 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 9:03 pm BLOOD CULTURE 2 OF 2.
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 8:15 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
IMAGING:
========
CHEST (PA & LAT) Study Date of ___
IMPRESSION:
1. No pneumothorax. No focal consolidations.
2. Redemonstration of mild pulmonary vascular congestion.
3. Trace pleural effusions, which are improved from prior study.
4. Moderate cardiomegaly is stable.
TUNNELED DIALYSIS LINE PLACEMENT Study Date of ___
IMPRESSION:
Successful replacement of a 23cm tip-to-cuff length tunneled
dialysis line. The tip of the catheter terminates in the right
atrium. The catheter is ready for use.
Brief Hospital Course:
Mr ___ is a ___ male with a history of atrial
fibrillation on systemic anticoagulation, s/p PPM placement iso
AV nodal disease, COPD with home oxygen requirement, ESRD on HD
(TTS), severe aortic stenosis, who presented from his nursing
home because of a dislodged dialysis catheter.
ACUTE ISSUES:
=============
#Dislodged HD catheter
#ESRD on HD (TThSat)
This is patient's second presentation for dislodged HD catheter
within the past several months, unclear why he is having this
difficulty. Patient without signs/symptoms of infection. No
obvious signs of skin or tissue breakdown around the site. Blood
cultures were negative. Patient had replacement of HD line with
___ on ___. Patient received hemodialysis on ___ after line
placement, in keeping with his routine schedule. Of note,
patient was found to be several kilograms above his dry weight
but insisted on terminating HD prematurely before reaching goal
fluid removal. He was continued on home sevelamer and
nephrocaps.
#Hypotension
Patient's SBPs have been in the low 100s over the past weeks
prior to admission, subsequently falling to ___ prior to
transfer to ED. Hypotension likely ___ decreased cardiac output
in the setting of severe aortic stenosis. Patient did not have
any signs/symptoms of infection/sepsis. Patient received 500cc
IVF in ED. His blood pressure was stable at his baseline of low
100s through the rest of admission. His home metoprolol was held
in setting of hypotension.
#Elevated BNP
#Heart failure with reduced ejection fraction (LVEF 30%) -
Patient has a known history of severe cardiomyopathy,
multifactorial in etiology. NT-proBNP was elevated this
admission higher than previous values, although this is in the
setting of ESRD. Chest x-ray revealed mild pulmonary vascular
congestion and trace pleural effusions. Patient did not have any
increase in his oxygen requirement above baseline or subjective
dyspnea. He had some fluid removal through hemodialysis. His
home metoprolol was held in the setting of soft blood pressures.
CHRONIC PROBLEMS:
=================
#Troponinemia, stable
Troponin .15 with MB 3 on admission, stable on repeat in the
setting of ESRD. No acute ischemic changes on ECG. Very unlikely
to represent ACS.
#Severe aortic stenosis (low flow low gradient)
Patient was last evaluated in cardiology clinic ___ (Dr.
___. There was some discussion of referral for TAVR
evaluation should patient have limited exercise tolerance
related to his valvular disease. Given his deconditioning and
multiple medical comorbidities, however, additional workup for
TAVR including coronary angiography was deemed likely futile.
#Atrial fibrillation
Home metoprolol was held in the setting of hypotension. Home
warfarin was held for replacement of his HD catheter.
#Presumed CAD
Continued home atorvastatin
#COPD
Stable through admission. Continued home inhalers, 2L O2
supplementation by nasal cannula as needed.
#Macrocytic anemia
Hemoglobin was stable and at baseline throughout admission.
#T2DM
Maintained on insulin sliding scale
#Dyslipidemia
Continued home atorvastatin
#GERD
Continued home famotidine
#Depression
Continued home fluoxetine
TRANSITIONAL ISSUES:
====================
[ ] At hemodialysis session on ___, patient was noted to be
several kilograms above his dry weight. Patient insisted on
terminating his HD session prematurely despite not at goal
volume removal. He may need additional fluid removal at next HD
session
[ ] Patient should have INR next checked on ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Atorvastatin 80 mg PO QPM
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Famotidine 20 mg PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. FLUoxetine 20 mg PO DAILY
7. Gabapentin 100 mg PO DAILY
8. Nephrocaps 1 CAP PO DAILY
9. Polyethylene Glycol 17 g PO DAILY
10. Ramelteon 8 mg PO QHS:PRN insomnia
11. Senna 17.2 mg PO BID
12. sevelamer CARBONATE 1600 mg PO TID W/MEALS
13. TraZODone 12.5 mg PO QHS:PRN insomnia/agitation
14. Warfarin 3 mg PO DAILY
15. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
16. Fleet Enema (Mineral Oil) ___AILY:PRN if bisacodyl
suppository ineffective
17. Fluticasone Propionate 110mcg 2 PUFF IH BID
18. lactulose 20 gram/30 mL oral DAILY:PRN
19. Multivitamins 1 TAB PO DAILY
20. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08
gram-1.8 kcal/mL oral TID W/MEALS
21. ProMod Protein (protein supplement) 30 mL oral BID
22. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate
23. LamoTRIgine 25 mg PO DAILY
24. Loratadine 10 mg PO DAILY
25. Metoprolol Succinate XL 6.25 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
3. Atorvastatin 80 mg PO QPM
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Famotidine 20 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. Fleet Enema (Mineral Oil) ___AILY:PRN if bisacodyl
suppository ineffective
8. FLUoxetine 20 mg PO DAILY
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
10. Gabapentin 100 mg PO DAILY
11. lactulose 20 gram/30 mL oral DAILY:PRN
12. LamoTRIgine 25 mg PO DAILY
13. Loratadine 10 mg PO DAILY
14. Metoprolol Succinate XL 6.25 mg PO BID
15. Multivitamins 1 TAB PO DAILY
16. Nephrocaps 1 CAP PO DAILY
17. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08
gram-1.8 kcal/mL oral TID W/MEALS
18. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate
19. Polyethylene Glycol 17 g PO DAILY
20. ProMod Protein (protein supplement) 30 mL oral BID
21. Ramelteon 8 mg PO QHS:PRN insomnia
22. Senna 17.2 mg PO BID
23. sevelamer CARBONATE 1600 mg PO TID W/MEALS
24. TraZODone 12.5 mg PO QHS:PRN insomnia/agitation
25. Warfarin 3 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
-Dislodged hemodialysis catheter
-ESRD on hemodialysis
SECONDARY DIAGNOSES:
-Severe aortic stenosis
-Chronic systolic heart failure
-Atrial fibrillation
-Type II diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
-You were admitted because your dialysis catheter came dislodged
What did you receive in the hospital?
-You had your dialysis catheter replaced by interventional
radiology
-You received dialysis
What should you do once you leave the hospital?
-You should take all your medications as prescribed
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
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2169-03-15 00:00:00
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2169-03-15 17:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hypotension, unresponsiveness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M with ESRD on HD TThS, HFrEF (EF 30%), mixed
cardiomyopathy, cor pulmonale ___ COPD/OSA, severe pulmonary
HTN, chronic AF on warfarin, AV nodal disease s/p PPM ___ c/b
device infection with new ___ device placement ___, HTN,
HLD, probable CAD, DM who presents from dialysis with
unresponsiveness and hypotension.
While at HD, pt was noted to be unresponsive and cyanotic
appearing after receiving 3.5h of scheduled 4h dialysis. CPR was
planned to be started but pt woke up on his own. HR at that time
noted to be irregular in the 70-80s. Unable to recount events of
his syncopal event. Denies any presyncopal symptoms. Felt
slightly lightheaded afterward the event with some nausea and
shortness of breath but no chest pain. These symptoms resolved
after a few minutes. This has not occurred in the past with
dialysis, and he has no history of recent falls or prior
syncope. Prior to dialysis that day he was feeling overall well,
and denies fevers, chills, cough, abdominal pain, vomiting,
dysuria, diarrhea. In the ED, - Initial vitals were: T98, HR 80,
BP 89/62 (lowest BP 66/46 while in ED), RR 18, 95-100% RA - Exam
notable for: BP 89/62, otherwise benign - Labs notable for:
Trop-T 0.13, MB 4, lactate 2.0, Na 130, K 5.9, Cr 3.2, WBC 11.4
(67.7% PMNs), INR 1.7 - Studies notable for: CXR with pulmonary
vascular congestion and no frank pulmonary edema, bilateral
small pleural effusion - Patient was given: 750cc NS, On arrival
to the CCU, patient reports feeling well after receiving some
fluid down in the ED and with improvement in his BP. He denies
any current lightheadedness/dizziness, chest pain, shortness of
breath, palpitations, fever/chills, URI symptoms, nausea,
diarrhea, dysuria, hematochezia or melena. He does report some
stable morning cough with white phlegm production - no increase
in coughing, phlegm production, or change in phlegm color. ROS:
Positive per HPI. Remaining 10 point ROS reviewed and negative.
Past Medical History:
T2DM
HFrEF
HTN
HLD
CAD
Pacemaker placement ___ due to AV nodal disease
ESRD on HD
Atrial fibrillation
COPD (home 2L O2)
Skin cancer
OSA on CPAP
Pulmonary HTN
GOUT
Social History:
___
Family History:
Both parents died of heart failure
Son with HTN
Physical Exam:
ADMISSION EXAM
===============
VS: T98, BP 107/75, HR 73, O2 92% on RA
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI
NECK: Supple. JVP flat
CARDIAC: Normal rate, regular rhythm. harsh systolic ejection
murmur.
LUNGS: CTAB. Respiration is unlabored with no accessory muscle
use. No adventitious breath sounds.
ABDOMEN: Soft, non-tender, non-distended. No palpable
hepatomegaly or splenomegaly.
EXTREMITIES: Cool, dry. No clubbing, cyanosis, or peripheral
edema.
SKIN: No significant lesions or rashes. Several scabs on his
bilateral legs, sacral decubitus ulcer dressed
PULSES: Distal pulses palpable and symmetric.
NEURO: A&Ox3, moving all 4 extremities spontaneously, CNII-XII
intact
DISCHARGE EXAM
==============
VS: 24 HR Data (last updated ___ @ 529)
Temp: 98.6 (Tm 98.6), BP: 104/66 (91-110/53-68), HR: 68
(63-72), RR: 16 (___), O2 sat: 99% (90-99), O2 delivery: 2L
GENERAL: Lying in bed, NAD
HEENT: MMM.
NECK: Supple. JVP flat
CARDIAC: Normal rate, regular rhythm. harsh systolic ejection
murmur.
LUNGS: CTAB, mild wheezing
ABDOMEN: Soft, non-tender, non-distended. No palpable
hepatomegaly or splenomegaly.
EXTREMITIES: No peripheral edema.
PULSES: Distal pulses palpable and symmetric.
NEURO: A&Ox3, moving all 4 extremities spontaneously
Pertinent Results:
ADMISSION LABS
==============
___ 02:55PM BLOOD WBC-11.4* RBC-4.15* Hgb-13.4* Hct-42.5
MCV-102* MCH-32.3* MCHC-31.5* RDW-15.9* RDWSD-60.3* Plt ___
___ 02:55PM BLOOD Neuts-67.7 Lymphs-15.4* Monos-12.0
Eos-2.3 Baso-0.9 Im ___ AbsNeut-7.69* AbsLymp-1.75
AbsMono-1.36* AbsEos-0.26 AbsBaso-0.10*
___ 02:55PM BLOOD Glucose-113* UreaN-19 Creat-3.2*# Na-130*
K-5.9* Cl-92* HCO3-22 AnGap-16
___ 09:06PM BLOOD Glucose-122* UreaN-23* Creat-3.5* Na-129*
K-5.8* Cl-94* HCO3-20* AnGap-15
___ 02:55PM BLOOD ___ PTT-30.6 ___
___ 02:55PM BLOOD cTropnT-0.13*
___ 09:06PM BLOOD CK-MB-4 cTropnT-0.13*
___ 02:55PM BLOOD Calcium-8.4 Phos-3.1 Mg-2.1
___ 04:25PM BLOOD Lactate-2.0
DISCHARGE LABS
===============
___ 05:35AM BLOOD WBC-10.1* RBC-3.20* Hgb-10.4* Hct-33.4*
MCV-104* MCH-32.5* MCHC-31.1* RDW-15.9* RDWSD-60.8* Plt ___
___ 05:35AM BLOOD ___ PTT-71.5* ___
___ 05:35AM BLOOD Glucose-94 UreaN-45* Creat-5.2*# Na-140
K-4.5 Cl-99 HCO3-27 AnGap-14
___ 05:35AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.3
IMAGING
=======
CHEST PORTABLE AP (___)
Low lung volume. Pulmonary vascular congestion without frank
pulmonary edema and bilateral small pleural effusions as on ___.
STUDIES/PROCEDURES
====================
Device interrogation note ___:
Summary:
1. No HRE's to explain pt's loss of consciousness
2. Pacer function normal with acceptable lead measurements and
battery status. See uploaded report for details.
3. Programming changes: None
4. Follow-up: Routine device clinic follow up
MICROBIOLOGY
=============
___ 11:29 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending): No growth to date.
___ 5:23 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 12:19 pm BLOOD CULTURE Source: Line-tunneled HD.
Blood Culture, Routine (Pending): No growth to date.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
=======================
___ M with ESRD on HD TThS, HFrEF (EF 30%), mixed
cardiomyopathy, cor pulmonale ___ COPD/OSA, severe pulmonary
HTN, chronic AF on warfarin, AV nodal disease s/p PPM ___ c/b
device infection with new ___ device placement ___, HTN,
HLD, probable CAD, DM who presents from dialysis with
unresponsiveness
and hypotension.
#CORONARIES: unknown, suspected ischemic disease
#PUMP: EF 30% (___)
#RHYTHM: V-paced, HR 70
ACUTE ISSUES:
=============
#Syncope - resolved
Presented for witnessed syncopal episode during HD concerning
for cardiac etiology given sudden onset and rapid resolution,
given patient's extensive cardiac comorbidities. Most likely in
setting of fluid shifts during HD causing poor forward flow in
setting of severe aortic stenosis causing poor perfusion in the
setting of fluid shifts of HD. ACS less likely given trops at
baseline (elevated in setting of ESRD). Seizure less likely
given no definite post-ictal state or witnessed tonic clonic
activity. Rapid neurologic recovery less consistent with TIA. Of
note, TAVR eval and ICD previously deferred by outpatient teams
due to invasive nature and functional status. Patient was given
750 cc of fluid in the ED with improvement of blood pressure and
mental status. Upon reaching the CCU his blood pressures has
returned to baseline and he was feeling well. His device was
interrogated on ___ which did not reveal any high rate events
or malfunction of the pacemaker.
#Hypotension - resolved
Patient with hypotension to ___ (lowest 66/46 while in ED)
that improved after 750 cc fluid bolus. There was no report of
fever, leukocytosis above baseline, findings on CXR, or
localizing symptoms of infection to suggest sepsis. Normal
mentation and normal lactate reassuring against shock. ___
related to hypovolemia/fluid shifting during HD given
improvement with fluids.
#HFrEF (EF 30%)
#Mixed cardiomyopathy
#severe low flow low gradient AS (valve area <1cm2)
Patient with episode of syncope/hypotension potentially in
setting of worsening. Less likely due to HF exacerbation - no
evidence of frank pulmonary edema on CXR or and seems euvolemic
on exam. Has had ongoing discussion with outpt cardiologist Dr.
___ as to whether or not patient would want to pursue TAVR
although per recent clinic note, further invasive therapies seem
unwarranted at this point given his poor rehab potential (has
been at rehab for over a year) and has multiple medical
comorbidities. His home metoprolol was held in the setting of
hypotension and restarted on ___. Patient is not on ___
due to baseline hypotension. He should have continued
conversations with Dr. ___ potential for TAVR if he
becomes more symptomatic from his severe AS, or for potential
biventricular ICD placement.
#Afib
CHADS2VASC 6
On home warfarin and metoprolol. Initially held home metoprolol
in setting of hypotension. Home metoprolol was restarted on
___. His INR was noted to be sub-therapeutic at 1.7 and
downtrended to 1.4. Patient was started on a heparin drip given
high CHADs2VASC while continuing home warfarin with a goal INR
___. Downtrending INR was a barrier to discharge and he remained
on a heparin drip while bridging to therapeutic INR until 1.8 on
day of discharge, thought to be acceptable in the absence of hx
prior stroke or mechanical valve. Anticipate him to be
therapeutic day after discharge.
#ESRD on HD ___:
Recently started on HD three months prior through R IJ tunneled
catheter. Nephrology was consulted who agreed that syncopal
event likely related to excess UF in patient with low flow AS.
Continued home sevelamer and nephrocaps. Last HD session on
___
#Troponemia
Trop-T to 0.13 and stable on repeat, similar to previously noted
elevated Trop 0.11-0.15, likely in setting of ESRD. CKMB 4. No
acute ischemic changes on ECG or chest pain.
CHRONIC ISSUES:
===============
#HLD #suspected CAD: Continued home atorvastatin 80 qPM.
#COPD: Per rehab no longer on inhalers/bronchodilators, though
noted to have a history of COPD. On home 2L O2 PRN O2>88%. Has
not seen his pulmonologist in over ___ years - will set up follow
up appointment for this.
#T2DM: Placed on ISS.
#GERD: Continue home famotidine.
#Depression: Continued home fluoxetine
#OSA: Did not come in on home CPAP, should have pulmonology
follow up to initiate CPAP if appropriate.
TRANSITIONAL ISSUES
===================
[] Due for HD on ___
[] Will require follow-up daily INR checks or earliest
available.
[] TAVR not currently appropriate option. Though continue to
re-address at future cardiology follow-up. ___, CRT-D not
within ___.
[] Consider decreasing metoprolol on HD days.
[] Consider lessening ultrafiltration for volume removal in
setting of severe AS.
[] Will need to re-establish care with pulmonology to reconcile
bronchodilators for COPD and CPAP for OSA
CORE MEASURES
=============
CODE: Full confirmed
#CONTACT/HCP: ___ Relationship: Spouse Phone number:
___
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atorvastatin 80 mg PO QPM
2. Famotidine 20 mg PO DAILY
3. FLUoxetine 20 mg PO DAILY
4. Gabapentin 100 mg PO BID
5. LamoTRIgine 25 mg PO DAILY
6. Metoprolol Tartrate 6.25 mg PO BID
7. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
8. sevelamer CARBONATE 800 mg PO DAILY
9. TraZODone 50 mg PO QHS:PRN insomnia
10. ___ MD to order daily dose PO DAILY16
Discharge Medications:
1. Metoprolol Succinate XL 12.5 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Famotidine 20 mg PO DAILY
4. FLUoxetine 20 mg PO DAILY
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Gabapentin 100 mg PO DAILY
7. LamoTRIgine 25 mg PO DAILY
8. Loratadine 10 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
11. Polyethylene Glycol 17 g PO DAILY
12. sevelamer CARBONATE 1600 mg PO TID W/MEALS
13. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
Syncope
Hypotension
Severe Aortic stenosis
Atrial Fibrillation
SECONDARY DIAGNOSIS
=====================
Chronic systolic heart failure
End stage renal disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
Please see below for more information on your hospitalization.
It was a pleasure taking part in your care here at ___!
We wish you all the best!
- Your ___ Care Team
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were sent to the hospital from dialysis for low blood
pressure.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- When you came to the hospital your blood pressure had
improved. The low blood pressure is likely due to dialysis
taking off a little too much fluid too quickly.
- We checked your pacemaker which did not show any irregular
heart rhythms
- We evaluated you for infection which was negative.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Weigh yourself every morning, seek medical attention if your
weight goes up more than 3 lbs.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
Followup Instructions:
___
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2191-01-07 13:46:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right ankle fracture
Major Surgical or Invasive Procedure:
___ IM Nail R tibia, posterior malleolar screws
History of Present Illness:
___ presents after mech fall on ice wearing high heels with
R leg pain. No headstrike or LOC. Unable to ambulate at scene.
Only complains of R leg pain. Denies numbness/tingling,
weakness,
or other complaints.
Past Medical History:
none
Social History:
___
Family History:
non contributory
Physical Exam:
NAD
AAOx3
RIGHT LOWER EXTREMITY:
Dressing in place without significant drainage
Extremity without obvious deformity
Air Cast Boot in place
___ FHL ___ TA PP Fire
SILT LFCN, PFCN, Obturator, Saphenous, Sural, DP, SP, Plantar
2+ DP, ___ pulses; foot warm, well-perfused
Compartments soft (thigh, leg, foot)
Minimal pain to passive stretch of toes
No noted knee effusion
Pertinent Results:
___ 01:40AM GLUCOSE-107* UREA N-12 CREAT-0.7 SODIUM-140
POTASSIUM-3.1* CHLORIDE-104 TOTAL CO2-20* ANION GAP-19
___ 01:40AM WBC-6.1# RBC-3.88* HGB-12.0 HCT-34.9* MCV-90
MCH-31.0 MCHC-34.5 RDW-12.1
___ 01:40AM NEUTS-46.5* LYMPHS-45.3* MONOS-6.1 EOS-1.1
BASOS-1.0
___ 01:40AM PLT COUNT-275
___ 03:52AM ___ PTT-22.5* ___
Brief Hospital Course:
Ms. ___ was admitted to the Orthopedic service on ___ for
right tib/fib and tri-mal type ankle fracture after being
evaluated and treated with closed reduction in the emergency
room. She underwent IM nail R tibia and posterior malleolar
screws without complication on ___. Please see operative
report for full details. She was extubated without difficulty
and transferred to the recovery room in stable condition. In
the early post-operative course she did well and was transferred
to the floor in stable condition. She continued to progress
without issue, resuming regular diet and voiding.
She had adequate pain management and worked with physical
therapy while in the hospital. An air cast boot was placed on
her Right leg. She also complained of vaginal irritation and
was treated orally for yeast infection. The remainder of her
hospital course was uneventful and she is being discharged to
home in stable condition.
Medications on Admission:
None
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours)
as needed for Pain for 2 weeks.
Disp:*50 Tablet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*25 Capsule(s)* Refills:*2*
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*25 Tablet(s)* Refills:*0*
4. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous QPM (once a day (in the evening)) for 2 weeks: 40
mg daily for 2 weeks.
Disp:*15 syringe* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
right tib-fib and tri-mal type ankle 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:
Wound Care:
- Keep Incision clean and dry.
- Keep pin sites clean and dry.
- You can get the wound wet or take a shower starting from 7
days after surgery, but no baths or swimming for at least 4
weeks.
- Dry sterile dresssing may be changed daily. No dressing is
needed if wound continues to be non-draining.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
Activity:
- Continue to be touch down weight bearing on your right leg
- You should not lift anything greater than 5 pounds.
- Elevate right leg to reduce swelling and pain.
- Do not remove splint/brace. Keep splint/brace dry.
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox to prevent blood clots.
- You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on ___ 2.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
- If you have questions, concerns or experience any of the below
danger signs then please call your doctor at ___ or go
to your local emergency room.
Followup Instructions:
___
|
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2185-07-11 14:15:00
|
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 following a fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
GCS Score at the Scene: ----- [X] Unknown
- If unknown, GCS score at presentation to our ED: ___
ICH volume by ABC/2 method: 7.6 cc
ICH Score: 1
Pre-ICH mRS ___ social history for description): 3
HPI: The patient is a ___ woman with a past medical
history of dementia who presents with confusion following a fall
(unclear etiology) with noncontrast head CT showing a right
intraparenchymal hemorrhage in the occipital lobe. History is
provided with the assistance of patient's 3 grandchildren at
bedside.
Patient lives with her daughter and son-in-law. She is able to
walk independently and occasionally uses a cane. She needs
assistance with all of her activities of daily living including
getting dressed and showering. She wears diapers and needs
assistance when she uses the bathroom. She cannot cook or
clean.
At baseline, she does not know the date. She likes to watch TV.
On the day prior to presentation, she slid out of her recliner
in
the evening. She hit her buttock and did not hit her head.
Overnight, her daughter awoke around 2:30 AM to hear a thud.
She
found patient in her bedroom on the ground. The room was
somewhat disorganized and the pictures on the nightstand were
all
on the ground. This had never happened before. Patient is
unaware as to how she fell and she states that she might of
gotten up to use the bathroom.
Patient was initially brought to ___ where she was
found to have a urinary tract infection (she was given
ceftriaxone) and a noncontrast head CT showed a right occipital
lobe hemorrhage. She was transferred to ___ for further
management.
At the time of my evaluation, patient reports a right-sided
headache that has now improved after receiving Tylenol. She
does
not know why she is in the hospital and has no other complaints.
Of note, patient reportedly also fell 1 week ago while walking
in
the kitchen. She slid and landed on her buttock at the time and
did not reportedly hit her head.
ROS unable to be reliably obtained.
Past Medical History:
Dementia (unclear subtype)
Hypothyroidism
Osteoarthritis in hips
Social History:
___
Family History:
Daughter: ___
Physical ___:
ADMISSION PHYSICAL EXAM:
Vitals: 98.4 80 111/62 97% RA
General: NAD, resting in bed, chronically ill-appearing
HEENT: NCAT, no oropharyngeal lesions, moist mucous membranes,
sclerae anicteric
___: RRR
Pulmonary: CTAB
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Drowsy but arouses to voice. Does not answer
questions when asked the date. When asked where she is, she
answers shopping mall on multiple choice testing (grandchildren
state that this is her baseline). Unable to answer the question
who is her president. Able to follow simple commands both
appendicular (show me your thumb, show me 2 fingers) and midline
(stick out your tongue). Speaks ___ word phrases fluently.
Inattentive during examination and frequently has to be
redirected. Does not attend as well to the left visual field.
- Cranial Nerves - PERRL 3->2 brisk. Left homonymous
hemianopsia. EOMI, no nystagmus. V1-V3 without deficits to light
touch bilaterally. No facial movement asymmetry. Hearing intact
to finger rub bilaterally. Mild dysarthria. Palate elevation
symmetric. Tongue midline.
- Motor - Normal bulk and tone. L upward drift. No tremor or
asterixis. Strength is grossly intact throughout.
- Sensory - No deficits to light touch, pin, or proprioception
bilaterally.
-DTRs: ___ hypoactive throughout. Plantar response
extensor
on the left and mute on the right.
- Coordination - Hesitates with finger-nose-finger testing
bilaterally but grossly intact.
- Gait - Deferred.
DISCHARGE PHYSICAL EXAM:
Vitals: Tm 98.7, HR 74-88, BP 104-143/67-83, RR ___, >91%RA
Gen: older woman sitting in bed, NAD
HEENT: NCAT, no bruising appreciated, no oropharyngeal lesions,
moist mucous membranes
___: RRR
Pulmonary: CTAB
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Awake, alert, oriented to self, place
(hospital, ___, not to season (___). Names spoon and
coffee. Able to follow simple midline and appendicular commands
but requires significant redirection. Speaks ___ word phrases
fluently. Does not attend as well to the left visual field.
- Cranial Nerves - PERRL 3->2 brisk. Left homonymous
hemianopia. EOMI, no nystagmus. V1-V3 without deficits to light
touch bilaterally. No facial movement asymmetry. Hearing intact
to finger rub bilaterally. Mild dysarthria. Palate elevation
symmetric. Tongue midline.
- Motor - Normal bulk and tone. Moves all extremities
antigravity. No tremor or
asterixis. Strength is grossly intact throughout.
- Sensory - No deficits to light touch, pin, or proprioception
bilaterally.
-DTRs: ___ hypoactive throughout. Plantar response
extensor
on the left and mute on the right.
- Coordination - Hesitates with finger-nose-finger testing
bilaterally but grossly intact.
- Gait - able to stand and pivot with assistance.
Pertinent Results:
___ 05:00AM BLOOD WBC-6.3 RBC-3.55* Hgb-10.8* Hct-33.2*
MCV-94 MCH-30.4 MCHC-32.5 RDW-14.1 RDWSD-48.7* Plt ___
___ 03:45PM BLOOD Neuts-74.5* Lymphs-13.9* Monos-10.4
Eos-0.4* Baso-0.3 Im ___ AbsNeut-6.90* AbsLymp-1.29
AbsMono-0.96* AbsEos-0.04 AbsBaso-0.03
___ 03:45PM BLOOD ___ PTT-27.2 ___
___ 05:00AM BLOOD Glucose-84 UreaN-17 Creat-0.8 Na-139
K-4.0 Cl-104 HCO3-24 AnGap-15
___ 05:00AM BLOOD cTropnT-<0.01
___ 05:00AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.1
___ 05:00AM BLOOD WBC-6.7 RBC-3.55* Hgb-10.7* Hct-33.3*
MCV-94 MCH-30.1 MCHC-32.1 RDW-14.0 RDWSD-47.5* Plt ___
___ 03:45PM BLOOD ___ PTT-27.2 ___
___ 05:00AM BLOOD Glucose-93 UreaN-13 Creat-0.8 Na-140
K-4.0 Cl-102 HCO3-21* AnGap-21*
___ 05:00AM BLOOD Calcium-9.2 Phos-3.3 Mg-2.2
IMAGING:
OSH CT ___, 10:45a): Right occipital lobe IPH.
?layering with
hypodensity extending into the right occipital lobe.
MRI/A ___:
IMPRESSION:
1. Grossly unchanged 29 x 19 mm acute right occipital
intraparenchymal
hemorrhage without definite underlying enhancing mass. However,
a prominent adjacent vessel is seen which could potentially
represent draining veins in the setting of arteriovenous
malformation, or possibly a developmental venous anomaly which
could suggest an underlying cavernous malformation, though no
definite nidus is seen, potentially effaced by the volume of
hemorrhage. Alternatively, given the scattered areas of
subcortical chronic microhemorrhage, cerebral amyloid is
considered a reasonable explanation for the cause of bleed. In
this case, the surrounding prominent vascularity may be due to
reactive hyperemia.
2. Additional 20 x 18 mm right posterior temporal subacute
intraparenchymal hemorrhage without definite underlying
enhancing lesion or vascular malformation seen.
3. Small right temporal subacute subdural hematoma measuring up
to 6 mm in
maximal thickness, not well seen on the prior CT examination.
4. Mild narrowing of the P1 and P 2 segments of the bilateral
posterior
cerebral arteries and distal M1 segment of the right middle
cerebral artery, likely atherosclerotic.
5. 7 x 3 mm posteriorly directed extradural aneurysm of the
petrous segment of the left internal carotid artery.
6. Otherwise patent intracranial arterial vasculature without
high-grade
stenosis or occlusion.
7. Mild global atrophy and confluent areas of white matter
signal abnormality in a configuration most suggestive of chronic
small vessel ischemic disease.
8. Mild paranasal sinus mucosal wall thickening and bilateral
mastoid air cell opacification, nonspecific, which can be seen
in the setting of acute
sinusitis given the appropriate clinical context.
RECOMMENDATION(S): Continued follow-up examinations with
gadolinium enhanced MRI to resolution of hemorrhage is
recommended in order to definitively exclude an underlying mass
or vascular malformation.
Brief Hospital Course:
Ms. ___ is an ___ woman with a past medical history of
dementia who presented with confusion following a fall (unclear
etiology) with noncontrast head CT showing a right
intraparenchymal hemorrhage in the occipital lobe. Examination
was notable for a left homonymous hemianopsia and baseline
mental status deficits. There was no evidence of significant
trauma; OSH lumbar spine CT showed degenerative disease but no
fracture per Neuroradiology.
Etiology of bleed was most likely amyloid angiopathy in the
setting of underlying dementia, less likely underlying mass
lesion or hemorrhagic conversion of a prior ischemic infarct, or
AVM/cavernoma. There was no evidence of expansion of the bleed
on repeat imaging. Would consider repeat imaging in ___ months
to re-evaluate for an underlying lesion after hemorrhage
resolves. Aspirin and all anticoagulation was held in the
setting of the bleed. She should continue to avoid these
medications; can use limited NSAIDs in ___ weeks. She was
treated with ceftriaxone for 3 days for a presumed UTI (final
culture negative). She remained afebrile with stable vital
signs. She had some urinary retention in addition to
incontinence for which she was straight catheterized, this
should be continued to be followed closely. Repeat UA was
negative thus infection was not thought to be the cause of this
incontinence and retention. She will be discharged to rehab
where she will continue to work with ___ and OT.
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 75 mcg PO DAILY
2. Gabapentin 100 mg PO TID
3. Donepezil 10 mg PO QHS
4. RisperiDONE 1 mg PO QAM
5. RisperiDONE 1.5 mg PO QPM
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Donepezil 10 mg PO QHS
3. Gabapentin 100 mg PO TID
4. Levothyroxine Sodium 75 mcg PO DAILY
5. RisperiDONE 1 mg PO QAM
6. RisperiDONE 1.5 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right occipital intraparenchymal hemorrhage
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of confusion after a fall
resulting from an ACUTE HEMORRHAGIC STROKE, which is bleeding in
the brain.
The brain is the part of your body that controls and directs all
the other parts of your body, so damage to the brain 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:
STOP Aspirin.
Avoids NSAIDs for the next ___ weeks
Please take your other medications as prescribed.
Please follow-up with Neurology and your primary care physician.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10662778-DS-20
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| 20 |
2159-09-05 00:00:00
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2159-09-05 10:28:00
|
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
___ Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L ankle fracture
Major Surgical or Invasive Procedure:
___: ORIF L ankle
History of Present Illness:
___ yo F with hx of breast cx who was walking down her stairs out
of her apartment when she fell down the last few stairs. Noticed
immediate pain and deformity of her ankle. Reports the knee felt
like it "gave out" which it does sometimes due to her MS. ___
knee pain currently. Ankle is relatively comfortable in ED.
Past Medical History:
hx breast cancer ___ years ago
Social History:
___
Family History:
Non-contributory
Physical Exam:
___ acute distress
Unlabored breathing
Abdomen soft, non-tender, non-distended
Splint in place, clean, dry, and intact
Fires TA, GC, ___, FHL. SILT.
Pertinent Results:
___ 10:37PM BLOOD WBC-11.7* RBC-4.19 Hgb-12.9 Hct-39.0
MCV-93 MCH-30.8 MCHC-33.1 RDW-11.9 RDWSD-41.2 Plt ___
___ 10:37PM BLOOD Neuts-78.7* Lymphs-14.0* Monos-5.3
Eos-1.3 Baso-0.3 Im ___ AbsNeut-9.17* AbsLymp-1.63
AbsMono-0.62 AbsEos-0.15 AbsBaso-0.04
Xray L ankle ___: Images demonstrate fixation of medial
malleolar fracture with fixation screws. Lateral malleolar
fracture is transfixed by a lateral plate with multiple
interlocking screws. Trans syndesmotic screws are evident. For
details of the surgical procedure, please see the procedure
report.
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have L ankle fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for ORIF L 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 rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
non weight bearing in the left lower extremity, and will be
discharged on aspirin 325mg daily for DVT prophylaxis. The
patient will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Atenolol 50 mg PO DAILY
3. Bisacodyl 10 mg PO DAILY:PRN constipation
4. Docusate Sodium 100 mg PO BID
5. Ondansetron 8 mg PO Q8H:PRN nausea
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
7. Senna 8.6 mg PO BID:PRN constipation
8. Aspirin 325 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L ankle 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
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40mg daily for 4 weeks
WOUND CARE:
- You may shower. ___ 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.
- ___ 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
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
Physical Therapy:
Activity: Left lower extremity: Non weight bearing
splint LLE
Treatments Frequency:
Site: L ankle
Description: ACE wrap dsg and splint, CDI
Care: monitor for s/s infection
Followup Instructions:
___
|
10663181-DS-8
| 10,663,181 | 27,480,793 |
DS
| 8 |
2181-10-21 00:00:00
|
2181-10-21 20:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Rapid atrial fibrillation and fever of unknown origin
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ male with the past medical of
diabetes mellitus well controlled with last HgbA1C = 6.1%, who
presents as a transfer from ___. He reports 5 days
of fever 100-103, headache and fatigue 3 weeks ago. This
resolved and he felt well again. He flew to ___ and while in
___ last ___ (ten days after the initial fever) he
developed
additional fevers 100.2-103.5 with had a decreased appetite and
lethargy. One difference with his febrile illness this time was
that he developed a tickle in throat with a dry cough and
shortness of breath when speaking. He went to see his PCP today
after returning from his trip and was found to have new
tachycardia with atrial fibrillation. He also reported diarrhea
and an 18 lb weight loss. He did not have any chest pain or
shortness of breath. In the ___ he had a normal chest
x-ray and a negative CTA. Diltiazem 10 mg IV was given without
effect on heart rate but his blood pressure dropped into the
___.
His blood pressure improved with IV fluids. He had a negative
flu swab. He was given 4 L of normal saline and digoxin 0.25
mg.
He was also given 10 units of regular insulin.
He was then transferred to ___ for an infectious disease
evaluation given his tick exposures at home (200 tick bites in
the last year) and significant travel to ___. He was there in
___ prior to becoming ill. He also had low platelet counts
87. In the emergency room at ___ is vital signs were 98.2,
heart rate 120, blood pressure 100/65, respiratory rate 18, and
oxygen sat 98% on room air upon and upon presentation to the ___.
In the ___ his labs are significant for a blood glucose of 244
his
bicarb was 21, his VBG showed a normal pH of 7.41. His flu swab
was negative. His albumin was low at 2.5 his lipase was
borderline elevated at 77. His parasite smear is pending. His
platelet count again returned low at 80. He received 4 L of IV
crystalloid and diltiazem 30 mg in the ___. his EKG demonstrates
atrial fibrillation at 128 bpm normal axis no q waves and no
acute ST changes.
He has never been sick prior to this.
.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Hypercholesterolemia
diabetes
Social History:
___
Family History:
His father has a history of renal disease, his brother has a
history of diabetes. His father died of renal failure/hip
fracture at age ___. His mother died of stroke she was ___ years
old.
Physical Exam:
ADMISSION EXAM
97.8 PO |121 / 80R | 130| 18| 91% on ra
VITALS:
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
NECK: No nuchal rigidity
CV: Heart irregularly irregular, no clear murmur but difficult
to
appreciate given the rate, no S3, no S4. No JVD.
RESP: Lungs largely clear to auscultation with good air movement
bilaterally. Breathing is non-labored except when he speaks.
Occasional cough
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: erythematous papule on L inner arm at site of old tick
bite. No EM.
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM
AVSS, initially AFib in ___ (including w ambulation) and then
later in day spontaneously converted to NSR in ___, BP wnl
throughout, sat >95% on RA
very pleasant, NAD, looks well
neck supple
MMM, no lesions
initially irregularly irregular but later regular, no mrg
CTAB
neg CVAT
sntnd, neg HSM
wwp, neg edema
no rash
A&O grossly, EOMI, PERRL, no droop, ___ BUE/BLE
Pertinent Results:
Admission Labs:
___ 11:44PM BLOOD WBC-11.8* RBC-4.51* Hgb-13.5* Hct-39.7*
MCV-88 MCH-29.9 MCHC-34.0 RDW-13.0 RDWSD-42.1 Plt Ct-80*
___ 05:03AM BLOOD WBC-11.2* RBC-4.44* Hgb-13.1* Hct-38.6*
MCV-87 MCH-29.5 MCHC-33.9 RDW-13.1 RDWSD-41.2 Plt Ct-85*
___ 07:10AM BLOOD WBC-8.0 RBC-4.41* Hgb-13.0* Hct-39.1*
MCV-89 MCH-29.5 MCHC-33.2 RDW-13.2 RDWSD-43.5 Plt ___
___ 11:44PM BLOOD Neuts-70 Bands-1 ___ Monos-6 Eos-1
Baso-0 Atyps-2* ___ Myelos-0 AbsNeut-8.38* AbsLymp-2.60
AbsMono-0.71 AbsEos-0.12 AbsBaso-0.00*
___ 05:03AM BLOOD ___ PTT-30.6 ___
___ 11:44PM BLOOD Glucose-244* UreaN-31* Creat-0.9 Na-137
K-4.5 Cl-100 HCO3-21* AnGap-16
___ 11:44PM BLOOD Lipase-77*
___ 05:03AM BLOOD proBNP-1885*
___ 05:03AM BLOOD Calcium-7.5* Phos-2.8 Mg-2.3
___ 11:44PM BLOOD Albumin-2.5*
___ 07:10AM BLOOD CRP-35.4*
___ 09:15AM BLOOD HIV Ab-NEG
___ 11:44PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 11:55PM BLOOD ___ pO2-41* pCO2-35 pH-7.41
calTCO2-23 Base XS--1
___ 11:55PM BLOOD Lactate-1.7
======
PERTINENT INTERVAL RESULTS
Echocardiogram ___:
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is at least 15 mmHg. Normal left ventricular wall thickness,
cavity size, and regional/global systolic function (biplane LVEF
= 65 %). Diastolic function could not be assessed. The right
ventricular cavity is mildly dilated with normal free wall
contractility. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve leaflets are myxomatous.
There is mild bieaflet mitral valve prolapse. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Tricuspid valve prolapse is present. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Preserved global and regional left ventricular
systolic function. Mildly dilated right ventricle with normal
free wall systolic function. Mxyomatous mitral and tricuspid
valve with no significant regurgitation. Mild pulmonary
hypertension.
RUQ U/S ___
IMPRESSION:
Hepatic and renal cysts. No lesion suspicious for abscess.
___ 07:10AM BLOOD Neuts-31.9* Lymphs-56.3* Monos-7.9
Eos-1.5 Baso-0.5 Im ___ AbsNeut-2.55# AbsLymp-4.50*
AbsMono-0.63 AbsEos-0.12 AbsBaso-0.04
___ 05:03AM BLOOD ___ PTT-30.6 ___
___ 07:10AM BLOOD Glucose-273* UreaN-16 Creat-0.9 Na-141
K-3.9 Cl-100 HCO3-28 AnGap-13
___ 05:03AM BLOOD ALT-27 AST-25 AlkPhos-52
___ 05:03AM BLOOD proBNP-1885*
___ 12:50PM BLOOD TSH-1.8
___ 07:10AM BLOOD CRP-35.4*
___ 09:15AM BLOOD HIV Ab-NEG
___ 09:15AM BLOOD HIV1 VL-NOT DETECT
___ 07:33AM BLOOD CHLAMYDIA DIFFERENTIATION AB PANEL-PND
___ 09:05AM BLOOD MYCOPLASMA PNEUMONIAE ANTIBODIES (IGG,
IGM)-PND
___ 09:05AM BLOOD ANAPLASMA PHAGOCYTOPHILUM (HUMAN
GRANULOCYTIC EHRLICHIA AGENT) IGG/IGM-PND
___ 09:05AM BLOOD FRANCISELLA TULARENSIS SEROLOGY-PND
___ 12:10AM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-300* Ketone-10* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 12:10AM URINE RBC-2 WBC-2 Bacteri-NONE Yeast-NONE
Epi-<1
___ 12:00PM URINE HISTOPLASMA ANTIGEN-PND
___ 03:00AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ cx, O&P, pending
___ legionella neg
___ lyme IgG pending
___ malaria antigen neg
Malaria smear neg x3
BCx NGTD ___ and ___ UCx NG final
OSH babesia PCR neg
OSH anaplasma phagocytophlm PCR POSITIVE
==========
DISCHARGE RESULTS
___ 07:33AM BLOOD WBC-6.4 RBC-4.75 Hgb-13.9 Hct-42.7 MCV-90
MCH-29.3 MCHC-32.6 RDW-13.2 RDWSD-44.1 Plt ___
Brief Hospital Course:
Mr. ___ is a ___ male with the past medical history
of well-controlled DM2 who presents with fever of uncertain
etiology and new A fib with RVR. Found to have anaplasmosis.
ACUTE/ACTIVE PROBLEMS:
# RAPID ATRIAL FIBRILLATION- NEW ONSET
Although it is unclear how long this may have been present,
fever precipitated RVR. Echo did not show any significant
valvular disease, TSH was normal at the outside hospital and
again at ___. He was treated for rapid A. fib heart rate
130-150 which improved to low 100s after 20 mg of IV diltiazem
and 30 mg of p.o. diltiazem. His Diltiazem was uptitrated to
achieve good effect and on discharged, changed to Diltiazem XR
360mg po qd. He spontaneously converted to sinus on day of
discharge with HRs in ___ and tolerating diltiazem well, so
this was continued. Cardiology was consulted ___ since
patient with new onset A. fib and would be a candidate for
cardioversion. He is very interested in cardioversion, and they
will pursue this as an outpatient once fever has diagnosed
definitively and resolved. The patient has a Chads2vasc score of
2 with one-point for diabetes and one point potentially for age
___ with birthday coming soon. The risks and benefits of
anticoagulation were discussed, and he elected to do this;
cardiology also advised for this plan. He was given Xarelto
starting on ___.
.
#FEVERS/WEIGHT LOSS/malaise/thrombocytopenia:
# anaplasmosis
Initially it was not clear what was causing these symptoms.
Given his travel and exposure history, a very broad ddx was
created and he had a number of tests as above. He was seen by
the infectious disease service who recommended multiple
serologies and tests listed above. His liver U/S showed no
abscesses, HIV was negative, and there was no evidence of acute
bacterial pneumonia, urinary infection, or blood infection. His
platelets returned to normal and he was afebrile throughout his
___ stay. Just prior to discharge, ___
called and informed us that his anaplasma PCR had returned
positive. He was therefore started on doxycycline 100mg po bid
x14d (to cover for anaplasma as well as empirically for lyme).
He will follow-up with ID as an outpatient. Patient up to date
with age-appropriate cancer screening given non-smoker and with
recent colonoscopy per his report
# HYPERGLYCEMIA:
Most likely secondary to acute illness. He was started on
sliding scale insulin and home Glimiperide was held. In an
effort to avoid insulin, he will continue Glimepiride on D/C
with the addition of Metformin. If BGs remain elevated a week or
two as an outpatient, he will need to see his PCP to discuss
additional measures, and to see how long Metformin needs to
continue.
CHRONIC/STABLE PROBLEMS:
#CHRONIC NECK PAIN
- advised o/p ortho evaluation
TRANSITIONAL ISSUES:
- continue to monitor heart rates and consider up or
downtitration of diltiazem
- patient to follow up with cardiology for consideration of
cardioversion
- patient to follow up with ID
- patient to complete course of doxycycline as above; if fevers
recur, would suggest broad workup at that time
- continue to monitor blood sugars and consider need for up or
downtitration of DM regimen
- please follow up pending micro results as per discharge
letter, but note that he is being treated empirically for lyme
in addition to known anaplasma
- consider outpatient ortho evaluation for chronic neck pain
For billing purposes only: >30 minutes spent on patient care and
coordination on day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. glimepiride 4 mg oral DAILY
2. Aspirin 81 mg PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO BID
4. Simvastatin 40 mg PO QPM
5. Glucos Chond Cplx Advanced (glucosam-chond-hrb 149-hyal ac)
750 mg-100 mg- 125 mg-1.65 mg oral DAILY
6. Ascorbic Acid Dose is Unknown PO DAILY
7. B complex-minerals UNKNOWN UNKNOWN oral Frequency is Unknown
Discharge Medications:
1. Diltiazem Extended-Release 360 mg PO DAILY
RX *diltiazem HCl 360 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Doxycycline Hyclate 100 mg PO Q12H Duration: 20 Doses
Take with full cup of water, upright, avoid direct sun
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day
Disp #*27 Tablet Refills:*0
3. MetFORMIN (Glucophage) 850 mg PO DAILY
RX *metformin 850 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Rivaroxaban 20 mg PO DINNER
RX *rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth every
evening with dinner Disp #*30 Tablet Refills:*0
5. Ascorbic Acid as directed mg PO DAILY
6. B complex-minerals 1 tablet oral DAILY
7. Aspirin 81 mg PO DAILY
8. Fish Oil (Omega 3) 1000 mg PO BID
9. glimepiride 4 mg oral DAILY
10. Glucos Chond Cplx Advanced (glucosam-chond-hrb 149-hyal ac)
750 mg-100 mg- 125 mg-1.65 mg oral DAILY
11. Simvastatin 40 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial fibrillation
Mild pulmonary hypertension
Fever
Thrombocytopenia
Uncontrolled DM2
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 fever of unclear origin,
as well as atrial fibrillation with fast rate.
You were seen by the infectious disease specialists who looked
for different causes of infection. We found out that you had an
infection called anaplasma, for which you were started on
doxycycline. Several additional tests are still outstanding and
you will follow-up with the ID team as an outpatient to discuss
next steps.
You were also seen by the cardiologists for a new diagnosis of
atrial fibrillation. Your echocardiogram showed mild pulmonary
hypertension (elevated blood pressure in the lungs). You were
given medicine that helped slow your heart rate and blood
thinners to prevent a future stroke. You will see the cardiology
doctors in follow-up to discuss cardioversion.
Your high blood sugars and fast heart rates will likely improve
with treatment of the infection, so seeing your primary care
provider for adjustment of your new atrial fibrillation and
diabetes medications will be important.
As discussed, you have a small renal cyst that will need
outpatient follow up. We will inform your PCP of the same.
You will likely need repeat set of labs next week when you see
your PCP.
We will contact you with any urgent lab abnormalities among the
pending labs from here but you can also follow up these labs
with your PCP.
We wish you the best in your recovery,
Your ___ Team
Followup Instructions:
___
|
10664064-DS-13
| 10,664,064 | 26,669,528 |
DS
| 13 |
2141-10-11 00:00:00
|
2141-10-11 14:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Cipro / Penicillins / Ticlid
Attending: ___.
Chief Complaint:
R hip pain
Major Surgical or Invasive Procedure:
R hip TFN
History of Present Illness:
The patient is a ___ yo F who presents with R hip pain after
a fall on stairs earlier today. She tripped while going up
stairs
and denies any head strike or LOC. She had immediate R hip pain
and was taken to ___ where xrays showed a R hip
fracture. She was then transferred to ___ for further
management. She denies numbness or paresthesias in the RLE, as
well as pain anywhere else.
Past Medical History:
CAD s/p 4 vessel CABG
HTN
Hypercholesterolemia
Bilateral TKA ___ years ago in ___
Appendectomy
L humerus fracture complicated by LUE DVT treated with coumadin
which she no longer takes
Social History:
___
Family History:
NC
Physical Exam:
97.1 60 124/44 100% RA
GEN: NAD, A&Ox3
RLE:
Skin intact without erythema or ecchymosis
No gross deformity
Leg is shortened and externally rotated
No tenderness to palpation of knee or ankle
SILT DP/SP/S/S
___
2+ ___
Brief Hospital Course:
The patient was admitted to the Orthopaedic Trauma Service for
repair of a L intertrochanteric femur fracture. The patient was
taken to the OR and underwent an uncomplicated left TFN. The
patient tolerated the procedure without complications and was
transferred to the PACU in stable condition. Please see
operative report for details. Post operatively pain was
controlled with a PCA with a transition to PO pain meds once
tolerating POs. The patient tolerated diet advancement without
difficulty and made steady progress with ___.
The patient was transfused 3 units of blood for acute blood loss
anemia.
Weight bearing status: weight bearing as tolerated.
The patient received ___ antibiotics as well as
lovenox for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 2 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge.
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin EC 325 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC QPM Duration: 14 Days
RX *enoxaparin 40 mg/0.4 mL please inject subcutaneously into
abdomen every night Disp #*14 Syringe Refills:*0
5. Lisinopril 20 mg PO BID
6. Metoprolol Tartrate 50 mg PO BID
7. Multivitamins 1 TAB PO DAILY
8. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours as
needed Disp #*60 Tablet Refills:*0
9. Senna 1 TAB PO BID
10. Simvastatin 40 mg PO DAILY
11. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
R intertrochanteric hip fracture
Discharge Condition:
stable
Discharge Instructions:
Wound Care: You can get the wound wet/take a shower starting
from 3 days post-op. 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 continued to be non-draining.
******WEIGHT-BEARING*******
Weightbearing as tolerated right lower extremity
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
- Take Lovenox for DVT prophylaxis for 2 weeks post-operatively.
Followup Instructions:
___
|
10664347-DS-9
| 10,664,347 | 25,278,470 |
DS
| 9 |
2119-05-04 00:00:00
|
2119-05-05 20:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: PLASTIC
Allergies:
ampicillin
Attending: ___
Chief Complaint:
R hand pain s/p cat bite
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o RHD female with PMH significant for SLE presents with
chief complaint of R hand swelling and pain. Patient states
that she was bitten on the palm of her R hand 5 days ago by her
cat (housecat, vaccines up to date). She states that over the
following 4 days, the pain was only intermittent and was overall
tolerable. However, last night she awoke with a significant
worsening of her pain and also experienced chills while
attempting to sleep. She presented to her PCP today and they
recommended that she be evaluated at ___ for possible
operative management.
Past Medical History:
SLE, CAD
PSH: Wrist fusion (done ___ at ___), L TKA, multiple hip
surgeries (8 on R hip, 8 on left)
Social History:
___
Family History:
Noncontributory
Physical Exam:
Gen: Alert, responsive, NAD
Neck: Supple
CV: RRR.
Pulm: CTAB
And: soft, NT, ND, no rebound, no guarding
Ext: R hand : Two 0.5cm puncture wounds on the thenar eminence
with improving erythema, no induration, no fluctuance or
discharge. Erythema improved on the volar forearm with improved
TTP. Baseline ROM of digits. Multiple superficial scratches on
the dorsal aspect of the hand without evidence of infection.
Full, painless AROM/PROM of shoulder, elbow. Patient is unable
to range the wrist secondary to previous fusion. No fusiform
swelling of the digits or tenderness over the flexor sheath.
+EPL/FPL/DIO (index) fire
+SILT axillary/radial/median/ulnar nerve distributions
+Radial pulse
Pertinent Results:
Lab results:
___ 02:00PM BLOOD WBC-9.0 RBC-3.80* Hgb-13.0 Hct-37.7
MCV-99* MCH-34.2* MCHC-34.5 RDW-12.1 Plt ___
___ 02:00PM BLOOD Neuts-77.9* Lymphs-16.1* Monos-4.8
Eos-0.3 Baso-0.9
___ 02:00PM BLOOD Glucose-95 UreaN-9 Creat-0.7 Na-139 K-3.6
Cl-103 HCO3-23 AnGap-17
XRay R hand, wrist, forearm: IMPRESSION:
1. Rod fixation of the right wrist with complete fusion of the
carpal bones and distal radius without evidence for hardware
failure.
2. Probable old ulnar styloid fracture.
3. Palmar soft tissue swelling without evidence of acute
fracture or definite radiographic evidence for osteomyelitis.
No subcutaneous gas.
Brief Hospital Course:
___ presented to the ED with a 5 day history of progressive pain
and swelling in the setting of a cat bite. Initial physical
exam was remarkable for erythema involving the volar forearm as
well as tenderness to palpation over the thenar eminence and the
volar wrist. Plain films without evidence of fracture or
dislocation. The patient was admitted into ED observation on
HD0 and started on ___ in the ED. She was admitted to
plastics on HD1 for further management and her antibiotics were
changed to Unasyn. The patient was monitored closely while on
Unasyn given her h/o rash as a teenager to ampicillin. The
patient tolerated Unasyn without rash/allergy or other problems.
Her R arm was also splinted and elevated while in the hospital.
The patient's erythema and tenderness improved on Unasyn and she
was discharged w/out further intervention on HD2 with PO
augmentin. Blood cultures were pending at the time of discharge
The patient will folllow-up as an outpatient in ___ clinic
in 1 -2 weeks. Patient was stable at discharge.
Medications on Admission:
Atorvastatin, Hydroxychloroquine, Atenolol, Excedrin Migraine
PRN
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain / fever
Take every 6 hours as needed for pain. Do not take more than 3g
in a 24 hour period.
2. Atenolol 100 mg PO DAILY
3. Atorvastatin 20 mg PO HS
4. Hydroxychloroquine Sulfate 400 mg PO BID
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Only take for pain not controlled by tylenol.
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*7 Tablet Refills:*0
6. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days
RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1 tab
by mouth twice a day Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left hand cellulitis
Discharge Condition:
Patient is stable, has normal mental status and is ambulating
without difficulty.
Discharge Instructions:
You have been seen and observed after your cat bite. You
received IV antibiotics in the hospital and will be discharged
on antibiotics. It is important to complete the entire course of
this medication.
Activity:
1. You may resume your regular diet.
2. Please resume regular activities as tolerated.
3. Please continue to elevate your hand
.
Medications:
1. Resume your regular medications.
2. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging. Please note that
Percocet and Vicodin have Tylenol as an active ingredient so do
not take these meds with additional Tylenol. Do not take more
than 3g of Tylenol in a 24 hour period.
3. Take prescription pain medications for pain not relieved by
tylenol.
4. Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
Followup Instructions:
___
|
10664400-DS-19
| 10,664,400 | 28,006,725 |
DS
| 19 |
2175-02-07 00:00:00
|
2175-02-07 22:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / Hydrocodone
Attending: ___.
Chief Complaint:
Fever, productive cough.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with PMH rheumatoid arthritis returns to the
ED with compaints of cough and fever.
She was seen ___ in the ED for worsening SOB, cough, and
persistent fever to 102. At that time, CXR was unrevealing
however clinical suspicion for pneumoina was high and she was
given azithromycin and discharged home. Despite being treated
with azithromycin, she continued to report ongoing fevers to 102
and productive, painful cough and returned to the ED. Notably,
one of her grandson's who she takes care of has had a case of
"walking pneumonia."
In the ED, initial 102.4 87 120/80 20 97% WBC 4.7 HGB: 11.3,
Lactate:1.2, U/A negative. She was given Levaquin 750mg IV
and admitted to medicine for further management. Vitals on
transfer: 99.5 87 20 104/67 100%RA
On arrival to the medical floor, vitals were T:100.5 P:77
BP:105/69 RR:77 SaO2: 97% on Room air. She reported sorethroat
from coughing, and ongoing dyspnea with productive cough. She
also reports chronic headache and neckpain secondary to multiple
neck surgeries and removal of infected hardware most previously
in ___.
REVIEW OF SYSTEMS:
Denies: vision changes, rhinorrhea, congestion, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
Anterior cervical diskectomy and reconstruction (___)
Cervical spine wound infection
Depression c/b SI
Hypothyroid
Cocaine abuse
Obstructive sleep apnea
Rheumatoid arthritis
s/p exp lap
s/p CCY
I&D of deep cervical abscess (___)
Bilateral Knee and Hip replacement
R rotator cuff repair x2
Social History:
___
Family History:
2 Children with RA. 1 child with fibromyalgia
Physical Exam:
Admission PHYSICAL EXAM:
VS - T:100.5 P:77 BP:105/69 RR:77 SaO2: 97% on Room air.
GENERAL - Middle aged female appearing fatigued, alert,
interactive, in NAD
HEENT - Tender cervical lymphadenopathy, no tonsillar exudate
NECK - Supple, JVP non-elevated
HEART - RRR, nl S1-S2, no MRG
LUNGS - Right sided inspiratory wheezes, no rales/ronchi, good
air movement, resp unlabored, no accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, No edema
NEURO - awake, A&Ox3, CNs II-XII intact
Discharge Physical Exam
VS - T:98.2 P:69 BP:115/74 RR:17 SaO2: 98% RA.
GENERAL - Female appearing stated age, NAD, slightly odd affect.
AAOx3.
HEENT - MMM, OP clear, no tonsillar exudate
NECK - Supple, JVP non-elevated
HEART - RRR, nl S1-S2, no MRG
LUNGS - Clear to ausculation bilaterally, no tactile fremitus
without adventitious breath sounds. resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, No edema. 2+ pulses
NEURO - awake, A&Ox3, CNs II-XII intact
Pertinent Results:
___ 04:53AM BLOOD WBC-3.4* RBC-4.20 Hgb-10.8* Hct-36.1
MCV-86 MCH-25.8* MCHC-30.0* RDW-13.7 Plt ___
___ 04:38AM BLOOD WBC-3.3* RBC-4.24 Hgb-11.0* Hct-36.8
MCV-87 MCH-25.9* MCHC-29.8* RDW-14.0 Plt ___
___ 03:40PM BLOOD WBC-4.7 RBC-4.39 Hgb-11.3* Hct-37.8
MCV-86 MCH-25.8* MCHC-30.0* RDW-14.1 Plt ___
___ 04:53AM BLOOD Glucose-107* UreaN-7 Creat-0.9 Na-141
K-3.3 Cl-105 HCO3-28 AnGap-11
___ 04:38AM BLOOD Glucose-133* UreaN-9 Creat-1.0 Na-140
K-3.5 Cl-103 HCO3-23 AnGap-18
___ 03:40PM BLOOD Glucose-91 UreaN-8 Creat-0.8 Na-140 K-3.5
Cl-104 HCO3-26 AnGap-14
___ 04:53AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.4
___ 04:01PM BLOOD Lactate-1.2
___ 04:15PM URINE Color-Yellow Appear-Clear Sp ___
___ 04:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
Micro:
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
Imaging:
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: ___ female with history of cough
and dyspnea
and fever.
COMPARISONS: ___.
FINDINGS: Frontal and lateral views of the chest were obtained.
There is
minimal bibasilar atelectasis without focal consolidation. No
pleural
effusion or pneumothorax. The cardiac and mediastinal
silhouettes are stable with the cardiac silhouette top normal.
Mild elevation of left hemidiaphragm
is again seen.
IMPRESSION: No acute cardiopulmonary process. No significant
change from one day prior.
Pending at discharge:
Blood cultures
Brief Hospital Course:
___ year old female with a past medical history of RA (not
actively being treated) who presented with fevers and cough
despite two days of treatment with azithromycin who subsequently
was admitted for treatment of community acquired pneumonia.
Active Issues:
# Community acquired pneumonia: This patient presented to the
emergency room 2 days prior with cough and fever. Her chest xray
at the time was clear. She was empirically treated with
azithromycin. She came back to the emergency room two days later
with cough and fever to 102. Her chest xray was clear. Her white
count was initially decreased at 3.8. Cultures were done which
are pending at the time of discharge. She was started
empirically rochephin and azithromycin for community acquired
pneumonia. She subsequently improved as evidenced by
defervescence. She was discharged to home on
cefpodoxime/azithromycin with the differential diagnosis of
community acquired pneumonia versus viral upper respiratory
tract infection.
-Azithromycin x 5 days (7 day course)
-Cefpodoxime x 8 days (10 day course)
Medications on Admission:
Calcium 600 + D(3) 600 mg (1,500 mg)-400 unit Tab 2 Tablet BID
diazepam 5 mg Tab daily
Simvastatin 10 mg Daily
Omeprazole 20 mg daily
Zolpidem 5 mg Tab ___ QHS PRN
Synthroid ___ mcg Daily
Sertraline 25 mg Daily
Gabapentin 300 mg Cap 1 QHS
Folic acid 1 mg Tab Daily
fluticasone 50 mcg/actuation Nasal Spray,Daily
olyethylene glycol 3350 17 gram/dose PRN
Discharge Medications:
1. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 8 days.
Disp:*16 Tablet(s)* Refills:*0*
2. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
3. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: Two (2)
Tablet PO twice a day.
4. diazepam 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for Anxiety.
5. simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. zolpidem 5 mg Tablet Sig: ___ Tablets PO HS (at bedtime) as
needed for insomnia.
7. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. sertraline 25 mg Tablet Sig: One (1) Tablet PO once a day.
9. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
10. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
11. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
spray Nasal once a day.
12. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Respiratory illness (viral vs community acquired pneumonia)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted with high fever and cough. We believe that you
have something called a community acquired pneumonia. You
responded very promptly to antibiotics. Your fever has away. You
will likely continue to have a cough for another week or two
while your lung inflammation clears. We will be continuing
antibiotic treatment as an outpatient.
Please START
1. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a
day for 8 days.
2. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
We have made no changes to your existing home medications.
Please continue your normal home medications. If you experience
any of the danger symptoms listed below please call your primary
care physician or consider going to the nearest emergency
department.
We have made a follow up appointment with one of our physicians
so they can check in your progress promptly after your
discharge. It is listed below.
Followup Instructions:
___
|
10664400-DS-21
| 10,664,400 | 23,413,042 |
DS
| 21 |
2178-08-28 00:00:00
|
2178-08-28 17:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / Hydrocodone
Attending: ___
Chief Complaint:
Left sided chest pain
Major Surgical or Invasive Procedure:
NOne
History of Present Illness:
___ with PMH back pain, chronic pelvic pain, chronic abdominal
pain, OSA, RA, and reportedly remote cocaine abuse who was
referred to the ED by her PCP for ___ stress test due to concern
over unstable angina. The patient has had sharp, non-radiating
intermittent left-sided chest pain not related to exertion, but
worse with deep inspiration and increased stress. She has had
HTN in the past week (being monitored by PCP), reaching to
150s/100s and HR 100s. She endorses lightheadedness today, and
diaphoresis for past few days. She was seen in this ED on ___,
with normal ECG and negative trops, but possible pneumonia on
CXR, for which she completed a z-pack. She denies fevers,
chills, changes in abdominal chronic pain or changes in stool.
She also complains of bilateral flank pain. She denies any
recent recreational drug use
For attending- Patient reports pain with deep breath last week
with her pneumonia but that has improved and now denies
pleuritic symptoms.
In the ED, initial vitals were Vitals on arrival:
Temp. 97.6, HR 66, BP 121/69, RR 20, 99% RA
Labs in the ED showed WBC 9.3, Hg 12.5, Hct 41.1, platelets 312.
Na 141, K 3.8, Cl 102, Bicarb 28, BUN 10, Cr 0.9. Trop X 2
negative. Aspirin 324 mg given X 1, zoplidem 5 mg, omeprazole 20
mg.
EKG: Sinus rhythm with a PVC. Vent. rate 68 PR: 140 QRS: 74
QTc: 418
CXR showed no acute cardiopulmonary abnormality.
___ Persantine Stress Test: Atypical symptoms with no
ischemic ST segment changes.
Appropriate hemodynamic response to the Persantine infusion.
Nuclear
report sent separately.
___ MIBI IMPRESSION:
1. Possible partially reversible, small, moderate severity
perfusion defect involving the LAD territory.
2. Normal left ventricular cavity size and systolic function.
Compared with prior study of ___, the defect is new.
Cardiology fellow consulted with recommendation to admit to ___
with repeat MIBI in AM.
Vitals prior to transfer
Temp. 98.5 HR 61 BP 131/74 RR 18 96% RA
On the floor patient was complaining of
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
Anterior cervical diskectomy and reconstruction (___)
Cervical spine wound infection
Depression c/b SI
Hypothyroid
Cocaine abuse
Obstructive sleep apnea
Rheumatoid arthritis
s/p exp lap
s/p CCY
I&D of deep cervical abscess (___)
Bilateral Knee and Hip replacement
R rotator cuff repair x2
Social History:
___
Family History:
Per OMR
2 Children with RA. 1 child with fibromyalgia
Physical Exam:
PHYSICAL EXAM ON ADMISSION
=======================================
Vitals: 96.8 169/67 69 20 98% on RA
Weight: 83.6 kg
General: NAD, A&Ox3
HEENT: NCAT, EOMI, throat non-injected
Neck: JVP flat
CV: RRR, no murmurs
Lungs: CTAB, no wheezes or rales
Abdomen: +BS, soft, mild TTP on deep palpation of the RUQ, no
rebound or guarding
GU: Deferred
Extr: No edema
Neuro: CNII-XII intact, strength and sensation grossly intact,
gait deferred
Skin: No rash
PHYSICAL EXAM ON DISCHARGE
========================================
T=98.3F BP=109/67 HR=69 RR=20 O2 sat= 98% RA
GENERAL: in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 8-9 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts. Chest pain was not reproducible.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: ___ 2+
Left: ___ 2+
Pertinent Results:
LABS ON ADMISSION
====================================
___ 08:40PM cTropnT-<0.01
___ 08:40PM GLUCOSE-79 UREA N-10 CREAT-0.9 SODIUM-141
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-28 ANION GAP-15
___ 08:40PM NEUTS-60.1 ___ MONOS-5.9 EOS-2.3
BASOS-0.2 IM ___ AbsNeut-5.55 AbsLymp-2.89 AbsMono-0.55
AbsEos-0.21 AbsBaso-0.02
___ 08:40PM WBC-9.3 RBC-4.71 HGB-12.5 HCT-41.1 MCV-87
MCH-26.5 MCHC-30.4* RDW-14.3 RDWSD-45.4
___ 08:40PM PLT COUNT-312
___ 02:58AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
LABS ON DISCHARGE
====================================
___ 04:47AM BLOOD Glucose-89 UreaN-15 Creat-1.0 Na-141
K-4.1 Cl-103 HCO3-28 AnGap-14
___ 04:47AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 04:47AM BLOOD Calcium-9.2 Phos-4.9* Mg-2.5
___ 04:47AM BLOOD WBC-8.2 RBC-4.30 Hgb-11.5 Hct-37.3 MCV-87
MCH-26.7 MCHC-30.8* RDW-14.3 RDWSD-44.6 Plt ___
___ 04:47AM BLOOD Plt ___
___: EKG: Sinus rhythm with a PVC. Vent. rate 68 PR: 140
QRS: 74 QTc: 418
CXR showed no acute cardiopulmonary abnormality.
___ CXR: FINDINGS: Heart size remains borderline
enlarged. Mediastinal and hilar contours are normal. Pulmonary
vasculature is normal. Lungs are clear without focal
consolidation. No pleural effusion or pneumothorax is seen.
Previously noted somewhat linear opacity in the left mid lung
field has resolved. There are no acute osseous abnormalities.
IMPRESSION: No acute cardiopulmonary abnormality.
___ Persantine Stress Test: Atypical symptoms with no
ischemic ST segment changes. Appropriate hemodynamic response to
the Persantine infusion. Nuclear report sent separately.
___ MIBI IMPRESSION: The stress image quality is adequate
but limited due to soft tissue and breast attenuation. Rest
image quality is severely limited due to poor counts. 1.
Possible partially reversible, small, moderate severity
perfusion defect involving the LAD territory.
2. Normal left ventricular cavity size and systolic function.
Compared with prior study of ___, the defect is new.
___: Repeat Rest MIBI IMPRESSION: Perfusion defect. Final
read pending.
Cardiac cath ___:
The LMCA is free of angiographic CAD
The LAD is free of angiographic CAD
The circumflex is free of angiographic CAD
The RCA is free of angiographic CAD
Brief Hospital Course:
___ with PMH back pain, chronic pelvic pain, chronic abdominal
pain, OSA, RA, and reportedly remote cocaine abuse who was
referred to the ED by her PCP for ___ stress test due to concern
over unstable angina.
# Chest pain:
Patient was evaluated because she presented with recurrent
intermittent sharp, non-radiating left-sided chest pain not
related to exertion. Patient underwent persantine stress test
significant for possible partially reversible, small, moderate
severity perfusion defect involving the LAD territory. However
this imaging finding was severely limited. EKG and Troponins
were negative for signs of ischemia. Thus patient was admitted
for repeat resting MIBI to evaluate if cardiac cath is
warranted. Repeat MIBI was positive and patient underwent
cardiac cath on ___ that showed no evidence of angiographic
coronary artery disease.
# Hypertension:
Patient was noted to be hypertensive to 150/90's during her PCP
___. During hospital stay patient's blood pressure
ranged from 120-160 range. She was started on 5 mg of amlodipine
daily.
# Hypothyroidism: Continued Levothyroxine 100 mcg daily.
# Rheumatoid arthritis:
Per patient report she had not yet started methotrexate therapy.
Continue follow upw with rheumatology
# Depression:
Continued sertraline 50 mg QHS, zolpidem 5 mg qhs prn insomnia,
and Diazepam 5 mg daily
TRANSITIONAL ISSUES:
=====================
- Pravastatin 20 mg daily started this hospitalization. Continue
to monitor lipids.
- Amlodipine 5 mg daily started this hospitalization for
hypertension. Continue to monitor blood pressure and adjust as
tolerated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Zolpidem Tartrate ___ mg PO QHS
2. Diazepam ___ mg PO QHS:PRN back pain
3. Polyethylene Glycol 17 g PO DAILY:PRN constipation
4. Omeprazole 40 mg PO DAILY
5. Cetirizine 10 mg PO DAILY
6. Vitamin D 800 UNIT PO DAILY
Discharge Medications:
1. Diazepam ___ mg PO QHS:PRN back pain
2. Omeprazole 40 mg PO DAILY
3. Polyethylene Glycol 17 g PO DAILY:PRN constipation
4. Vitamin D 800 UNIT PO DAILY
5. Zolpidem Tartrate ___ mg PO QHS
6. Cetirizine 10 mg PO DAILY
7. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
8. Pravastatin 20 mg PO QPM
RX *pravastatin 20 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Chest Pain
Hypertension
Hyperlipidemia
Secondary:
Anemia
Cervical Osteomyelitis
Cervical Spondylitic Radiculopathy
Chronic Pelvic Pain
Depression
RA
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 chest pain. Your heart was imaged you were
found to have a small reversible defect in providing blood to
your heart. However, this first imaging scan was not completely
clear and we re-evaluated you and this study showed signs of
decreased blood flow to the heart so you had a procedure called
cardiac catheterization. You did not have any evidence of
blockages in the heart which is great news.
We recommend that you start taking a medication called
pravastatin for your cholesterol and amlodipine for your blood
pressure.
Please follow-up with your primary care physician.
Your ___ Team
Followup Instructions:
___
|
10664571-DS-19
| 10,664,571 | 22,804,360 |
DS
| 19 |
2175-03-26 00:00:00
|
2175-03-26 13:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
respiratory distress and fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ AFib, HTN, breast and thyroid CA, s/p tracheostomy several
years ago after breast cancer surgery and hysterectomy
presenting from ___ with respiratory distress and
fever. EMS crew arrived on scene to find her in respiratory
distress, with a heart rate of 180, febrile although temperature
not documented. Patient was in atrial flutter versus atrial
fibrillation per EMS report. She was saturating at 75-80% on her
trach collar without any supplemental oxygen when EMS arrived,
was put on a nonrebreather blow by into the trach collar and
quickly raised her saturations to the mid ___. Of note patient
recently was evaluated for cough and fever with CXR done at
___ that showed possible early PNA, started on avelox
on ___, but either did not receive this at all or not a full
course per ___ staff. UTI recently dx, on cipro
starting ___, completed 3 day course. Per family has lived in
___ for about 6 months. Looked well on ___ when
they saw her.
.
In the ED, she was quickly put on the ventilator with 5 of PEEP
50% FiO2 and raised her oxygen yet further to 97. Copious blood
tinged purulent secretions were noted from trach on arrival.
CXR with multiple opacities noted, RUL most prominent,
concerning for multifocal PNA. UA concerning for UTI so pt was
started on vancomycin, zosyn, and ciprofloxacin. Temp noted to
be 101.2 in ED, given 650 mg of tylenol x 2. Exam notable for
rhonchi throughout lung fields. Also received IV NS. HR on
arrival was HR on arrival was 138 Aflutter or afib per report, w
BP 130s-140s systolic. Around 10:___onverted to sinus
rhythm with subsequent decrease in BP to 90's systolic, bolus of
IV NS given with improvement. VS on transfer BP 107/48 MAP 62
HR 56 on CPAP ___ with 50% FiO2.
.
On arrival to the ICU, pt is nonverbal but shakes head no when
asked if she has any pain, looks comfortable. Pt is still on
CPAP ___, weaned down to ___.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Depression
Bilateral breast CA
Thyroid CA (had short term trach after this, was removed at age
___
Movement disorder (blepharospasm)
psychosis
bilateral blindness (recent trauma to R eye)
HTN
atrial fibrillation
hypercholesterolemia
hypoparathyroidism
s/p tracheostomy (complication of intubation from lumpectomy
about ___ years ago)
Social History:
___
Family History:
maternal aunt with ___
F- heart failure in his ___
Physical Exam:
ADMISSION EXAM
General: alert, appears comfortable, nonverbal
HEENT: MMM, oropharynx clear, pupils 5 mm and irregular
bilaterally, nonreactive
Neck: supple, JVP not elevated, no LAD
Lungs: rhonchi throughout auscultated anteriorly
CV: Regular rate and rhythm, normal S1 + S2, III/VI systolic
murmur best heard at RUSB, no rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place with clear yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. nonverbal but responds to commands to open eyes, hold
fingers, wiggle toes.
Pertinent Results:
ADMISSION LABS
___ 08:30AM BLOOD WBC-11.3*# RBC-4.13* Hgb-12.2 Hct-36.1
MCV-88 MCH-29.5 MCHC-33.8 RDW-12.8 Plt ___
___ 08:30AM BLOOD Glucose-110* UreaN-31* Creat-0.6 Na-143
K-4.4 Cl-105 HCO3-25 AnGap-17
___ 08:30AM BLOOD Calcium-9.8 Phos-5.0* Mg-1.7
CXR ___
New multifocal opacities worrisome for multifocal pneumonia,
although an unusual pattern of asymmetric edema could also be
considered in the appropriate clinical setting. Persistent
colonic dilatation, for which clinical correlation is suggested.
Brief Hospital Course:
___ AFib, HTN, breast and thyroid CA, s/p tracheostomy several
years ago presenting from ___ with respiratory
distress and fever, UTI, multifocal PNA
.
# Respiratory distress: Most likely in setting of multifocal
PNA. Pt with h/o tracheostomy placement after thyroid surgery
and lumpectomy, normally on trach collar but initially required
CPAP ventilation when admitted. Covered for HCAP with
vancomycin, zosyn for 10 day course, requiring PICC line
insertion.
.
# UTI: UA suggestive of UTI, culture showing pansensitive
Klebsiella. Covered by vanc/zosyn.
.
# Afib: RVR initially on admission and prior to transfer to
medical ward. Now resolved, most likely in setting of illness
and having had her AV nodal blockers held on admission. Not on
warfarin. Continued outpatient doseing of metoprolol, diltiazem,
and aspirin. Telemetry monitor misread her as having rapid
heart rate, and was disconcordant with same time EKG showing
good rate control in ___.
.
# breast cancer: cont home anastrozole
.
# depression and psychosis: cont perphenazine
.
# blindness: cont eye drops from home
.
# hypothyroidism: cont levothyroxine
.
# Code = DNR, ok to intubate.
Medications on Admission:
heparin 5000 units TID
fluticasone 110 mg inhaled BID
ipratropium bromide Q4H PRN
dorzolamide-timolol ___ % Drops BID
diltiazem HCl 45 mg PO Q6H
anastrozole 1 mg daily
pantoprazole 40 mg daily
levothyroxine 137 mcg daily
metoprolol tartrate 100 mg BID
calcitriol 0.25 mcg daily
perphenazine 16 mg BID
Colace 100 mg bid
potassium chloride 20 mEq Two (2) packets TID
ciprofloxacin 400 mg daily (dc'ed ___
multivitamin
albuterol nebs BID
prednisolone acetate eyedrops 1 drop right eye TID
tylenol ___ mg Q4H PRN pain/fever
aspirin 81 mg daily
Discharge Medications:
1. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation QID (4 times a day).
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
___ Puffs Inhalation BID (2 times a day).
4. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic TID (3 times a day).
5. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily ().
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. dorzolamide-timolol ___ % Drops Sig: One (1) Drop
Ophthalmic BID (2 times a day).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. perphenazine 8 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
11. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation BID (2 times a day).
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain, fever.
13. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for affected area.
14. levothyroxine 137 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
15. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
16. diltiazem HCl 90 mg Tablet Sig: 0.5 Tablet PO QID (4 times a
day).
17. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 4 days: through ___.
18. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Respiratory Distress
Multifocal Pneumonia
URI - Klebsiella
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted with difficulty breathing due to pneumonia.
You also were found with a urinary tract infection. You were
treated with IV then oral antibiotics and non-invasive
ventilation through your trach mask. You had a few episodes of
fast heart rate which were controlled with resumption of your
normal medications. You did well and made a good recovery. You
are discharged on your home medications, as well as an
antibiotic that you will need to complete.
Followup Instructions:
___
|
10664616-DS-22
| 10,664,616 | 25,159,622 |
DS
| 22 |
2153-01-01 00:00:00
|
2153-01-13 22:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
lidocaine / cleaners / pollen / ? malignant hyperthermia /
epinephrine / levofloxacin
Attending: ___.
Chief Complaint:
Ataxia, CT head abnormality
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo RH man with history HTN, HLD, DM2,
___'s thyroiditis and L cavernoma (found incidentally) who
was sent in by PCP today for pupil asymmetry, gait difficulties
and L sided weakness.
He was admitted at ___ ___ years ago for "progressively
worsening
nausea and imbalance" after being intubated for apneic event
with
left sided weakness. There was no stroke seen on the MRI, though
it did show old blood products and cavernoma on the left side.
He
underwent conventional angiogram which did not show any AVM.
Since his admission, Mr. ___ did have ___ episodes of
lightheadedness and room spinning lasting 30 minutes and L arm
numbness/tingling and ?stiffness (not at the same time) but did
not think much about it as they seemed milder.
This morning, he woke up with lightheadedness and felt "icky."
He
went to see his PCP (happened to have a regular scheduled appt)
this afternoon. There his lightheadedness worsened with ?some
unsteadiness (especially when they asked him to stand on the
scale) and brief dizziness. His PCP examined him and saw pupil
asymmetry, L weakness and imbalance so asked the daughter to
come
in and bring him to ED. At the OSH ED, the daughter noted that
he
had left sided "drift" in arm and leg and was told that he was
weak and his CT showed enlargement from the last scan as well as
"vasogenic edema" and he needs to be transferred to ___ for
evaluation.
When patient is asked, his main complaint is that he feels
lightheaded and "off" though he can't describe it much further.
He did not actually feel that he was weak, though he was told by
other people that he was weak. He is bothered by the tingling in
his left pinky, occasionally in his hand.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech. No bowel or bladder incontinence or retention.
+ left sided weakness per family, balance issues. ?memory issues
in last ___ weeks.
On general review of systems, the pt denies recent fever or
chills. Denies cough, some exertional dyspnea. 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:
DM II, HTN, Hyperlipidemia, ___'s thyroiditis
Social History:
___
Family History:
Unknown as patient is adopted
Physical Exam:
ADMISSION EXAM
Vitals: 98.0 80 180/95 16 98% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
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, awake. Able to relate history without
difficulty, though vague on the details and difficulty
explaining
some of his symptoms. Slightly inattentive, misses ___ on ___
backward, though speed is good. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt was able to name both high and low
frequency objects. Speech was 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 ok
knowledge of current events (able to recall World Cup going on,
but initially said it was at ___, then corrected to ___.
There was no evidence of neglect. There was no evidence of
left-right confusion as the patient was able to accurately
follow
the instruction to touch left ear with right hand.
-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. Drift on left but NO
pronation. NO orbiting around left forearm. No adventitious
movements, such as tremor, noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5
-Sensory: No deficits to light touch, cold sensation throughout.
Decreased vibration to ankle on R, to knee on L. Proprioception
is good.
No decreased pinprick/cold/light touch or vibration in L hand.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: +romberg but good initiation, stride and speed. Able to
walk on heels. Some difficulty with tandem initially but
improves.
DISCHARGE EXAM
Full strength. Right parietal drift upward.
Pertinent Results:
___ 06:30AM GLUCOSE-210* UREA N-15 CREAT-0.9 SODIUM-138
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-27 ANION GAP-14
___ 06:30AM CALCIUM-9.1 PHOSPHATE-3.0 MAGNESIUM-2.1
___ 06:30AM WBC-5.1 RBC-5.13 HGB-15.4 HCT-44.7 MCV-87
MCH-30.0 MCHC-34.5 RDW-12.2
___ 06:30AM PLT COUNT-172
___ 11:16PM URINE HOURS-RANDOM
___ 11:16PM URINE UHOLD-HOLD
___ 11:16PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 11:16PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 10:33PM GLUCOSE-102* UREA N-15 CREAT-0.8 SODIUM-137
POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-29 ANION GAP-11
___ 10:33PM estGFR-Using this
___ 10:33PM CALCIUM-9.1 PHOSPHATE-3.4 MAGNESIUM-2.0
___ 10:33PM WBC-5.3 RBC-4.62 HGB-14.0 HCT-40.3 MCV-87
MCH-30.4 MCHC-34.9 RDW-12.3
___ 10:33PM NEUTS-50.4 ___ MONOS-7.7 EOS-2.1
BASOS-0.6
___ 10:33PM PLT COUNT-146*
___ 10:33PM ___ PTT-30.5 ___
MRI Brain
Again seen is a 2.2 x 1.7 cm amount of region of bones T2
hyperintensity and
peripheral magnetic susceptibility in the parietal
periventricular white
matter abutting the left lateral ventricular atrium. There is
no evidence of
interval hemorrhage. Surrounding FLAIR hyperintensities may
reflect a
component of gliosis. Other scattered FLAIR hyperintensities are
in keeping
with chronic small vessel ischemic disease. Post-contrast images
demonstrate a
draining vessel referring, likely a developmental venous anomaly
(101a:127).
There is no restricted diffusion to suggest an acute or subacute
infarction.
There is no mass effect or shift of normally midline structures.
The
ventricles and sulci are prominent, consistent with global
atrophy.
Intracranial flow voids are maintained. The visualized
paranasal sinuses and
mastoid air cells are clear.
IMPRESSION:
1. No significant change of the left parietal periventricular
cavernoma. The
post-contrast images show an adjacent developmental venous
anomaly.
2. No evidence of hemorrhage or infarction
Brief Hospital Course:
Mr. ___ was admitted to the general neurology service for
further workup after a ___ performed as an outpatient showed a
possible change in the size of his known left parietal cavernous
malformation, and examination by PCP showed ___ question of new
left pronator drift.
Upon admission, his exam was notable not for a left pronator
drift, but rather a right upwards parietal drift, to be expected
due to his known cavernoma. He underwent MRI brain to further
evaluate for evolution of this cavernoma, and it was found to be
unchanged from prior imaging studies. He had no signs or
symptoms concerning for seizures.
His symptoms were likely due to dehydration or a viral illness.
He was discharged home with follow up and was instructed to call
his PCP with any further episodes of lightheadedness.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Simvastatin 40 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Lisinopril 20 mg PO DAILY
3. Simvastatin 40 mg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Left parietal cavernous malformation
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 neurology service at ___ after a CT
scan of your head showed possible change in the size of your
known cavernous malformation. While you were here, we found
nothing unexpected on your neurological examination. We did an
MRI of your brain which showed that the size of your cavernous
malformation was unchanged.
You should follow up with your doctors as previously ___.
It was a pleasure taking care of you during this hospital stay.
Followup Instructions:
___
|
10664643-DS-21
| 10,664,643 | 21,964,713 |
DS
| 21 |
2140-02-12 00:00:00
|
2140-02-12 15:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
acute onset of right-sided arm weakness and speech disturbance
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
Mr. ___ is a ___ right handed man with history
notable for DMII, HTN, and HLD presenting with acute onset of
right-sided arm weakness and speech disturbance, for which a
code
stroke was activated.
Mr. ___ wife reports last speaking to him at 11:52 this
morning, during which time his speech was noted to be normal and
he was otherwise asymptomatic. On returning home at 2:15 ___, she
noted that his speech was "slurred" and that he was more
confused
regarding the onset of his symptoms or the events of the day.
She
asked Mr. ___ to raise both arms, and noted that the right
arm drifted to the bed. She administered 324 mg of aspirin and
activated EMS. En route to ___, Mr. ___ wife noticed
some
improvement in his speech and confusion, though felt that he had
not returned to his baseline on arrival.
At time of code stroke activation approximately ten minutes
after
arrival, Mr. ___ was able to recall some of the above
history, noting that he had difficulty expressing his thoughts
as
speech during the ambulance ride and noticing right arm
weakness.
Prior to onset of these symptoms, he noticed "tingling"
paresthesiae starting from his right hand, radiating up his
right
arm, and traveling to his face and lips over the course of
"minutes", following which he noticed his speech difficulty. He
reports two similar episodes in the past, the most recent ___
years ago, that was diagnosed as a TIA with reportedly
unremarkable imaging. Mr. ___ denies headaches or vision
change associated with either episode.
ROS: On review of systems, Mr. ___ headaches,
lightheadedness, loss of vision, blurred vision, diplopia,
vertigo, dysarthria, dysphagia, bowel or bladder incontinence or
retention, difficulty with gait, fevers, chills, chest pain,
dyspnea, nausea, vomiting, diarrhea, constipation, abdominal
pain, dysuria, myalgias, arthralgias, or rash.
Past Medical History:
DMII
HTN
HLD
GERD
Peyronie disease s/p penile implant (___)
Social History:
___
Family History:
Non-contributory
Physical Exam:
Vitals: T: 97.4 HR: 85 BP: 156/86 RR: 17 SpO2: 100% RA
General: Alert, cooperative, in NAD
HEENT: NCAT, MMM
___: RRR
Pulmonary: No tachypnea or increased WOB
Abdomen: ND
Extremities: warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented to time and place, able
to relate history without difficulty. Speech is fluent with full
sentences, intact repetition, and intact verbal comprehension.
Naming intact. No dysarthria. Able to follow both midline and
appendicular commands.
- Cranial Nerves: PERRL (3 to 2 mm ___. VF full to number
counting. EOMI, no nystagmus. V1-V3 without deficits to light
touch bilaterally. Trace R NLFF with symmetric activation,
though
not at baseline per wife. Hearing diminished to conversation,
improved with hearing aid on left. Palate elevation symmetric.
Trapezius strength ___ bilaterally. Tongue midline.
- Motor: No pronator drift. No tremor.
[Delt][Bic][Tri][ECR][FEx][IP][Quad][Ham][TA]
L 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 1+
R 2+ 2+ 2+ 2+ 1+
- Sensory: No deficits to light touch or pinprick bilaterally.
No extinction to DSS.
- Coordination: No dysmetria with finger to nose testing
bilaterally.
- Gait: Narrow-based and steady.
========================
Discharge exam
Normal exam - Face symmetric with activation.
Pertinent Results:
___ 03:50PM URINE HOURS-RANDOM
___ 03:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 03:50PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 03:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 03:27PM CREAT-0.8
___ 03:27PM estGFR-Using this
___ 03:21PM GLUCOSE-120* LACTATE-2.9* NA+-137 K+-4.1
CL--101 TCO2-25
___ 03:12PM GLUCOSE-110* UREA N-13 CREAT-0.8 SODIUM-138
POTASSIUM-5.4* CHLORIDE-98 TOTAL CO2-25 ANION GAP-15
___ 03:12PM estGFR-Using this
___ 03:12PM ALT(SGPT)-17 AST(SGOT)-25 ALK PHOS-70 TOT
BILI-0.4
___ 03:12PM cTropnT-<0.01
___ 03:12PM ALBUMIN-4.5 CALCIUM-9.4 PHOSPHATE-3.6
MAGNESIUM-1.5*
___ 03:12PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 03:12PM WBC-7.9 RBC-4.60 HGB-14.0 HCT-42.5 MCV-92
MCH-30.4 MCHC-32.9 RDW-13.4 RDWSD-45.6
___ 03:12PM PLT COUNT-255
___ 03:12PM ___ PTT-30.3 ___
==================
CTA Head and Neck ___
1. No evidence for acute intracranial hemorrhage or vascular
territorial
infarction.
2. Multifocal atherosclerotic disease throughout the
intracranial cervical
vasculature, as above, without high-grade stenosis, occlusion,
or aneurysm
greater than 3 mm.
3. Postsurgical changes following prior right canal wall down
mastoidectomy.
4. Additional findings, as above.
.
.
MRI Brain ___
1. Study is mildly degraded by motion.
2. No evidence for acute intracranial hemorrhage or infarction.
3. Mild global parenchymal volume loss and evidence of chronic
small vessel
ischemic disease.
4. Postsurgical changes status post right canal wall down
mastoidectomy,
better seen on prior CT examination.
5. Paranasal sinus disease and trace left mastoid fluid, as
described.
Brief Hospital Course:
Mr. ___ is a ___ right handed man with history
notable for DMII, HTN, and HLD presenting with acute onset of
right-sided arm weakness and speech disturbance, for which a
code
stroke was activated.
His neurologic exam was normal at the time of evaluation.
On a more detailed history, he describes evolution of
paresthesias over his right arm going into his face and hand
over ___ minutes. This then progressed to speech difficulty
where he had difficulty getting the words out.
Therefore, the time course most consistent with migraine. His
prior events occurred ___ years ago and then ___ years ago making
events too rare to justify daily migraine prophylaxis. It is
interesting that he had cluster headaches in the past as there
is some overlap between cluster and migraine headache. His
history of severe motion sickness also increases likelihood of
migraine.
Seizure was considered and is much less likely given the timing
of her symptoms as we would expect her sensory symptoms to
spread over a period of seconds instead of 15 minutes. We do not
believe this represents TIA as the events clearly evolved over
time. MRI Brain is negative for stroke.
He should follow up with PCP with referral to neurology if
events recur and consideration prophylactic medication if
appropriate.
Medications on Admission:
Metformin 1,000 mg BID
Lisinopril 10 mg daily
Atorvastatin 80 mg daily
ASA 81 mg daily
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Lisinopril 10 mg PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Migraine
Discharge Condition:
Note that the discharge procedures took over 30 min to complete
a discharge exam, address all questions and concerns, explain
plans and set up proper follow-up.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
You were admitted due to transient symptoms of right sided arm
and face sensory changes in addition to difficulty with speech
that evolved over ___ minutes and then resolved.
Initially care providers were worried about acute stroke or TIA.
However, your symptoms are not consistent with this as they
evolved slowly over 30 minutes and then resolved slowly.
Currently, your neurologic exam is normal.
Therefore, we think that the most likely etiology of your
symptoms is a migraine phenomena. You have had similar events in
the past that occur very rarely - therefore we would not suggest
starting a daily med at this time for migraine prevention.
It is also interesting that you have a history of cluster
headache. Sometimes migraine and cluster headache can overlap
and the fact that you have prominent motion sickness also goes
along with migraine phenomena.
In the future, these episodes may recur or become more frequent.
If they do, you should see a neurologist to consider starting a
daily migraine medication versus ask your primary care provider
to prescribe something for headache.
We also considered seizure but the time course of your events is
not consistent with this. We would not recommend an EEG at this
time.
It was a pleasure taking care of you,
___ Neurology
Followup Instructions:
___
|
10664905-DS-16
| 10,664,905 | 24,489,369 |
DS
| 16 |
2168-05-24 00:00:00
|
2168-05-24 16:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Tetracyclines / Celebrex / sulfa drugs / latex /
lisinopril
Attending: ___.
Chief Complaint:
abnormal LFTs
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ woman with PMHx notable for hypertension,
osteoarthritis, recent UTI on nitrofurantoin, and likely
sclerosing cholangitis who was referred to the ED by her
gastroenterologist for abnormal LFTs.
Labs were drawn on ___ at an outside facility and so are
not directly viewable in OMR. Her son did take pictures however
which showed an AST 56, ALT 81, AP 565, GGT 1614. GTT is
reportedly up-trending from prior in 800s, though unclear
exactly
when this was from. Was directed by GI to come to ED for
expedited evaluation.
Of note, she had been following with GI at ___ (Dr. ___ for several years reportedly for a dilated bile duct.
Interval labs from ___ were up-trending, and so underwent
MRCP at that time. Was referred to ___ where
imaging was reviewed and thought to show multiple intrahepatic
biliary strictures, overall consistent with sclerosing
cholangitis. Unclear if primary vs. secondary to long-standing
biliary obstruction or other cause. Findings were discussed at
interdisciplinary pancreas conference with low concern for
malignancy and so ERCP was deferred at that time.
Past Medical History:
hypertension
cholecystitis
osteoarthritis
colonic polyps
skin cancers
___ reaction
bilateral oophorectomy
cataracts
Social History:
___
Family History:
No known history of biliary or liver disease in family.
Physical Exam:
Admission Physical Exam
VITALS: 97.8 191/100 63 20 97 RA
GENERAL: Older appearing woman in no acute distress.
Comfortable.
NEURO: AAOx3. CNII-XII grossly intact. Motor strength ___ in
upper and lower extremities bilaterally. Sensation grossly
intact. Speech normal.
HEENT: NCAT. EOMI. MMM.
CARDIAC: Regular rate & rhythm. Normal S1/S2. No murmurs, rubs,
or gallops.
PULMONARY: Clear to auscultation bilaterally. Breathing
comfortably on room air.
ABDOMEN: Soft, non-tender, non-distended. No hepatosplenomegaly.
EXTREMITIES: Warm, well perfused, non-edematous.
Discharge Physical Exam
VS:
24 HR Data (last updated ___ @ 713)
Temp: 98.4 (Tm 98.7), BP: 158/80 (138-179/80-92), HR: 57
(57-70), RR: 18 (___), O2 sat: 95% (93-96), O2 delivery: Ra
GENERAL: Older appearing woman in no acute distress.
Comfortable.
HEENT: NCAT. EOMI. MMM.
CARDIAC: Regular rate & rhythm. Normal S1/S2. No murmurs, rubs,
or gallops.
PULMONARY: Clear to auscultation bilaterally. Breathing
comfortably on room air.
ABDOMEN: Soft, non-tender, non-distended. No hepatosplenomegaly.
EXTREMITIES: Warm, well perfused, non-edematous.
NEURO: AAOx3. CNII-XII grossly intact. Motor strength ___ in
upper and lower extremities bilaterally. Sensation grossly
intact. Speech normal.
Pertinent Results:
Admission Labs
___ 04:20PM BLOOD WBC-5.6 RBC-4.21 Hgb-12.1 Hct-37.9 MCV-90
MCH-28.7 MCHC-31.9* RDW-14.8 RDWSD-48.6* Plt ___
___ 04:20PM BLOOD Neuts-60.5 ___ Monos-14.4*
Eos-3.2 Baso-0.7 Im ___ AbsNeut-3.40 AbsLymp-1.18*
AbsMono-0.81* AbsEos-0.18 AbsBaso-0.04
___ 04:57PM BLOOD ___ PTT-29.2 ___
___ 04:20PM BLOOD Glucose-107* UreaN-18 Creat-1.0 Na-136
K-4.5 Cl-97 HCO3-27 AnGap-12
___ 04:20PM BLOOD ALT-56* AST-46* AlkPhos-564* TotBili-0.4
___ 04:20PM BLOOD Albumin-4.0 Calcium-10.1 Phos-2.2*
Mg-2.8*
___ 04:20PM BLOOD TSH-1.4
___ 04:20PM BLOOD T4-9.9
___ 04:20PM BLOOD IgG-1057 IgM-84
___ 04:29PM BLOOD Lactate-1.4
Pertinent Findings
___ 07:55AM BLOOD ALT-45* AST-39 AlkPhos-500* TotBili-0.3
Discharge Labs
___ 07:35AM BLOOD WBC-6.1 RBC-3.86* Hgb-11.2 Hct-35.1
MCV-91 MCH-29.0 MCHC-31.9* RDW-14.9 RDWSD-49.5* Plt ___
___ 07:35AM BLOOD Glucose-91 UreaN-21* Creat-1.0 Na-137
K-4.6 Cl-97 HCO3-27 AnGap-13
___ 07:35AM BLOOD ALT-43* AST-38 LD(LDH)-161 AlkPhos-487*
TotBili-0.3
___ 07:35AM BLOOD Calcium-9.4 Phos-3.1 Mg-2.5
___ 04:20PM BLOOD IgG-1057 IgM-84
___ 04:20PM BLOOD T4-9.9
___ 04:20PM BLOOD TSH-1.4
Brief Hospital Course:
PATIENT SUMMARY
================
Ms. ___ is a ___ woman with PMHx notable for
hypertension, chronic biliary dilatation, and sclerosing
cholangitis now admitted for rising LFTs in a cholestatic
pattern concerning for sclerosing cholangitis, in the setting of
worsening weakness and fatigue x5 weeks.
ACUTE ISSUES
==============
#Sclerosing cholangitis
#Transaminitis
The patient presented with cholestatic pattern of LFT
abnormalities with predominantly elevated alk phos and GGT. This
was presumably due to known biliary obstruction visualized on
prior MRCP in ___, thought to be from sclerosing cholangitis
though unclear if primary versus secondary from chronic biliary
obstruction. Malignancy was considered less likely at
interdisciplinary pancreatic conference in ___ given
clinical stability at that time, but ERCP was recommended
symptoms were worsening. There was low suspicion of
choledocholithiasis based on normal RUQUS. There was no evidence
of acute infection. Serologic ___ performed: AMA, ___,
___, IgG, IgM, GGT, ___ and pending at discharge. MRCP
performed which showed improvement in scan, no cholestasis or
CBD dilation, but with some strictures in liver with mild
hepatic duct dilation.
# FATIGUE
The patient had been feeling more tired and participating less
at living facility. Her exam was without any focal weakness.
Suspected etiologies included hepatic abnormalities vs. recent
Zoster flare vs. UTI (finishing treatment on admission). No
other major metabolic derangements. TSH and T4 wnl. ___ was
consulted and determined pt to be at baseline w/ ___ needs.
Nutrition recommended Ensure w/ meals, vitamin w/ minerals QD.
# HYPERTENSION
The patient was hypertensive 160-190s while admitted. She has
known history of hypertension but recently stopped home
amlodipine reportedly due to SBP ___ in clinic. She had SBPs as
high as 180 but as low as ___. Recommend continued monitoring
but a liberal control strategy may be safer.
# URINARY TRACT INFECTION
Diagnosed at assisted living facility with symptoms of dysuria
and malodorous urine. Completed 7-day course nitrofurantoin on
___.
# REGURGITATION
Her caretaker and son described intermittent mucous
regurgitation, which did not seem to be overt vomiting,
partially digested food products or dysphagia (food sticking in
throat). This problem was unlikely related to LFT abnormalities
or biliary issues. Speech and swallow was consulted, but did not
see the patient by the time of discharge.
CHRONIC / STABLE ISSUES
================================
# OSTEOARTHRITIS: Patient was reportedly on tramadol,
gabapentin, and Tylenol at the facility. Tramadol was recently
started to reduce Tylenol burden on liver although patient had
not started taking this medication yet. Patient also had history
of not doing well on sedating medications. Patient continued on
Gabapentin 100 mg PO/NG BID, Acetaminophen 1000 mg PO/NG
Q8H:PRN, tramadol lose dose PRN at night for pain.
# GERD: treated with aluminum-Magnesium Hydrox.-Simethicone
___ mL PO/NG QID:PRN, TUMS TID after meals PRN GERD. PPI not
given as declined by proxy.
TRANSITIONAL ISSUES
==================
[] The patient was reported to have lots of mucus secretions in
her mouth. She did not have any overt signs of difficulty with
swallowing fluids or solids. Would recommend obtaining speech
and swallow evaluation as an outpatient. ___ also benefit from
EGD pending speech/swallow evaluation.
[] The patient had labile blood pressures while inpatient with
SBPs ranging from 90-170. She had discontinued amlodipine as an
outpatient due to hypotension. Consider restarting as
appropriate, but a liberal control strategy may avoid
hypotension.
[] consider compression stockings for orthostatic hypotension
[] Sclerosing cholangitis: follow-up final read of MRCP and
serologic testing in outpatient liver clinic and discussion of
treatment.
#CODE STATUS: DNR/DNI (confirmed, MOLST on file)
#CONTACT: ___ (son: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. cranberry unknown oral DAILY
2. Florastor (Saccharomyces boulardii) 250 mg oral BID
3. Gabapentin 100 mg PO BID
4. Metamucil (psyllium husk) 3.4 gram/5.4 gram oral DAILY
5. Miconazole Powder 2% 1 Appl TP BID
6. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
7. Oysco-500 (calcium carbonate) 500 mg calcium (1,250 mg) oral
QPM
8. Artificial Tears Preserv. Free ___ DROP BOTH EYES BID
9. Salonpas (methyl salicylate-menthol) unknown topical QPM
10. Witch ___ 50% Pad ___ID
11. Vitamin D 1000 UNIT PO DAILY
12. Calcium Carbonate 500 mg PO BID:PRN GERD
13. melatonin 5 mg oral QHS:PRN
14. Senna 17.2 mg PO BID:PRN Constipation - First Line
15. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
abdominal discomfort
Discharge Medications:
1. cranberry 1 tab oral DAILY
2. Salonpas (methyl salicylate-menthol) 1 U topical QPM
3. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
abdominal discomfort
4. Artificial Tears Preserv. Free ___ DROP BOTH EYES BID
5. Calcium Carbonate 500 mg PO BID:PRN GERD
6. Florastor (Saccharomyces boulardii) 250 mg oral BID
7. Gabapentin 100 mg PO BID
8. melatonin 5 mg oral QHS:PRN
9. Metamucil (psyllium husk) 3.4 gram/5.4 gram oral DAILY
10. Miconazole Powder 2% 1 Appl TP BID
11. Oysco-500 (calcium carbonate) 500 mg calcium (1,250 mg)
oral QPM
12. Senna 17.2 mg PO BID:PRN Constipation - First Line
13. Vitamin D 1000 UNIT PO DAILY
14. Witch ___ 50% Pad ___ID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
===============
Sclerosing cholangitis
Transaminitis
SECONDARY DIAGNOSES
===============
Hypertension
Urinary tract infection
Regurgitation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you were feeling
fatigued and had elevated liver labs.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We sent lab tests to look for a reason for your liver lab
abnormalities.
- You got imaging of your liver and gallbladder that showed
overall improvement with some narrowing of vessels in the liver.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- You should have your swallowing issues evaluated by a speech
and swallow expert. They may recommend further testing or
consultation with a GI doctor or ENT doctor.
- Avoid narcotics like tramadol which may make you feel altered.
- Call your doctor if you develop any symptoms that concern you.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10665897-DS-31
| 10,665,897 | 26,945,370 |
DS
| 31 |
2187-02-02 00:00:00
|
2187-02-03 10:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abnormal labs
Major Surgical or Invasive Procedure:
Tunneled line removal
Replacement of tunneled dialysis line
History of Present Illness:
___ yo F with h/o ESRD on HD (anuric), DM, CHF, HTN, Dementia,
and multiple PMHx who presents with ___ transferred from
her nursing home (___).
Per RN, she had low grade fever 99.0 and BP 165/71 at dialysis
(___ on ___ blood cx
drawn, sent to ___ lab, grew GNR. NH was informed and pt was
transferred to ___ last night ___.
Prior to this, NH only noticed decreased appetite from baseline.
At baseline, pt is alert, oriented to name and place but not
time, answers questions only when asked, requires assistance
with all ADLs, bowel inct, screams if she needs to use bathroom.
Past Medical History:
- HTN
- DM, requiring insulin
- ESRD on HD TThS
- s/p left AV fistula revision/declotting ___, tunneled HD
catheter ___, h/o line associated bacteremia (methicillin
resistant coag neg staph ___
- h/o GI bleed with gastric ulcer
- ? h/o chronic pancreatitis
- chronic constipation (admit to ED ___, resolved with
enemas)
- Left ventricular thrombus: With h/o embolus to left toe
- DVT bilateral lower extremities
- Diastolic CHF: EF >55%, LVH
- Anemia, on EPO with HD
- Cortical blindness: Can see light/dark, but no figures
- Hypothyroidism: TSH 3.4 (___)
- Seizure disorder, diagnosed with ICU admission ___
- gastritis
- cerebellar stroke
- dementia
- PVD
- Fall with left hip injury ___
Social History:
___
Family History:
CAD in mother and father. Parents not living. Sister and niece
healthy
Physical Exam:
On admission
96.0 96.0 175/79 72 20 96% RA
General: Elderly woman lying in bed, in no acute distress
HEENT: NC/AT, exquisite tenderness in right mastoid (behind ear)
region extending to neck, left eyelid open and right eyelid
closed with discharge, sclera anicteric, MMM, poor oral hygiene
(white coated tongue)
Neck: tender, limited neck flexion, extension, lateral movements
due to pain, no LAD
Lungs: Clear anteriorly, right back lower base rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, diffusely tender, non-distended, bowel sounds
present, no rebound tenderness or guarding
Ext: Well-healed ulcers b/l, warm shins but cool feet, no
clubbing, cyanosis or edema, moving all extremities, right ___
toe onychomycoses.
Neuro: alert, oriented to name and place, but not time.
On discharge - exam unchanged from above, except as below
Neuro: Awake and arousable, but does not answer questions or
make eye contact. No focal neurological deficits.
Pertinent Results:
___ 3:45 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES.
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 4 S
MEROPENEM------------- 1 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ 2215 ON ___
-___.
GRAM NEGATIVE ROD(S).
___ 4:18 pm CATHETER TIP-IV Source: cath. tip.
WOUND CULTURE (Preliminary):
PSEUDOMONAS AERUGINOSA. >15 colonies.
Admission labs:
___ 12:30AM BLOOD WBC-19.0*# RBC-4.00* Hgb-10.6* Hct-36.4
MCV-91 MCH-26.6* MCHC-29.2* RDW-18.3* Plt ___
___ 12:30AM BLOOD Neuts-83.5* Lymphs-11.8* Monos-3.4
Eos-1.2 Baso-0.1
___ 12:30AM BLOOD Plt ___
___ 03:45PM BLOOD ___ PTT-30.0 ___
___ 09:20AM BLOOD
___ 12:30AM BLOOD Glucose-284* UreaN-61* Creat-5.9*# Na-141
K-4.3 Cl-100 HCO3-23 AnGap-22*
___ 12:30AM BLOOD ALT-10 AST-17 AlkPhos-202* TotBili-0.2
___ 12:30AM BLOOD Lipase-12
___ 12:30AM BLOOD Albumin-3.8 Calcium-9.4 Phos-3.7 Mg-2.5
___ 12:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:44AM BLOOD Lactate-1.2
___ 09:20AM BLOOD WBC-20.3* RBC-4.25 Hgb-11.2* Hct-39.2
MCV-92 MCH-26.5* MCHC-28.7* RDW-18.6* Plt ___
___ 04:00PM BLOOD WBC-10.1# RBC-3.87* Hgb-10.3* Hct-35.5*
MCV-92 MCH-26.5* MCHC-28.8* RDW-18.5* Plt ___
___ 08:20AM BLOOD WBC-8.8 RBC-3.88* Hgb-10.4* Hct-34.7*
MCV-90 MCH-26.9* MCHC-30.0* RDW-18.7* Plt ___
Discharge labs:
___ 06:15AM BLOOD WBC-8.2 RBC-3.92* Hgb-10.5* Hct-35.2*
MCV-90 MCH-26.7* MCHC-29.7* RDW-18.8* Plt ___
___ 06:15AM BLOOD Glucose-116* UreaN-90* Creat-8.3* Na-133
K-5.2* Cl-98 HCO3-21* AnGap-19
___ 06:15AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.7*\
Radiology Report CHEST (SINGLE VIEW) Study Date of ___ 1:33
AM
PA AND LATERAL CHEST RADIOGRAPH: Left-sided dialysis catheter
tip terminates within the right atrium. Bilateral low lung
volumes are noted with crowding of bronchovascular markings.
Cardiac silhouette appears mildly prominent, likely accentuated
by low lung volumes. Opacification of the right lung base may
represent atelectasis versus infectious process in the correct
clinical setting.
Radiology Report CT ABD & PELVIS WITH CONTRAST Study Date of
___ 1:42 AM
IMPRESSION:
1. No evidence of inflammatory process within the abdomen.
2. Diffuse fecal loading with excessively distended rectum due
to fecal
contents.
3. Thickening of anterior bladder wall, correlate with clinical
exam and
UA/labs.
4. Bilateral small pleural effusions, right > left.
5. Opacification at the right lung base adjacent to pleural
effusion likely atelectasis versus infection in the correct
clinical setting. Separate more rounded area of opacification at
right lung base(2:4) is concerning for consolidation with
possible cavitation.
6. Left adnexal cystic lesion, similar to prior exam, may be
further evaluated with US nonemergently if not already
performed.
7. Severe atherosclerotic calcification in the abdominal aorta
with near
occlusion of the abdominal aorta by atherosclerotic plaque just
above the
origin of the ___, unchanged from prior. Distal to this region,
the aorta
appears patent. Skin collaterals and underperfused kidneys
likely secondary to severe aortic atherosclerotic calcification.
8. Distened gallbladder without gallastone.
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
1:42 AM
IMPRESSION:
1. Opacification of the left mastoid air cells may suggest
mastoiditis of indeterminate chronicity.
2. No acute intracranial hemorrhage.
Radiology ___ ___ REMOVE TUNNELED CENTRAL W/O PORT Study
Date of ___ 4:03 ___
IMPRESSION:
Uncomplicated retrieval of a left-sided internal jugular
tunneled hemodialysis catheter.
Radiology Report C-SPINE NON-TRAUMA ___ VIEWS Study Date of
___ 2:46 ___
IMPRESSION:
1) Limited exam due to positioning/mobility.
2) Mild degenerative changes.
3) Suspected ligamentous laxity at C3/4.
4) Suspected dense ossification of the ALL in the lower cspine,
which may be contributing to fusion and decreased mobility.
However,t his extends beyond the lower edge of these images and
is not fully evaluated.
5) No bone detruction, focal severe disc narrowing or
prevertebral soft tissue swelling to confirm changes related to
infection.
6) If clinically indicated, cross-sectional imaging would help
for further assessment of cervical spine alignment, degenerative
changes, and soft tissues.
HEAD CT ___
1. Limited study due to motion artifact without CT evidence for
acute
intracranial process.
2. Partial opacification of the left mastoid air cells.
Clinical correlation is recommended.
TTE ___
The left atrium is normal in size. There is moderate symmetric
left ventricular hypertrophy. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of ___, the findings are similar.
IMPRESSION: Suboptimal image quality. No vegetations seen.
Pulmonic valve not well-visualized.
Brief Hospital Course:
___ yo F with h/o ESRD on HD (anuric), DM, CHF, HTN, Dementia,
and multiple PMHx who was transferred from her nursing home with
GNR sepsis, found to be pseudomonas sepsis.
# Pseudomonas sepsis: Patient presented with GNR bacteremia by
blood cx ___, hypothermia (T 95.8F) and leukocytosis (WBC
19) consistent with sepsis. Blood culture identified as
Pseudomonas aeruginosa which was also found on the tunneled cath
dialysis tip that was removed per renal consult. She also had a
cavitary lesion on CXR, which could be a source of pseudomonas,
although it was noted that cavitary lesions are usually due to
TB, staph aureus or anaerobes. Patient's antibiotic course was
narrowed to Cefepime for pseudomonal coverage from Vancomycin,
Cefepime and Metronidazole. She was switched to Ceftazidime
after replacement of a tunneled cath line so that she could be
receive it during dialysis. The patient had a transthoracic
echocardiogram on ___ which showed no vegetations and
antibiotic course will be two weeks, should be continued at
dialysis through ___.
Patient also initially had a left mastoid fluid on CT head
concerning for mastoiditis and right mastoid tenderness on
admission. However, there was no erythema or ulceration
consistent with acute otitis externa, confirmed by ENT
consultation.
#Cervical spine ligament laxity: Pt had neck tenderness but no
stiffness on admission. She received a cervical spine x-ray that
showed anterolisthesis and ligament laxity. Neurosurgery
consulted and recommended a cervical collar for 2 weeks and
follow-up with the ___ clinic in 2 weeks, which will
need to be scheduled by rehab.
#ESRD: Last dialysis on ___. Pt is on ___ dialysis schedule
per Nursing home. Her tunneled cath was removed per renal. A
new tunneled cath was placed on ___ after patient was
afebrile and has had no new blood culture growth. Resumed HD on
___ and should continue with ___ schedule after discharge.
She will receive the above described antibiotics at dialysis
after each session.
#Mental status: Patient is lethargic at baseline but arousable
to voice and will answer with head nod. There was briefly some
concern that she was not able to take oral medications or food
and she had a repeat head CT which showed no acute intracranial
process. On the day of discharge, she was at her apparent
baseline mental status and was able to take PO medications
without difficulty.
Chronic Issues
#Chronic constipation: continued home bowel regimen
#Hypothyroidism: continue home Levothyroxine
#Hypertension: Hypertensive on admission because she had only
received labetolol overnight. She started her home meds
Amlodipine, Labetalol, Captopril and her blood pressure became
normotensive/mildly elevated (SBP's 120-160's).
Transitional Issues
-follow-up blood culture results
-will continue to receive ceftazidime for a total 2 week course
with her dialysis sessions, will be continued through ___.
-will need to wear c-collar for 2 weeks until she is seen by
___ clinic
-schedule follow-up in ___ clinic with Dr. ___ in 2
weeks (___)
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from NH records.
1. Epoetin Alfa 7000 UNIT IV QWEEK Start: HS
2. Artificial Tears ___ DROP BOTH EYES BID
3. Lactulose 30 mL PO DAILY
4. Cyanocobalamin 100 mcg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Bisacodyl 10 mg PO HS:PRN constipation
7. Nitroglycerin Ointment 2% ___ in TP Q6H:PRN SBP > 180
8. Acetaminophen 650 mg PO Q4H:PRN pain
9. Hydrocodone-Acetaminophen (5mg-500mg 1 TAB PO Q6H:PRN pain
10. Glucagon 1 mg IM PRN glc < = 40
11. Levothyroxine Sodium 125 mcg PO DAILY
12. Omeprazole 40 mg PO DAILY
13. Simvastatin 20 mg PO DAILY
14. Senna with Docusate Sodium *NF* (sennosides-docusate sodium)
8.6-50 mg Oral 2 tabs BID
15. Labetalol 350 mg PO BID
16. Hydrocodone-Acetaminophen (5mg-500mg 1 TAB PO Q12H
17. Amlodipine 7.5 mg PO DAILY
18. Ferrous Sulfate 325 mg PO DAILY
19. GlipiZIDE 2.5 mg PO BID
20. Captopril 25 mg PO BID
21. sevelamer CARBONATE 800 mg PO TID W/MEALS
22. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Amlodipine 7.5 mg PO DAILY
3. Artificial Tears ___ DROP BOTH EYES BID
4. Aspirin 81 mg PO DAILY
5. Bisacodyl 10 mg PO HS:PRN constipation
6. Cyanocobalamin 100 mcg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. Captopril 25 mg PO BID
9. FoLIC Acid 1 mg PO DAILY
10. Glucagon 1 mg IM PRN glc < = 40
11. Labetalol 350 mg PO BID
12. Lactulose 30 mL PO DAILY
13. Levothyroxine Sodium 125 mcg PO DAILY
14. Omeprazole 40 mg PO DAILY
15. sevelamer CARBONATE 800 mg PO TID W/MEALS
16. Simvastatin 20 mg PO DAILY
17. Epoetin Alfa 7000 UNIT IV QWEEK
18. GlipiZIDE 2.5 mg PO BID
19. Hydrocodone-Acetaminophen (5mg-500mg 1 TAB PO Q6H:PRN pain
20. Hydrocodone-Acetaminophen (5mg-500mg 1 TAB PO Q12H
21. Nitroglycerin Ointment 2% ___ in TP Q6H:PRN SBP > 180
22. Senna with Docusate Sodium *NF* (sennosides-docusate sodium)
8.6-50 mg Oral 2 tabs BID
23. CefTAZidime 1 g IV POST HD Duration: 8 Days
Two week course finished on ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Pseudomonas aeruginosa sepsis
Neck pain
Secondary diagnoses:
ESRD on dialysis
HTN
T2DM
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
You were seen in the hospital for a bacterial infection in your
blood, which may have been related to your cathether. Your
dialysis cathether was removed and a new line was replaced.
There was no evidence of vegetations on your heart valves and
you will only need antibitoics for a total of two weeks (last
day ___, they will give you antibiotics at dialysis.
You should have a repeat chest CT scan in approximately 4 weeks.
You will also have to wear a cervical collar until you are seen
in the ___ clinic in 2 weeks.
START taking ceftazidime 1 gm with HD for a total of two weeks,
last day of antibiotics ___.
Followup Instructions:
___
|
10665897-DS-32
| 10,665,897 | 26,546,010 |
DS
| 32 |
2187-06-21 00:00:00
|
2187-06-21 12:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever, lethargy
Major Surgical or Invasive Procedure:
HD catheter removal ___
placement tunneled HD line - femoral site ___ under general
anesthesia
History of Present Illness:
This is a ___ y/o female with ESRD on HD, s/p recent admission
___ for Pseudomonal line infection (line changed ___, DM
on insulin, dementia, h/o CVA, who presents today with fever of
102 at HD and lethargy for several days. Patient is unable to
provide any history at this time due to lethargy/mental status.
I spoke with her ___ rehab staff, who were not aware of
today's events but did tell me she has not been eating for the
last 1 week. She is normally alert and responsive at baseline,
and answers questions, but is not oriented x 3. In speaking
with the patient's sister, she confirmed the above. Per ___
staff, no documented cases of influenza there. No known focal
symptoms, except for fever today and lethargy x several days
with decreased/minimal po intake.
.
At HD, patient received 1 dose of Vancomycin and 1 dose of
Ceftazidime (documented by HD notes and ED notes). She was sent
to the ED by EMS. VS were stable and she was given 500 cc of
NS. She was then admitted to medicine. Of note, K was
hemolyzed in the ED with value of 7.7; recheck was 5.7 prior to
admission to the floor.
.
Currently, the patient follows commands but barely opens her
eyes and does not answer any of my questions.
.
I confirmed medications and diet orders with ___ staff tonight.
Past Medical History:
- HTN
- DM, requiring insulin
- ESRD on HD, MWF
- s/p left AV fistula revision/declotting ___, tunneled HD
catheter ___, h/o line associated bacteremia (methicillin
resistant coag neg staph ___, h/o Pseudomonas line infection
___ s/p line exchange
- h/o GI bleed with gastric ulcer
- ? h/o chronic pancreatitis
- chronic constipation (admit to ED ___, resolved with
enemas)
- Left ventricular thrombus: With h/o embolus to left toe
- DVT bilateral lower extremities
- Diastolic CHF: EF >55%, LVH
- Anemia, on EPO with HD
- Cortical blindness: Can see light/dark, but no figures
- Hypothyroidism
- Seizure disorder, diagnosed with ICU admission ___
- gastritis
- cerebellar stroke
- dementia
- PVD
- Fall with left hip injury ___
Social History:
___
Family History:
CAD in mother and father. Parents not living. Sister and niece
healthy
Physical Exam:
VS: Tm 102, Tc 98.4, BP 140/58, HR 84, RR 16, SaO2 100/RA
General: Lethargic, barely arousable elderly female,
diaphoretic; will follow commands but is non-verbal currently
HEENT: NC/AT, PERRL. MM dry
Neck: supple, no LAD
Chest: CTA anteriorly, but limited exam ___ poor effort
CV: RRR s1 s2 normal, no m/g/r
Abd: soft, NT/ND, NABS
Ext: no c/c/e
Neuro: lethargic, barely arousable but will follow commands;
does not respond to questions
Pertinent Results:
___ 02:40PM WBC-16.3* RBC-3.11* HGB-9.2* HCT-30.6*
MCV-99*# MCH-29.5 MCHC-29.9* RDW-16.2*
___ 02:40PM NEUTS-88.6* LYMPHS-7.0* MONOS-3.9 EOS-0.4
BASOS-0.1
___ 02:40PM PLT COUNT-183
___ 02:40PM ___ PTT-30.6 ___
___ 02:40PM ALBUMIN-3.8 CALCIUM-9.2 PHOSPHATE-2.7
MAGNESIUM-1.8
___ 02:40PM LIPASE-12
___ 02:40PM ALT(SGPT)-29 AST(SGOT)-67* ALK PHOS-167* TOT
BILI-0.6
___ 02:40PM GLUCOSE-143* UREA N-29* CREAT-3.7*#
SODIUM-139 POTASSIUM-7.7* CHLORIDE-98 TOTAL CO2-22 ANION GAP-27*
___ 02:43PM HGB-9.1* calcHCT-27
___ 02:43PM GLUCOSE-140* LACTATE-4.4* NA+-144 K+-6.4*
CL--99 TCO2-24
___ 03:13PM LACTATE-2.4* K+-5.7*
.
___ CXR: HD catheter via left IJ, tip in low SVC; normal
heart size; clear lungs; no PTX/pleural effusions/consolidations
.
___ EKG: SInus tach at 114 bpm; ST depressions in V3-V6
Brief Hospital Course:
___ y/o female with h/o ESRD on HD via tunneled line, prior h/o
line infections, h/o dementia, HTN, h/o CVA, admitted with
fevers at HD x 1 day and lethargy x several days. She had
sepsis on admission with tachycardia and leukocytosis. Her
blood cultures rapidly were positive with growth on ___,
and ___ with MRSA, including growth from the tip of her HD line
removed on ___ that was also cultured. This high grade
septicemia represents a HD catheter blood stream infection. ID
and renal followed her. Emperic antibiotics given at HD unit on
___ included vanco and ceftaz and this was narrowed to a 6 week
course of IV vanco dosed with dialysis and the use of vanco
locks for her HD line between dialysis. TTE was poor quality
but did not show vegetation and no TEE was performed given her
poor performance status and no signs of decompensated CHF or
heart block and that she would get long duration of IV
antibiotics given recurrence of line infection/bacteremia, so
___ would not change management. She received tunneled HD line
on R groin under GA on ___ and underwent HD on ___. The line
was placed with <48hrs of negative cultures (culture positive on
___ as we wanted to avoid a temp line then a tunneled line to
avoid excess procedures and that she could not wait more time
before dialysis and a prolonged hospitalization was less
desirable given her frailty.
I directly spoke with her nephrologist Dr. ___ will
manage treatment of this infection at her HD unit.
Problems:
# sepsis
#coag positive septecemia
# Encephalopathy, toxic/metabolic
# ESRD on HD
# HTN
# DM controlled with complications on insulin
Code - DNR/DNI (confirmed with sister and ___)
Contact - sister, ___ ___
___ - pending above
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. GlipiZIDE 5 mg PO BID
2. Lactulose 30 mL PO DAILY
3. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q12H
4. Amlodipine 7.5 mg PO DAILY
hold for sbp<105
5. Captopril 25 mg PO BID
hold for sbp<110
6. Aspirin EC 81 mg PO DAILY
7. Calcium Carbonate 500 mg PO DAILY
8. Vitamin D 200 UNIT PO DAILY
9. Omeprazole 40 mg PO DAILY
10. Senna 2 TAB PO DAILY
11. Docusate Sodium 100 mg PO BID
12. FoLIC Acid 1 mg PO DAILY
13. Cyanocobalamin 100 mcg PO DAILY
14. Levothyroxine Sodium 125 mcg PO DAILY
15. Labetalol 350 mg PO BID
16. Simvastatin 20 mg PO DAILY
17. sevelamer CARBONATE 800 mg PO TID W/MEALS
18. Albuterol Inhaler 2 PUFF IH BID:PRN SOB
19. Artificial Tears 1 DROP BOTH EYES BID
20. Nitroglycerin Ointment 2% ___ in TP Q6H:PRN SBP>180
21. Bisacodyl ___AILY:PRN constipation
22. Acetaminophen 650 mg PO Q4H:PRN pain
23. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q6H:PRN pain
24. Ferrous Sulfate 325 mg PO DAILY
25. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using REG Insulin
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Albuterol Inhaler 2 PUFF IH BID:PRN SOB
3. Amlodipine 7.5 mg PO DAILY
hold for sbp<105
4. Artificial Tears 1 DROP BOTH EYES BID
5. Aspirin EC 81 mg PO DAILY
6. Bisacodyl ___AILY:PRN constipation
7. Calcium Carbonate 500 mg PO DAILY
8. Captopril 25 mg PO BID
hold for sbp<110
9. Cyanocobalamin 100 mcg PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Ferrous Sulfate 325 mg PO DAILY
12. Labetalol 350 mg PO BID
13. Lactulose 30 mL PO DAILY
14. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using REG Insulin
15. FoLIC Acid 1 mg PO DAILY
16. Levothyroxine Sodium 125 mcg PO DAILY
17. Omeprazole 40 mg PO DAILY
18. Senna 2 TAB PO DAILY
19. Vitamin D 200 UNIT PO DAILY
20. GlipiZIDE 5 mg PO BID
21. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q12H
22. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q6H:PRN pain
23. Nitroglycerin Ointment 2% ___ in TP Q6H:PRN SBP>180
24. sevelamer CARBONATE 800 mg PO TID W/MEALS
25. Simvastatin 20 mg PO DAILY
26. Vancomycin-Heparin Lock (For HD/Pheresis Catheters) 12.5 mg
LOCK ONCE Duration: 1 Doses
27. Nystatin Oral Suspension 5 mL PO QID
28. Vancomycin 1000 mg IV HD PROTOCOL
dose by HD protocol, use guidance by nephrology and check
vancomycin levels
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
MRSA septicemia
HD catheter blood stream infection
sepsis
ESRD
complication of HD catheter - infection
HTN
prior stroke
vascular dementia
Discharge Condition:
Mental Status: Confused - sometimes.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were hospitalized with a serious infection called MRSA
bacteremia, caused by bacteria that entered your blood stream
from your dialysis catheter. This catheter was removed and you
were started on IV antibiotics (Vancomycin) to treat this
infection. A new HD line will be placed in your groin on
___.
You will need 6 weeks of IV antibiotics to treat this infection.
Antibiotics will be given with your dialysis and you will need
blood levels of vancomycin to ensure the level is not too high
or low.
You will also need vancomycin locks used in your HD catheter
between HD sessions.
Meds Changes
NEW
IV vancomycin dosed with dialysis
vancomycin dwell (lock) in between HD sessions
Followup Instructions:
___
|
10665897-DS-33
| 10,665,897 | 28,436,956 |
DS
| 33 |
2187-07-17 00:00:00
|
2187-07-17 14:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Loss of dialysis access
Major Surgical or Invasive Procedure:
Placement of external jugular tunnelled dialysis catheter
History of Present Illness:
___ w/ hx of CHF, HTN, DM, CVA, cortical blindness, dementia,
and ESRD who presents w/ R femoral HD catheter out. She is
oriented only to self and place and was unaware why she is in
the hospital; she remembered that her HD was out when reminded
but is not sure how it happened. Per the pt she gets dialysis
___ but does not think she has had it for "awhile." Feels good
o/w, no complaints - denies pain, F/C, N/V, CP/SOB. Does not
know her medical history or medications.
In the ED, Initial VS were 98.0 74 182/83 18 98%. Labs were
significant for a Cr of 4.7 (down from 9.4 recently), K of 5.4.
Blood cultures were sent. Coags and CBC could not be drawn do to
difficult stick. Nephrology was consulted who recommended
admission and plan for ___ consult for new access in AM. Of note
while in the ED, pt was noted to be significantly hypertensive
to SBP of 195, which was attributed to not having received ___ BP
meds. He received 7.5mg of amlodipine, Captopril 25mg, and
Labetolol 350mg, and BP improved to 180s.
Of note, pt recently admitted in ___ for MRSA bacteremia
including growth on her HD cath which was removed, and treated
with a 6 week course of IV vanco dosed with dialysis. Tunneleled
line was subsequently placed in the groin on ___.
On admission to the floor, patient feels well without any
complaints. VS were 97.5 164/84 77 16 100% ra
Past Medical History:
- HTN
- DM, requiring insulin
- ESRD on HD, MWF
- s/p left AV fistula revision/declotting ___, tunneled HD
catheter ___, h/o line associated bacteremia (methicillin
resistant coag neg staph ___, h/o Pseudomonas line infection
___ s/p line exchange
- h/o GI bleed with gastric ulcer
- ? h/o chronic pancreatitis
- chronic constipation (admit to ED ___, resolved with
enemas)
- Left ventricular thrombus: With h/o embolus to left toe
- DVT bilateral lower extremities
- Diastolic CHF: EF >55%, LVH
- Anemia, on EPO with HD
- Cortical blindness: Can see light/dark, but no figures
- Hypothyroidism
- Seizure disorder, diagnosed with ICU admission ___
- gastritis
- cerebellar stroke
- dementia
- PVD
- Fall with left hip injury ___
Social History:
___
Family History:
CAD in mother and father. Parents not living. Sister and niece
healthy
Physical Exam:
ADMISSION
VS: VS were 97.5 164/84 77 16 100% ra
GENERAL: Frail elderly female, NAD. Oriented to hospital, thinks
she's in RI, thinks it's ___
HEENT: NC/AT, blind at baseline and not tracking, sclerae
anicteric, MMM
NECK: thin, no JVD
LUNGS: CTA bilat, no r/rh/wh, good air movement
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: no edema, 2+ pulses radial and dp
NEURO: awake, Alert to hospital but not location or date, CNs
II-XII grossly intact with exception of not able to track due to
blindness. Moving all extremities
SKIN: Right groin tunneled is removed and site is clean,
non-erythematous, and non painful
DISCHARGE
97.4 149/73 73 13 99RA
GENERAL: Frail elderly female, NAD. Oriented to self and
hospital (does not know which), thinks it's 1900s
HEENT: NC/AT, blind at baseline and not tracking, sclerae
anicteric, MMM
NECK: thin, no JVD
LUNGS: CTA bilat, no r/rh/wh, good air movement
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: no edema, 2+ pulses radial and dp
NEURO: awake, Alert to hospital but not location or date, not
able to track due to blindness. Moving all extremities
SKIN: Right groin tunneled is removed and site is clean,
non-erythematous, and non painful. No vascular bruit.
Pertinent Results:
ADMISSION
___ 11:54PM BLOOD WBC-5.0 RBC-2.70* Hgb-8.2* Hct-26.7*
MCV-99* MCH-30.3 MCHC-30.7* RDW-17.2* Plt ___
___ 11:54PM BLOOD Neuts-43.7* Lymphs-42.9* Monos-6.1
Eos-7.0* Baso-0.3
___ 11:54PM BLOOD ___ PTT-34.9 ___
___ 06:35PM BLOOD Glucose-63* UreaN-28* Creat-4.7*# Na-140
K-5.4* Cl-102 HCO3-26 AnGap-17
___ 06:35PM BLOOD Calcium-9.9 Phos-2.9# Mg-2.1
___ 06:00AM BLOOD Vanco-19.2
INTERVENTIONAL RADIOLOGY
Successful placement of a right external jugular vein approach
hemodialysis catheter with its tip located in the right atrium.
The catheter measures 19 cm tip to cuff and is ready to use.
DISCHARGE
___ 07:00AM BLOOD WBC-4.1 RBC-2.74* Hgb-8.3* Hct-27.7*
MCV-101* MCH-30.2 MCHC-29.9* RDW-17.3* Plt ___
___ 07:00AM BLOOD Glucose-153* UreaN-40* Creat-6.3* Na-132*
K-5.5* Cl-97 HCO3-27 AnGap-14
___ 07:00AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.3
___ 06:28AM BLOOD Vanco-20.1*
Brief Hospital Course:
BRIEF HOSPITAL COURSE
___ w/ hx of CHF, HTN, DM, CVA, cortical blindness, dementia,
and ESRD who presents w/ R femoral HD catheter out. On admission
had K of 5.4 but without concerning EKG changes--initially
treated in insulin but given patient's labile blood sugars
required ___. Blood sugars stabilized. Tunnelled EJ line
was placed on ___ and patient recieved dialysis on ___ for a
prolonged period (in case pt unable to make it to regularly
scheduled ___ dialysis due to impending ___).
Vancomycin started on prior admit for MRSA bacteremia should be
continued per dialysis protocol through ___ to complete a 6
week course of antibiotics.
ACTIVE ISSUES
# ESRD with Removed R Femoral Line: Unclear how access was lost.
On admission had No urgent need for dialysis currently. No
acidosis, no respiratory issues, slightly HyperK+ but no peaked
T's on EKG. Tunnelled EJ line was placed on ___ and patient
recieved dialysis on ___ for a prolonged period (in case pt
unable to make it to regularly scheduled dialysis due to
impending ___). Otherwise sevelamer continued and
recieved one dose of EPO 3000 units and doxecalciferol 1mcg on
this admission.
# Recent MRSA Bacteremia: Per d/c summary, day 1 was ___ with
planned ___osed with dialsys. However, this was not
on outpt medication list. Patient's sister (___) thinks plan was
only for 2 weeks and that she is no longer on this. No events
this admission should alter treatment. Blood cultures were
negative. Will need vancomycin dosed at HD through ___ to
complete a 6 week course of treatment.
# DM: Glypizide was held on this admission and patient started
on insulin sliding scale. For Hyperkalemia was initially treated
in insulin but given patient's labile blood sugars required ___. Blood sugars stabilized on ___.
# HTN: On admission had SBPs in the 190s but had improvement
after giving home BP meds. Maintained in house with Amlodipine
7.5 mg QAM ___, QPM MWFSu, Labetolol 350mg BID and Captopril
25mg BID.
INACTIVE ISSUES
# h/o GI bleed with gastric ulcer: continued home omeprazole
# Anemia: on EPO with HD. Recieved one dose of EPO 3000 units on
___ on this admission.
# Hypothyroidism: continued Levothyroxine 125 mcg daily
# Chronic constipation: continued Colace, Bisacodyl, Senna,
Lactulose.
# HL: continued home simvastatin 20mg daily
# Dementia: maintained on delirium precautions
TRANSITIONAL ISSUES
# Vancomycin for prior MRSA bacteremia: No events this admission
should alter treatment. Blood cultures were negative. Will need
vancomycin dosed at HD through ___ to complete a 6 week
course of treatment.
# continue with ___ dialysis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Epoetin Alfa 7000 U SC WEEKLY Start: with dialysis
2. Vitamin D 50,000 UNIT PO MONTHLY
3. Artificial Tears ___ DROP BOTH EYES BID
4. GlipiZIDE 5 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Levothyroxine Sodium 125 mcg PO DAILY
7. Lactulose 30 mL PO DAILY
hold for diarrhea
8. Simvastatin 20 mg PO DAILY
9. Calcium Carbonate 500 mg PO BID
10. Omeprazole 40 mg PO DAILY
11. Senna 2 TAB PO DAILY
12. Labetalol 350 mg PO BID
hold for sbp <100, HR <60
13. Nystatin Oral Suspension 5 mL PO QID
14. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q12H
15. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q6H:PRN pain
hold for sedation, rr<12
16. Amlodipine 7.5 mg PO 3X/WEEK (___) Start: 0900 AM
hold for sbp<100
17. Amlodipine 7.5 mg PO 4X/WEEK (___) Start: 21:00
hold for sbp<100
18. Ferrous Sulfate 325 mg PO DAILY
19. Captopril 25 mg PO TID
hold for sbp <100
20. sevelamer CARBONATE 800 mg PO TID W/MEALS
21. Cyanocobalamin 100 mcg PO DAILY
22. FoLIC Acid 1 mg PO DAILY
23. Bisacodyl 10 mg PR HS:PRN constipation
24. Nitroglycerin Ointment 2% ___ in TP Q6H:PRN sbp >180
25. Albuterol Inhaler 2 PUFF IH BID PRN SOB
26. Acetaminophen 650 mg PO Q4H:PRN pain
27. Aspirin 81 mg PO DAILY
28. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Albuterol Inhaler 2 PUFF IH BID PRN SOB
3. Artificial Tears ___ DROP BOTH EYES BID
4. Bisacodyl 10 mg PR HS:PRN constipation
5. Calcium Carbonate 500 mg PO BID
6. Captopril 25 mg PO TID
hold for sbp <100
7. Cyanocobalamin 100 mcg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Ferrous Sulfate 325 mg PO DAILY
10. FoLIC Acid 1 mg PO DAILY
11. Labetalol 350 mg PO BID
hold for sbp <100, HR <60
12. Lactulose 30 mL PO DAILY
hold for diarrhea
13. Levothyroxine Sodium 125 mcg PO DAILY
14. Nystatin Oral Suspension 5 mL PO QID
15. Omeprazole 40 mg PO DAILY
16. Senna 2 TAB PO DAILY
17. sevelamer CARBONATE 800 mg PO TID W/MEALS
18. Simvastatin 20 mg PO DAILY
19. Aspirin 81 mg PO DAILY
20. GlipiZIDE 5 mg PO BID
21. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q12H
22. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q6H:PRN pain
hold for sedation, rr<12
23. Nitroglycerin Ointment 2% ___ in TP Q6H:PRN sbp >180
24. Vitamin D 50,000 UNIT PO MONTHLY
25. Amlodipine 7.5 mg PO 4X/WEEK (___)
Please give HS
26. Amlodipine 7.5 mg PO 3X/WEEK (___)
Please give in AM
27. Epoetin Alfa 7000 U SC WEEKLY
28. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
29. Vancomycin IV Sliding Scale
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
End Stage Renal Disease
Hypertension
Diabetes Mellitus
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
Thank you for choosing us for your care. You were admitted
because you lost your dialysis access. We also noticed that your
potassium was high so we gave you medicine to make this more
normal. We put in a new line in your neck so you could get
dialysis. You should get dialysis on ___ and
___.
Please START Vancomycin dosed per dialysis protocol through ___
to complete a 6 week course of antibiotics.
Please CHANGE your Amlodipine dosing schedule to:
Amlodipine 7.5 mg PO/NG 4X/WEEK (___) Give at 2100PM
Amlodipine 7.5 mg PO/NG 3X/WEEK (___) Give at 0900 AM
Otherwise we have made no changes to your medications.
Followup Instructions:
___
|
10665905-DS-16
| 10,665,905 | 20,231,564 |
DS
| 16 |
2137-12-26 00:00:00
|
2137-12-26 15:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Iodinated Contrast- Oral and IV Dye
Attending: ___.
Chief Complaint:
Nausea, vomiting, headache
Major Surgical or Invasive Procedure:
None this admission.
___: left craniotomy for clipping of ACOMM aneurysm
History of Present Illness:
Mr. ___ is a ___ year old male POD4 from left craniotomy
for aneurysm clipping. His post-operative course was significant
for severe pain and the chronic pain service was consulted. He
was discharged to home yesterday and was feeling generally well
and states his pain was tolerable. He ate spaghetti for dinner
and around ___ he was having uncontrolled pain which he
describes as in the left temporal/frontal region. He woke this
morning and took his medications however he had multiple
episodes
of nausea and vomiting and was unable to keep his medications or
food down. He went to an OSH and was transferred here for
neurosurgical evaluation. Head CT showed post-op changes without
acute hemorrhage.
He reports ___ headache with some dizziness. He currently
denies visual changes. Denies diarrhea, fevers, seizures,
incontinence of bowel and bladder, or recent trauma. He states
he
has been taking his medications as prescribed including bowel
meds but has not had a bowel movement since before surgery. He
reports he has 11 doses of methadone remaining at home.
Past Medical History:
HTN
HLD
narcotic dependence
Past surgical history
left craniotomy for ACOMM aneurysm clipping ___
multiple hernia repairs
cervical spine fusion
Social History:
___
Family History:
Mr. ___ has no family history of aneurysm or ruptured
aneurysms.
Physical Exam:
ON ADMISSION:
************
PHYSICAL EXAM:
O: T: 99.3 BP: 192/87 HR: 49 R: 16 O2Sats: 96% RA
Gen: WD/WN, complaining of severe pain, NAD.
HEENT: Pupils: PERRL EOMs: intact
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect- although frequently complaining of pain
Orientation: Oriented to person, place, and date- self corrected
for date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria. Some paraphasic errors when
answering date, self corrected.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2.5 to 2mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. Mild BUE tremors.
Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
ON DISCHARGE:
************
Opens eyes: [x]Spontaneous [ ]To voice [ ]To noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Pupils: Right 2.5-2mm Left 2.5-2mm
EOM: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No
Pronator Drift: [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No
Comprehension Intact: [ ]Yes [ ]No
Motor:
TrapDeltoidBicepTricepGrip
IPQuadHamATEHLGast
[x]Sensation intact to light touch
Wound:
[x]Sutures in place
[x]Well-approximated, no erythema or active drainage
Pertinent Results:
See OMR for pertinent lab results/imaging.
Brief Hospital Course:
___ male s/p left craniotomy for aneurysm clipping and
discharged home on ___, returned as transfer to ___ ED on ___
for post-operative headache, nausea, vomiting and constipation.
#Constipation
Upon his arrival back in the ED, the patient had severe nausea
and reported that he had not had a BM since before his surgery.
A KUB was done that revealed a large stool burden, but no
evidence of ileus. He was given a fleet enema and resumed on an
aggressive bowel regimen, including standing Docusate sodium,
Senna, Miralax and Bisacodyl as well as prn Milk of Magnesia. On
___, he was initiated on daily Relistor for opioid-induced
constipation. He had multiple BMs on ___.
#Nausea and vomiting
EKGs were performed that revealed the patient's QTc to be 419
and 440. He vomited x 1 on the morning of ___, and was given
Compazine. He continued to be nauseous and vomited two more
times. His diet was limited to clear liquids and he was given
Zofran x 1 as a second line agent. His nausea improved, and his
diet was advanced back to regular on ___.
#Chronic pain
The patient was resumed on his daily Methadone and put on prn
Oxycodone, APAP and Fioricet for pain control. His pain was
adequately controlled at time of discharge.
#S/P left craniotomy for aneurysm clipping.
Patient was neurologically intact on his return to the hospital.
No repeat imaging or LP was indicated. He was monitored with
neuro checks every 4 hours. He remained neurologically stable
until his discharge on ___.
Medications on Admission:
Discharge Medications from ___:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Dexamethasone 2 mg IV Q12H Duration: 2 Doses
This is dose # 2 of 2 tapered doses
RX *dexamethasone 2 mg 1 tablet(s) by mouth once, at bedtime
Disp #*1 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
5. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - Second Line
6. Naloxone Nasal Spray 4 mg IH ONCE MR1 severe respiratory
depression, altered mental status, associated with opiate use
Duration: 1 Dose
RX *naloxone [Narcan] 4 mg/actuation 1 actuation intranasally
Once MR1 Disp #*2 Spray Refills:*0
7. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth q6hrs Disp #*28 Tablet
Refills:*0
8. Polyethylene Glycol 17 g PO DAILY
9. Senna 17.2 mg PO QHS
10. Atorvastatin 20 mg PO QPM
11. BuPROPion XL (Once Daily) 150 mg PO DAILY
12. Lisinopril 20 mg PO DAILY
13. Methadone (Concentrated Oral Solution) 10 mg/1 mL 170 mg PO
DAILY
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Headache
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___
tablet(s) by mouth every 8 hrs prn Disp #*24 Tablet Refills:*0
2. Dexamethasone 2 mg PO Q12H Duration: 6 Doses
Start: Tomorrow - ___, First Dose: First Routine
Administration Time
This is dose # 1 of 3 tapered doses
RX *dexamethasone 1 mg 2 tablet(s) by mouth twice a day Disp
#*24 Tablet Refills:*0
3. Dexamethasone 2 mg PO DAILY Duration: 4 Doses
Start: After 2 mg Q12H tapered dose
This is dose # 2 of 3 tapered doses
4. Dexamethasone 1 mg PO DAILY Duration: 4 Doses
This is dose # 3 of 3 tapered doses
5. Famotidine 20 mg PO BID Duration: 14 Days
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*28
Tablet Refills:*0
6. Relistor (methylnaltrexone) 150 mg oral DAILY
Please follow-up with your PCP for additional refills of this
medication
RX *methylnaltrexone [Relistor] 150 mg 1 tablet(s) by mouth once
a day Disp #*30 Tablet Refills:*0
7. OxyCODONE (Immediate Release) ___ mg PO Q8H:PRN Pain -
Moderate
8. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
9. Atorvastatin 20 mg PO QPM
10. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line
11. BuPROPion XL (Once Daily) 150 mg PO DAILY
12. Docusate Sodium 100 mg PO BID
13. Lisinopril 20 mg PO DAILY
14. Methadone 170 mg PO DAILY
15. Polyethylene Glycol 17 g PO DAILY
16. Senna 8.6 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
ACOMM aneurysm
Chronic pain
Opioid-induced constipation
Post-operative nausea and vomiting
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call your neurosurgeons office and speak to the Nurse
Practitioner if you experience:
- Any neurological issues, such as change in vision, speech or
movement
- Swelling, drainage, or redness of your incision
- Any problems with medications, such as nausea vomiting or
lethargy
- Fever greater than 101.5 degrees Fahrenheit
- Headaches not relieved with prescribed medications
Medications:
- You were discharged on ___ on Oxycodone 5 mg 1 tablet every 6
hours as needed for pain. You may take this Oxycodone 5mg ___
tablets every 8 hours as needed for pain.
Activity:
- Start to resume all activities as you tolerate but start
slowly and increase at your own pace.
- Do not operate any motorized vehicle for at least 10 days
after your surgery your Nurse Practitioner can give you more
detail at the time of your suture removal.
Incision Care:
- Keep your wound clean and dry.
- Do not use shampoo until your sutures are removed.
- When you are allowed to shampoo your hair, let the shampoo run
off the incision line. Gently pad the incision with a towel to
dry.
- Do not rub, scrub, scratch, or pick at any scabs on the
incision line.
- You need your sutures removed 7 to 10 days after surgery. You
may have these removed by a local healthcare provider closer to
your place of residence.
Post-Operative Experiences: Physical
- Jaw pain on the same side as your surgery; this goes away
after about a month
- You may experience constipation. Constipation can be prevented
by:
o Drinking plenty of fluids
o Increasing fiber in your diet by eating vegetables, prunes,
fiber rich breads and cereals, or
fiber supplements
o Exercising
o Using over-the-counter bowel stimulants or laxatives as
needed, stopping usage if you experience
loose bowel movements or diarrhea
o Please continue your prescribed bowel medications for
preventing constipation, including your
Relistor, which was initiated this most recent admission
- Fatigue which will slowly resolve over time
- Numbness or tingling in the area of the incision; this can
take weeks or months to fully resolve
- Muffled hearing in the ear near the incision area
- Low back pain or shooting pain down the leg which can resolve
with increased activity
Post-Operative Experiences: Emotional
- You may experience depression. Symptoms of depression can
include
o Feeling down or sad
o Irritability, frustration, and confusion
o Distractibility
o Lower Self-Esteem/Relationship Challenges
o Insomnia
o Loneliness
- If you experience these symptoms, you can contact your Primary
Care Provider who can make a referral to a Psychologist or
Psychiatrist
- You can also seek out a local Brain Aneurysm Support Group in
your area through the Brain Aneurysm Foundation
o More information can be found at ___
Followup Instructions:
___
|
10666050-DS-19
| 10,666,050 | 25,263,674 |
DS
| 19 |
2147-02-24 00:00:00
|
2147-02-24 19:04:00
|
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 pressure
Major Surgical or Invasive Procedure:
___ Emergency repair of acute type A aortic dissection
History of Present Illness:
___ yo male with PNHX significant for HTN presented to OSH after
waking up ~2:30 this am with ___ chest pressure. Non radiating
initally then eventually radiated to back. Associated with SOB.
Has never had similar pain in the past. He took 2 ASA and when
the pain did not resolve, he called ___. He was given NTG spray
and NTG tabs at OSH without resolution of pain. D Dimer +, CTA
done showed acute aortic dissection. On presentation to OSH SBP
______ - upon transfer to ___ SBP 140's - Cardene and esmolol
started for blood pressure control -___ consulted and plan to
take emergently to OR for dissection repair (mech valve if
needed).
Past Medical History:
Hypertension
s/p Tonsillectomy
s/p Left ear skin cancer excision
Social History:
___
Family History:
Father - died from ruptured aortic aneurysm at age ___
Mother alive in ___
Physical Exam:
Pulse:66 Resp:12 O2 sat: 96% RA
B/P Right: Left: 90/55->146/82
___ Weight:220#
General: Awake, alert in NAD
Skin: Dry [x] intact []
HEENT: PERRLA [] EOMI []
Neck: Supple [] Full ROM []
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: None
Pertinent Results:
___ 05:03AM BLOOD WBC-6.0 RBC-2.83* Hgb-8.2* Hct-24.5*
MCV-86 MCH-29.1 MCHC-33.7 RDW-12.9 Plt ___
___ 08:00AM BLOOD WBC-9.8 RBC-4.91 Hgb-14.9 Hct-41.7 MCV-85
MCH-30.3 MCHC-35.8* RDW-13.2 Plt ___
___ 05:03AM BLOOD ___
___ 08:00AM BLOOD ___ PTT-35.6 ___
___ 05:03AM BLOOD Glucose-122* UreaN-28* Creat-1.1 Na-136
K-3.8 Cl-98 HCO3-30 AnGap-12
___ 08:00AM BLOOD Glucose-145* UreaN-22* Creat-0.9 Na-140
K-4.1 Cl-104 HCO3-26 AnGap-14
___ 01:21AM BLOOD ALT-20 AST-41* AlkPhos-41 Amylase-37
TotBili-4.6*
___ ECHOCARDIOGRAPHY REPORT
___ ___ MRN: ___ TEE (Complete)
Done ___ at 11:32:02 AM FINAL
Referring Physician ___
___ of Cardiothoracic Surg
___ ___ ___
___ Status: Inpatient DOB: ___
Age (years): ___ M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: emergent aortic dissection
ICD-9 Codes: ___.00
___ Information
Date/Time: ___ at 11:32 ___ MD: ___
___, MD
___ Type: TEE (Complete) Sonographer: ___, MD
Doppler: Full Doppler and color Doppler ___ Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: ___-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Sinus Level: *3.9 cm <= 3.6 cm
Aorta - Ascending: *4.0 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.4 m/sec <= 2.0 m/sec
Findings
LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or
thrombus in the ___ or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Mild symmetric LV hypertrophy with normal cavity
size, and global systolic function (biplane LVEF>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildy dilated aortic root. Mildly dilated ascending
aorta. Ascending aortic intimal flap/dissection.. Thickened
aortic wall c/w intramural hematoma.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
___ VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: Written informed consent was obtained from the
___. The ___ was under general anesthesia throughout the
procedure. The ___ appears to be in sinus rhythm. Results
were personally reviewed with the MD caring for the ___.
Conclusions
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
Mild symmetric left ventricular hypertrophy with normal cavity
size, and global systolic function (biplane LVEF = 55 %).
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level. The
ascending aorta is mildly dilated. A mobile density is seen in
the ascending aorta consistent with an intimal flap/aortic
dissection. The aortic wall is thickened consistent with an
intramural hematoma.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
There is a trivial/physiologic pericardial effusion.
Dr. ___ was notified in person of the results before surgery.
Postbypass:
Preserved biventricular systolic function.
A tube graft in the native ascending aorta, no leaks.
Aortic valve is intact.
No other new findings.
LVEF 55%.
I certify that I was present for this procedure in compliance
with ___ regulations.
Electronically signed by ___, MD, Interpreting
physician ___ ___ 14:22
© ___ ___. All rights reserved.
___ ___ M ___ ___
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
10:30 AM
___ CSRU ___ 10:30 AM
CT HEAD W/O CONTRAST Clip # ___
Reason: r/o bleed no movement right leg post op
UNDERLYING MEDICAL CONDITION:
___ year old man with s/p aortic dissection s/p repair
REASON FOR THIS EXAMINATION:
r/o bleed no movement right leg post op
CONTRAINDICATIONS FOR IV CONTRAST:
___
Wet Read by ___. on ___ ___ 11:05 AM
No evidence of acute intracranial process. Of note MRI, would be
more
sensitive for detection of acute ischemia
Final Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with s/p aortic dissection s/p
repair // r/o
bleed no movement right leg post op
TECHNIQUE: Axial helical MDCT images were obtained through the
brain without
administration of IV contrast. Multiplanar reformatted images in
coronal and
sagittal axes and thin section bone algorithm reconstructed
images were
acquired.
DOSE: DLP: 892 mGy-cm
CTDI: 55 mGy
COMPARISON: None.
FINDINGS:
There is no evidence of hemorrhage, edema, mass effect or
obvious hypodense
area to suggest infarction. Right basal ganglia, slightly less
dense than the
left-? Significance .
The ventricles and sulci are normal in size and configuration.
The basal
cisterns appear patent and there is preservation of gray-white
matter
differentiation.
No suspicious osseous lesion is identified. There is mild
mucosal thickening
of the bilateral maxillary and sphenoid sinuses with some fluid
and in
ethmoid sinuses. The remaining visualized paranasal sinuses,
mastoid air cells
and middle ear cavities are clear.
The globes are unremarkable.
IMPRESSION:
No evidence of acute intracranial hemorrhage or mass effect. No
obvious acute
infarct.
Of note MRI, would be more sensitive for detection of acute
infarction if not
contra-indicated.
BY ELECTRONICALLY SIGNING THIS REPORT, I THE ATTENDING PHYSICIAN
ATTEST THAT ___ HAVE REVIEWED THE ABOVE IMAGES FOR THE ABOVE
EXAMINATION(S) AND AGREE WITH THE FINDINGS AS DOCUMENTED ABOVE.
___, MD
___, MD electronically signed on ___ ___ 5:30
___
Imaging Lab
___ Head CT
IMPRESSION:
No evidence of acute intracranial hemorrhage or mass effect. No
obvious acute
infarct.
Of note MRI, would be more sensitive for detection of acute
infarction if not
contra-indicated.
Brief Hospital Course:
Mr. ___ was med-flighted from outside hospital to ___.
Upon admission he was emergently taken to the operating room
where he underwent emergency repair of his acute type A aortic
dissection. Please see operative note for surgical details.
Following surgery he was transferred to the CVICU for invasive
monitoring in stable condition.He awoke neurologically intact
and weaned to extubate. He weaned off of pressor support and
Beta-blocker/Statin/ASA and diuresis were initiated. POD#1 pt
reported weakness on his right side. Head Ct revealed:No
evidence of acute intracranial hemorrhage or mass effect. No
obvious acute infarct. Neurology was consulted. Per Neuro,
anticoagulation was started when csurg deemed safe. MRI not
needed as felt it would not change plan of management. Over the
next few days his weakness improved. He was evaluated by
Physical Therapy and Occupational therapy for strength and
mobility. POD#2 his rhythm went into atrial fibrillation. He was
placed on Amiodarone and anticoagulation was inititated.
Postoperative thrombocytopenia improved during his hospital
course, HIT eval was negative. He was transferred to the step
down unit for further recovery. He had a failure to void x 2.
The foley required reinsertion. He was placed on Flomax. He
continued to slowly progress and by the time of pod# 8 he passed
physical therapy and was cleared for discharge to home with VNS
services. He was ambulating, wound healing and pain well
controlled. Follow up appointments were advised.
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain/temp
2. Amiodarone 400 mg PO TID
___ BID x 7 days, then 200 mg BID x 7 days, then 200 mg daily
until reeval by Cardiologist
RX *amiodarone 200 mg 2 tablet(s) by mouth BID x 7 days Disp
#*60 Tablet Refills:*1
3. Aspirin EC 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*1
4. Atorvastatin 40 mg PO DAILY
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
6. Furosemide 40 mg PO DAILY
x 10 days
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*10 Tablet
Refills:*0
7. Potassium Chloride 20 mEq PO DAILY Duration: 10 Days
RX *potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp
#*10 Tablet Refills:*0
8. Metoprolol Tartrate 50 mg PO TID
RX *metoprolol tartrate [Lopressor] 50 mg 1 tablet(s) by mouth
three times a day Disp #*90 Tablet Refills:*1
9. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen [Percocet] 5 mg-325 mg ___ tablet(s)
by mouth q4h prn Disp #*50 Tablet Refills:*0
10. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
11. ___ MD to order daily dose PO DAILY16 post op AFib
RX *warfarin [Coumadin] 1 mg Per MD ___ by mouth daily
Disp #*150 Tablet Refills:*1
12. Warfarin 1 mg PO ONCE afib Duration: 1 Dose
RX *warfarin [Coumadin] 1 mg 1 tablet(s) by mouth once Disp #*1
Tablet Refills:*0
13. Calcium Carbonate 500 mg PO QID:PRN reflux
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Type A aortic dissection s/p emergency repair
Past medical history:
Hypertension
s/p Tonsillectomy
s/p Left ear skin cancer excision
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
right ___ edema 1+
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:
___
|
10666123-DS-6
| 10,666,123 | 23,637,772 |
DS
| 6 |
2160-03-06 00:00:00
|
2160-03-06 19:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
adhesive tape / Peanut / Pollen/Hayfever
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo woman h/o HTN, obesity s/p lap gastric bypass (___), s/p
abd hernia repair with mesh transferred from ___
for consideration of ERCP. Ms. ___ at baseline functional
with daily exercises. In USOH until 1d PTA noon, developed
acute midepigastric/RUQ abd pain a/w diaphoresis. Denied N/V,
F/chills. Went to ___ where ___ noted to be 9.3,
LFT/amylase were elevated (Tbili 1.6, AST 237, ALT 243, AlkPhos
240 Lipase 537). She was afebrile and had evidence of RUQ
tenderness. Abd CT revealed no e/o cholecystitis or CBD
dilatation. She was given iv unasyn and MSO4 2 mg IV along with
zofran. Given the elevated LFTs and the need for ERCP in the
setting of gastric bypass, referred here for further evals.
In ED, patient temp 98, BP 134/87 HR 97 RR 18 98% on RA.
LFT's elevated (WBC 9.3 ALT 388 AST 549 AlkPhos 237 TBili 2.3*,
Lipase 102). RUQ U/S showed cholelithiasis, neg ___, CBD
at 5 mm. Given unasyn and admitted to the floor.
Patient arrived on floor with ___ pain. Denies and
f/chills, N/V.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
A 10 pt review of sxs was otherwise negative.
Past Medical History:
# Morbid obesity s/p lap RouxenY bypass ___
# HTN
# Asthma - no recent flares
# GERD
# Cellulitis of her abdominal pannus.
# D&Cs for bleeding.
# Tonsillectomy.
# C-section in ___.
# Hysterectomy for uterine bleeding and right
salpingo-oophorectomy in ___.
# Lap gastric bypass ___.
# Abdominoplasty and bracioplasty ___.
# Mastopexy and thigh lift ___.
Social History:
___
Family History:
Her family history is noteworthy for heart disease,
hypertension, asthma and amyotrophic lateral sclerosis (ALS).
Physical Exam:
ADMISSION EXAM
--------------
Vital Signs: 98.0 154/92 65 18 100% on RA
glucose:
.
GEN: NAD, well-appearing, lying in bed, obese
EYES: PERRL, EOMI, conjunctiva clear, anicteric
ENT: moist mucous membranes, no exudates
NECK: supple
CV: RRR s1s2 nl, no m/r/g
PULM: CTA, no r/r/w
GI: normal BS, tender in RUQ, neg ___, no r/g, no HSM
EXT: warm, no c/c/e
SKIN: no rashes
NEURO: alert, oriented x 3, answers ? appropriately, follows
commands, non focal
PSYCH: appropriate
ACCESS: PIV
FOLEY: absent
DISCHARGE EXAM
--------------
Vital Signs: Tc 97.6 BP 162/105 P 55 R 18 Sat 97% RA
I/O: 1000/1350
.
GEN: NAD, well-appearing, lying in bed, obese
EYES: PERRL, EOMI, conjunctiva clear, anicteric
ENT: moist mucous membranes, no exudates
NECK: supple
CV: RRR s1s2 nl, no m/r/g
PULM: CTA, no r/r/w
GI: normal BS, tender in RUQ, neg ___, no r/g, no HSM
EXT: warm, no c/c/e
SKIN: no rashes
NEURO: alert, oriented x 3, answers questions appropriately,
follows commands, non-focal
PSYCH: appropriate
ACCESS: PIV
FOLEY: absent
Pertinent Results:
ADMISSION LABS
--------------
___ 12:45AM WBC-9.3 RBC-5.43* HGB-15.2 HCT-42.8 MCV-79*
MCH-27.9 MCHC-35.4* RDW-13.6
___ 12:45AM PLT COUNT-275
___ 12:45AM GLUCOSE-114* UREA N-12 CREAT-0.7 SODIUM-141
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-26 ANION GAP-16
___ 12:45AM ALT(SGPT)-388* AST(SGOT)-549* ALK PHOS-237*
TOT BILI-2.3*
___ 12:45AM LIPASE-102*
DISCHARGE LABS
--------------
___ 06:00AM BLOOD WBC-7.0 RBC-5.58* Hgb-15.4 Hct-43.9
MCV-79* MCH-27.5 MCHC-35.0 RDW-13.7 Plt ___
___ 06:00AM BLOOD Glucose-73 UreaN-9 Creat-0.7 Na-143 K-3.6
Cl-106 HCO3-23 AnGap-18
___ 06:00AM BLOOD ALT-220* AST-55* LD(LDH)-180 AlkPhos-253*
TotBili-1.1
___ 06:00AM BLOOD Calcium-9.5 Phos-4.4 Mg-1.8
MICROBIOLOGY
------------
None
IMAGING
-------
# OSH Abdominal CT (___): s/p gastric bypass with associated
postsurgical changes. No evidence of obstruction or leak, Small
hiatal hernia. Mild periportal edema. Mild splenomegaly. s/p
ventral hernia repair with mesh. Mesh repair appears to be
balled up in midline ant abdomen. Residual small fat-containing
ventral hernia noted.
# Right upper quadrant U/S (___): Negative sonographic ___
sign. The liver demonstrates no focal liver lesions. Limited
views of the right kidney are unremarkable. The gallbladder
demonstrates several shadowing small gallstones but there is no
pericholecystic free fluid or gallbladder wall. Common bile duct
is normal at 5 mm. There is no intra or extrahepatic duct
dilatation. Aorta is normal. The portal vein is patent.
IMPRESSION: Cholelithiasis without signs of cholecystitis.
MRCP ___:
1. No ductal stones.
2. Cholelithiasis.
3. Mild splenomegaly.
Brief Hospital Course:
___ yo woman h/o HTN, obesity s/p lap gastric bypass (___), s/p
abd hernia repair with mesh transferred from ___
for management of gallstone pancreatitis and
choledocholithiasis.
ACTIVE ISSUES
-------------
# Abdominal pain: likely gallstone pancreatitis with elevated
liver function tests. Abdominal CT at outside hospital and
right upper quadrant U/S without evidence of common bile duct
dilatation but increased liver function tests and lipase from
outside hospital. She was symptomatically much improved during
her stay at ___ and it is possible that the stone had passed
or was intermittently causing obstruction. Her liver function
tests improved over the course of her stay. She underwent MRCP,
which was largely unremarkable with no evidence of obstruction.
Her diet was slowly advanced. No IV antibiotics were
administered. Patient will see Surgery as an outpatient to
discuss future cholecystectomy. Upon PCP ___, she should
have repeat testing of her liver function tests.
# Hypertension: patient was continued on her home
hydrochlorthiazide with potassium chloride. Her blood pressure
was suboptimally controlled over the course of her stay. Upon
___ with her PCP, an additional antihypertensive should be
considered if she remains hypertensive.
INACTIVE ISSUES
---------------
# Seasonal allergies: patient was given fexofenadine in place of
her home Zyrtec.
TRANSITIONS OF CARE
-------------------
# ___: Patient will see Surgery as an outpatient to
discuss future cholecystectomy. Upon PCP ___, she should
have repeat testing of her liver function tests. There are no
other pending results.
# Code status: full code
# Contact: Husband ___, ___ (home),
___ (cell)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 12.5 mg PO DAILY
2. Potassium Chloride 10 mEq PO DAILY
Hold for K >
3. Beclomethasone Dipro. AQ (Nasal) *NF* 2 SPRAY OTHER DAILY
4. ZYRtec *NF* 5 mg Oral Daily
5. ZyrTEC-D *NF* (cetirizine-pseudoephedrine) ___ mg Oral
Daily
6. Vitamin D ___ UNIT PO QAM
7. Vitamin D 1000 UNIT PO NOON
8. Vitamin D ___ UNIT PO QPM
9. Guaifenesin ER 600 mg PO PRN cough
Discharge Medications:
1. Beclomethasone Dipro. AQ (Nasal) *NF* 2 SPRAY OTHER DAILY
2. Guaifenesin ER 600 mg PO PRN cough
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. Potassium Chloride 10 mEq PO DAILY
5. ZYRtec *NF* 5 mg Oral Daily
6. Vitamin D ___ UNIT PO QAM
7. Vitamin D 1000 UNIT PO NOON
8. Vitamin D ___ UNIT PO QPM
9. ZyrTEC-D *NF* (cetirizine-pseudoephedrine) ___ mg Oral
Daily
10. Outpatient Lab Work
Please check LFTs upon PCP ___
Discharge ___:
Home
Discharge Diagnosis:
Primary diagnosis:
Pancreatitis, likely etiology from gall stones
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at the ___. You came for
further evaluation of abdominal pain. Your laboratory data
showed evidence of pancreatitis, likely from obstructing
gallstones. However, further imaging with abdominal ultrasound
and MRCP did not show an obstructing gallstone. Your diet was
advanced slowly, and you are now ready to go home. Please be
sure to follow up with the appointments listed below and take
all medications as prescribed.
Followup Instructions:
___
|
10666130-DS-3
| 10,666,130 | 27,633,803 |
DS
| 3 |
2130-12-29 00:00:00
|
2130-12-29 20:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abd Pain, fever
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
______________________________________________
HMED ATTENDING ADMISSION NOTE
DATE of ADMISSION: ___
Time seen: 1230
_______________________________________________
Ms. ___ speaks creole. Much of the history was obtained through
her son, and with her sone interpreting.
Ms. ___ is an ___ yo female with a pmh of glaucoma, pulmonary
fibrosis, and HTN who presented with one day of fevers and RUQ
pain.
The pains started yesterday morning, located in the RUQ, and it
progressed throughout the day. It does not radiate, it was
associated with some nausea, though no emesis. She currently has
an appetite. She was febrile to 101 with chills and reported
rigors. She presented to ___. Labs there revealed
lipase >1000, ALT 855, AST 2350s, WBC 15.
___ showed gallstones with gallbladder thickening, no
gallbladder distention. She was given zosyn 4.5mg IV at 00:23
this AM and was transferred ___ for ERCP.
Initial vitals: 100.2 85 115/47 18 99% 2L Nasal Cannula
Given Zosyn, and tylenol. Labs significant for a WBC of 18. RUQ
showed nonshadowing gallstones or sludge balls within a
nondistended gallbladder without evidence of cholecystitis. No
common or intrahepatic
biliary ductal dilatation.
Fluids at 100ml/hr
Access: 20g PIV
Transfer vitals: 98.3 62 116/84 16 100% RA
On admission, she was soft spoken, she appeared comfortable,
though she endorsed some RUQ/epigastric pain.
ROS:
(+) Fever, chills, rigors, nausea
(-) Cough, sob, cp, vomiting, change in stool or urinary color
or habits. No myalgias. Ten point ROS otherwise negative.
Past Medical History:
Hypertension
Pulmonary Fibrosis
Glaucoma
Social History:
___
Family History:
Hypertension
Physical Exam:
Vitals: T: 98.8 BP: 130/70 P: 72 R: 17 O2: 96% on RA
General: Elderly female, NAD
HEENT: Dry MM, no JVP elevation, no scleral icterus
Lymph: No cervical LAD
Lungs: Dry inspiratory crackles in all lung fields
CV: Normal rate, regular rhythm, no murmurs
GI: Soft, TTP in the RUQ/epigastrum, BS+, no rebound or guarding
Ext: Warm, no edema
Skin: No active rash
Neuro: Speech appropriate, following commands.
Pertinent Results:
Admission labs
==================
___ 06:45AM BLOOD WBC-18.4* RBC-3.72* Hgb-10.5* Hct-33.6*
MCV-90 MCH-28.3 MCHC-31.3 RDW-14.3 Plt ___
___ 06:45AM BLOOD Neuts-88.1* Lymphs-8.0* Monos-3.7 Eos-0.1
Baso-0.2
___ 06:45AM BLOOD ___ PTT-29.0 ___
___ 06:45AM BLOOD Glucose-107* UreaN-17 Creat-0.9 Na-138
K-3.6 Cl-99 HCO3-28 AnGap-15
___ 06:45AM BLOOD ALT-653* AST-1157* LD(LDH)-1214*
AlkPhos-259* TotBili-1.9*
___ 06:45AM BLOOD Lipase-___*
___ 06:45AM BLOOD Albumin-3.2* Calcium-8.1* Phos-3.3 Mg-2.0
RUQ U/S:
=======================
COMPARISON: CT from ___ ___.
FINDINGS: The liver is normal in echotexture without focal
lesion, intra or extrahepatic biliary ductal dilatation with the
common bile duct measuring 3-5 mm. Non shadowing gallstones or
sludge balls are seen in a nondistended gallbladder. There is
no mural edema or pericholecystic fluid to suggest
cholecystitis. Sonographic ___ sign is not present however
is unreliable on pain medication. The pancreas is incompletely
assessed. The imaged aorta and IVC unremarkable. There is no
free fluid.
IMPRESSION: Nonshadowing gallstones or sludge balls within a
nondistended gallbladder without evidence of cholecystitis. No
common or intrahepatic biliary ductal dilatation.
Brief Hospital Course:
Ms. ___ is an ___ year old female with a history of HTN,
glaucoma and IPF who presents with abndominal pain, nausea, over
the past few days with imaging and labs concerning for
cholangitis.
# Biliary obstruction complicated by leukocytosis and ascending
cholangitis: Significant elevation in LFTs with a WBC of 18.
ERCP was performed with sphincterotomy and removal of a stone
and sludge. She was initially treated with Zosyn, then
transitioned to ciprofloxacin. Her LFTs improved and she
tolerated advancement of her diet from clears to a regular diet
without abdominal pain. Her WBC count dropped from 18 to 9 with
treatment and ERCP. She was discharged to complete a 10 day
course of antibiotics.
# Gallstone Pancreatitis: Elevation of lipase to ___, with TTP
in the epigastrum on admission. which may explain the fever and
leukocytosis. She was treated as above, and her exam was benign
on discharge. She was instructed to follow-up with her PCP about
potential cholecystectomy.
# Hypertension: Normotensive on the floor off of medications on
arrival in a patient on 3 agents for BP control. Her home meds
were held initially, and post procedure she was hypertensive.
She was restarted on her home medications with good effect and
return to normotension.
# Pulmonary fibrosis: No current O2 requirements. Stable
throughout her admission.
# Glaucoma: Stable. Continued home eye drops.
# Anemia: Unclear baseline, will trend.
Transitional issues:
- Follow-up with PCP for further consideration of
cholecystectomy
- Completion of 10 days of ciprofloxacin
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. losartan-hydrochlorothiazide 50-12.5 mg oral daily
2. Diltiazem Extended-Release 300 mg PO DAILY
3. Citalopram 10 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. Estrogens Conjugated 1 gm VG 2X/WEEK (MO,TH)
6. Vitamin D 1000 UNIT PO DAILY
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
8. Senna ___ TAB PO DAILY
9. Potassium Chloride 20 mEq PO DAILY
10. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
Discharge Medications:
1. Citalopram 10 mg PO DAILY
2. Diltiazem Extended-Release 300 mg PO DAILY
3. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
5. Lisinopril 40 mg PO DAILY
6. Potassium Chloride 20 mEq PO DAILY
Hold for K >
7. Senna ___ TAB PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
10. Estrogens Conjugated 1 gm VG 2X/WEEK (MO,TH)
11. losartan-hydrochlorothiazide 50-12.5 mg oral daily
Discharge Disposition:
Home
Discharge Diagnosis:
Cholangitis
Gallstone pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted to ___ an infection in your bile tract. You
had a procedure callled an ERCP during which they removed a
gallstone. You were treated with antibiotics, and your diet was
advanced and tolerated well.
You should discuss having your gallbladder removed with your
primary care doctor.
Followup Instructions:
___
|
10666304-DS-14
| 10,666,304 | 24,967,069 |
DS
| 14 |
2114-12-29 00:00:00
|
2114-12-31 18:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Acute on chronic lower back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year-old gentleman with a PMH of L4-L5 disc
herniation s/p diskectomy ___, discectomy in ___ with
subsequent facet injections, and chronic low back pain, now
presenting with acute onset low back pain. Patient was digging a
hole to bury his family's dog on the evening prior to admission,
and developed low back pain immediately afterward. It worsened
over the course of the day today, prompting admission. It feels
best standing up, worst sitting down. Pain is "burning" across
the lower back, extended up to mid-back. He has radiating
tingling and numbness (numbness is chronic) down the left
lateral leg. When lying down, he needs to have pillows under his
knees to feel comfortable. Prior to presentation, pain was ___
in severity. At home, he had nausea and vomited once. He denies
any back trauma, loss of bowel/bladder continence, urinary
retention, saddle anesthesia, fevers, chills, abdominal pain, or
any other symptoms. Pain feels similar to exacerbation that
prompted discectomy in ___. In the past for acute flares
of his back pain, he has taken prescription Celebrex, Demerol,
Valium and Percocet. In the past, high doses of ibuprofen (750
mg) caused stomach upset. He did not taken anything (Rx or OTC)
to help his pain prior to coming to the ED. His father is an
inpatient here s/p minor surgery with anesthesia side effects.
His family is under significant stress right now.
In the ED, initial vitals: 96.4 108 119/69 18 99% RA. Labs
notable for WBC 16 with 91% PMN, BUN 25, Cr 0.9, HCO3 19. No
imaging pursued. Given 2L NS, dilaudid 1mg x3 IV, lorazepam 2mg
IV x2, and Zofran x1. He vomited after these medications. He was
admitted for "serial neurologic exams and pain control," as
patient did not feel he would be able to tolerate oral
medications at home. Vitals prior to transfer: 98.4 80 132/50 16
98%.
Upon arrival to the floor, patient reports that pain is somewhat
improved to ___. He is able to walk around the room and floor
while telling me the history.
Past Medical History:
- L4-L5 disc herniation, s/p diskectomy (following football
injury) in ___
- repeat diskectomy in ___ (in ___, complicated
surgery with facet injections afterwards
- chronic LBP
- s/p tonsillectomy
- s/p ankle reconstructive surgery
- s/p laser eye surgery on ___
Social History:
___
Family History:
No known family history.
Physical Exam:
Admission:
VS - 98.0 139/69 86 18 94%RA
GENERAL - uncomfortable, appropriate, mother and sister also
present
HEENT - NCAT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no cerv LAD. No cervical spinous process TTP. No
neck muscle spasm.
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
MSK - No cervical, thoracic or lumbar spine TTP. Palpable muscle
spasms around mid-lumbar spine. No SI joint TTP.
NEURO - awake, A&Ox3, CNs II-XII intact and symmetric. Decreased
sensation to sharp stimulus on left lateral thigh and calf
(noted to be chronic). Sensation to cold is intact and symmetric
in extremities. DTRs 2+ throughout. UE and ___ with ___ strength
bilaterally. Steady but slow gait. Spine forward flexion limited
secondary to pain. Spine lateral flexion also limited secondary
to pain, worse on the left than on the right.
Discharge:
VS - 98.7 135/73 83 18 96%RA
GENERAL - uncomfortable, appropriate,alert and oriented x3
HEENT - NCAT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no cerv LAD. No cervical spinous process TTP. No
neck muscle spasm.
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
MSK - lumber spine ttp, No cervical, thoracic TTP. Palpable
muscle spasms around mid-lumbar spine. No SI joint TTP.
NEURO - awake, A&Ox3, CNs II-XII intact and symmetric. Decreased
sensation to sharp stimulus on left lateral thigh and calf
(noted to be chronic). DTRs 2+ throughout. UE and ___ with ___
strength bilaterally.
Pertinent Results:
Lumbar xray:
The only detectable abnormality in the lumbar spine is minimal
relative
narrowing of L4-5 with respect to the more superior disc spaces
and a small anterior osteophyte on the upper endplate of L5.
Lumbar spine is
straightened, but there is no subluxation. I see no
spondylolysis or other fracture. Conceivably, CT scanning would
be more sensitive in detecting a non-displaced fracture, but
there are no findings to suggest that on this study.
MRI Lumbar spine:
1. Central and left paracentral disc protrusions at L5-S1 with
efffacement of
the left subarticular zone and resulting in moderate to severe
left and
moderate right neural foraminal narrowing.
2. Central disc protrusion at L4-L5 which in conjunction with
facet joint
arthropathy results in mild to moderate spinal canal narrowing
with effacement
of the right subarticular zone and mild to moderate bilateral
neural foraminal
narrowing.
Brief Hospital Course:
Mr. ___ is a ___ year-old gentleman with a PMH of L4-L5 disc
herniation s/p diskectomy ___, discectomy in ___ with
subsequent facet injections, and chronic low back pain, now
presenting with acute onset low back pain.
# Low back pain: Patient has a history of lower back pain and
has had multiple spinal surgeries in the past. There was no
concern for cord compression given lack of saddle anesthesia,
sensory level or lower extremity weakness, and no incontinence
on arrival to ED. He became nauseated while in ED and was
admitted for further pain management in the setting of not being
able to tolerate PO medications. Symptoms were thought to be
secondary to musculoskeletal strain vs. a disc herniation that
occurred after straining himself while digging a hole. A
lumbar xray without evidence of fracture. At the request of the
patient and the family, an MRI of the lumbar spine was ordered
which should no acute spinal injury or narrowing. It did show
central and left paracentral disc protrusions at L5-S1 with
efffacement of the left subarticular zone and resulting in
moderate to severe left and moderate right neural foraminal
narrowing but it was felt surgical consultation was not
warranted at this time. His pain was controlled with dilaudid
and diazepam for muscle spasms. On hospital day 2, the patient
expressed a desire to leave because he was upset there would not
be a surgical intervention and he said his pain was not being
well controlled despite telling the medical team it had been
during rounds. He was encouraged to stay until physical therapy
worked with him but he decided to leave at this time following a
discussion with entire medical team and nursing staff. He was
provided follow up instructions for the ___.
# Anxiety: Patient with multiple recent stressors, and pain
exacerbating anxiety.
He was kept on diazepam for both muscle relaxation and anxiety
# Recent laser eye surgery: Was provided eye patches during
admission.
Transitions of Care:
1. Pt did not want to wait for ___ and was discharged with
instructions to follow up with ___. He was agitated
with care at time of discharge and would not provide time to
make an appointment.
Discharge Medications:
1. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone 4 mg 1 tablet(s) by mouth q4-6hrs prn Disp
#*30 Tablet Refills:*0
2. Diazepam 5 mg PO Q6H:PRN back spasms
RX *diazepam 5 mg 1 by mouth q4hrs prn Disp #*30 Tablet
Refills:*0
RX *diazepam 5 mg 1 tablet by mouth q4hrs prn Disp #*30 Tablet
Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 50 mg 1 capsule(s) by mouth twice a
day Disp #*60 Capsule Refills:*0
4. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 by mouth daily Disp #*30 Capsule
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on chronic lower back pain
Muscle spasms
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
lower back pain which we believe is secondary to muscle spasms.
Your physical exam showed no signs of acute spinal cord injury
and the MRI of your spine showed no spinal cord impingement. We
treated you with pain medication and muscle relaxers. We would
preferred you stay to work with physical therapy but you
expressed a desire to leave prior to this.
Followup Instructions:
___
|
10666345-DS-16
| 10,666,345 | 20,690,316 |
DS
| 16 |
2161-11-04 00:00:00
|
2161-11-06 13:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
tramadol
Attending: ___.
Chief Complaint:
Epigastric pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with h/o GERD, HTN, HLD, lung cancer s/p cyberknife (___)
who is blind presents to the emergency department with
epigastric
pain.
She was seen in the ED recently for a similar complaint, and
ultimately discharged after serial troponin and negative CTA.
She
was seen by her PCP and referred for an endoscopy. The endoscopy
___ identified an ulcerative mass in the distal third of the
esophagus concerning for malignancy, and biopsies were sent. She
has been taking Tylenol with codeine and the pain has
significantly improved. However when she tries to eat she gets
excruciating pain in her epigastric area, so she has been having
a decreased PO intake and is only able to eat soft foods (e.g.
apple sauce) and take sips of liquids. She reports she is now
having "tons of gas" with lots of belching ("great big burps")
and looser-than-normal stools with 2 episodes of loose stools
this morning. She also notes progressively worsening dyspnea
with
exertion, nausea, and malodorous urine with some difficulty
urinating (dribbling which is abnormal for her). She also notes
some room-spinning vertigo that can occur at rest occurring
several times a day, self-resolving after a few seconds, and not
exacerbated by movement. The "vertigo" has been going on the
past
week and during this time she has had difficulty walking.
In the ED:
Initial vital signs were notable for: 97.3 76 137/71 16 100% RA.
Vitals remained stable at time of transfer.
Exam notable for:
Frail, non-toxic
RRR, systolic murmur
Decreased breath sounds in RLL, coarse breath sounds
bilaterally,
no wheezing
Abdomen soft, focal tenderness in epigastric area, active bowel
sounds
Moving all extremities ___ strength ___, unsteady gait
Labs were notable for: WBC 11.3, lactate 1.8. Normal LFTs and
coags. Normal chem panel except for K 5.7 on moderately
hemolyzed
specimen. Cr 1.0. UA w/ lots of leuks, few bacteria, some blood,
although w/ 10 epis.
Studies performed include:
___:
1. No large territory infarction, intracranial hemorrhage, or CT
evidenc of mass. 2. Age-related global involutional changes.
CT abdomen/pelvis:
No evidence of obstruction or other acute findings within the
abdomen or pelvis to explain the patient's reported symptoms.
Multiple lesions within the lungs appear grossly similar.
However, it is unclear whether a 0.9 cm soft tissue density
along
the posterior right lower lobe, which is grossly similar to
prior, has been previously treated. Diffusely thickened
esophagus, new since the prior study, is suggestive of
esophagitis. Trace bilateral pleural effusions are new since the
prior study with smooth septal prominence within the lungs
suggestive of mild interstitial edema.
CXR w/ no definite effusion or new focal consolidation.
Redemonstration of right lower lobe lateral focal opacity,
similar to prior exams from ___, and may be due to
infection or underlying metastatic disease.
EKG w/ left bundle morphology similar to prior. No acute
ischemic
changes noted.
Patient was given:
IV ceftriaxone 1gm
PO losartan 50mg
PO pantoprazole 40mg
PO ranitidine 150mg
PO sucralfate 1gm
Upon arrival to the floor, patient continued to complain of
epigastric pain with severe bloating causing discomfort. She
denied any episodes of vertigo since arrival to the ED.
Past Medical History:
PAST MEDICAL HISTORY:
- Age-related macular degeneration
- GERD
- Hyperlipidemia
- Prior removal of a vocal cord polyp
- Hypertension
- Lung cancer
- Squamous cell cancer on the face
- Left bundle branch block
PAST SURGICAL HISTORY:
- s/p squamous cell cancer removal from face
- s/p vocal cord polyp removal
Social History:
___
Family History:
son died of met CA, daughter healthy
Physical ___:
ON ADMISSION:
=============
VITALS: T99.4, BP 142/83, HR 92, RR 20, O2 96% on RA
GENERAL: cachectic appearing, hard of hearing, alert and
interactive. In no acute distress.
HEENT: NCAT. PERRL. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. ___
systolic ejection murmur
LUNGS: Diffuse expiratory wheezing, rhonchi at RLL. No increased
work of breathing.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, TTP in epigastrium
with some voluntary guarding, no rebound.
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: Warm. No rash.
NEUROLOGIC: AOx3.
ON DISCHARGE:
=============
VITALS:
24 HR Data (last updated ___ @ 933)
Temp: 98.0 (Tm 98.5), BP: 157/87 (123-165/62-87), HR: 90
(69-90), RR: 18, O2 sat: 94% (93-95), O2 delivery: RA
GENERAL: Cachectic appearing elderly woman in no acute distress,
appears comfortable, blind and hard of hearing.
HEENT: NCAT. PERRL. Sclera anicteric and without injection. MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. ___
systolic ejection murmur at RUSB radiating to carotids, soft
systolic murmur appreciated at LLSB and apex.
LUNGS: Lungs clear to auscultation bilaterally, no wheezes. No
increased work of breathing.
ABDOMEN: Normal bowels sounds, soft, nontender, non distended,
no
guarding, no rebound.
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: Warm. No rash.
NEUROLOGIC: AOx3.
Pertinent Results:
ADMISSION LABS:
===============
___ 09:26AM BLOOD WBC-11.3* RBC-3.62* Hgb-11.2 Hct-32.5*
MCV-90 MCH-30.9 MCHC-34.5 RDW-13.6 RDWSD-44.6 Plt ___
___ 09:26AM BLOOD Plt ___
___ 09:26AM BLOOD Glucose-72 UreaN-17 Creat-1.0 Na-141
K-5.7* Cl-99 HCO3-24 AnGap-18
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 10:14 AM
IMPRESSION:
1. No evidence of obstruction or other acute findings within the
abdomen or pelvis to explain the patient's reported symptoms.
2. Multiple lesions within the lungs appear grossly similar.
However, it is unclear whether a 0.9 cm soft tissue density
along the posterior right lower lobe, which is grossly similar
to prior, has been previously treated.
3. Diffusely thickened esophagus, new since the prior study, is
suggestive of esophagitis.
4. Trace bilateral pleural effusions are new since the prior
study with smooth septal prominence within the lungs suggestive
of mild interstitial edema.
CT HEAD W/O CONTRAST Study Date of ___ 10:14 AM
IMPRESSION:
1. No acute territory infarction or intracranial hemorrhage.
2. Few calcific lesion along the inner table of the calvarium,
likely
meningiomas, are grossly stable to potentially slightly
increased in size
since the prior study in ___. The lesion along the right
frontal convexity was previously characterized as such on the MR
head of ___.
3. Age-related global involutional changes.
4. Paranasal sinus disease.
CHEST (PA & LAT) Study Date of ___ 10:46 AM
IMPRESSION:
No definite effusion or new focal consolidation.
Redemonstration of right
lower lobe lateral focal opacity, similar to prior exams from ___, and may be due to infection or underlying metastatic
disease.
DISCHARGE LABS:
===============
___ 04:35AM BLOOD WBC-6.5 RBC-3.15* Hgb-9.6* Hct-28.5*
MCV-91 MCH-30.5 MCHC-33.7 RDW-13.8 RDWSD-45.0 Plt ___
___ 04:35AM BLOOD Glucose-85 UreaN-5* Creat-0.7 Na-144
K-3.8 Cl-108 HCO3-25 AnGap-11
___ 04:35AM BLOOD Calcium-8.5 Phos-2.8 Mg-1.9
Brief Hospital Course:
Ms. ___ is a ___ woman with hx RLL squamous cell lung cancer
s/p cyberknife (___), HTN, HLD, GERD, blindness who presented
with epigastric pain likely ___ to necrotic esophageal ulcer
recently biopsied on EGD.
# Necrotic Esophageal Ulcer
# Esophagitis
She presented with severe pain when swallowing which was
attributed to an esophageal ulcer previously identified on EGD
___. Biopsy of the esophageal ulcer were negative for malignancy
at that time; biopsies from the stomach showed chronic gastritis
positive for H pylori. Possible underlying etiologies for her
ulcer include her prior cyberknife radiotherapy for lung cancer,
pill esophagitis, reflux esophagitis, and less likely cancer as
pathology was negative. She was started on IV pantoprazole BID
and sucralfate. She received liquid Tylenol w/ codeine for her
pain. She was offered Maalox, viscous lidocaine, and liquid
oxycodone but declined these.
#Constipation
She reported abdominal distention and belching. She was given
senna, docusate, and Miralax. She had difficulty swallowing the
Miralax and initially refused but was later able to tolerate it.
She refused suppositories. Palliative care service saw her and
recommended increased dose of senna, Miralax, and that
methylnaltrexone could be considered if refractory. She passed a
small amount of stool on ___.
#Malnutrition
She had ___ months of poor po intake prior to admission due to
pain in her esophagus and increased weakness. During her
hospital stay, she was able to tolerate soft foods such as
pudding and broth (including Ensure puddings) but declined all
other supplement products recommended by nutrition despite
discussion. She was maintained on full liquid diet given severe
epigastric pain with solid food intake in setting of necrotic
esophageal ulcer with poor PO intake. She should continue
soft/liquid diet including recommended supplementation. PEG was
discussed, pt preferred to defer at this time.
# H. pylori gastritis: Per GI, pt should start treatment for H
pylori ___ weeks after discharge from all institutions, as
treatment while institutionalized can lead to increased rates of
C. difficile colitis.
#Wheezing, resolved
Smoking history 1.5 packs x ___ yrs, reportedly previously seen
by pulmonology with spirometry demonstrating moderate to severe
obstruction. Stable on RA.
#Vertigo, resolved
Reports episodes of feeling "dizzy" like the room is spinning
lasting a couple seconds, resolved since admission. NCHCT
negative for acute process. Resolved by admission.
CHRONIC ISSUES:
# RLL Squamous cell carcinoma: recent Cyberknife SBRT completed
___. She has a long history of different lung cancers dating
back to ___. Follows most closely ___/ ___ of radiation
oncology. Scheduled for PET on ___.
#HTN: She was continued on home losartan.
#HLD: She was continued on home atorvastatin.
===================
TRANSITIONAL ISSUES
===================
[] Pt should continue full liquid diet with supplementation
until directed otherwise by gastroenterology
[] Pt will need repeat EGD within ___ weeks with GI to ensure
resolution of ulcer
[] Pt should follow up with gastroenterology
[] Pt will need treatment for H pylori ___ weeks after discharge
from rehabilitation facility
[] Pt should be weighted every other day to assess nutrition
status.
#CODE: FC
#CONTACT: ___ (Friend) HCP ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen w/Codeine Elixir ___ mL PO Q6H:PRN Pain -
Moderate
2. Atorvastatin 20 mg PO QPM
3. aspirin-caffeine 400-32 mg oral DAILY:PRN
4. Calcium Carbonate 400 mg PO QID:PRN reflux
5. DiphenhydrAMINE 25 mg PO DAILY:PRN itching
6. Docusate Sodium 100 mg PO BID
7. Losartan Potassium 50 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. raloxifene 60 mg oral DAILY
11. Ranitidine 150 mg PO DAILY
12. Sucralfate 1 gm PO TID
13. Senna 8.6 mg PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
2. Multivitamins W/minerals 15 mL PO DAILY
3. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
4. Simethicone 40-80 mg PO QID:PRN bloating
5. Acetaminophen w/Codeine Elixir 12.5 mL PO Q4H:PRN
breakthrough pain
Acetaminophen 300 mg/Codeine 30 mg in each 12.5 mL of elixir (1
tablet)
RX *acetaminophen-codeine 120 mg-12 mg/5 mL (5 mL) 5 mL by mouth
every four (4) hours Disp ___ Milliliter Refills:*0
6. Senna 17.2 mg PO BID constipation
7. Atorvastatin 20 mg PO QPM
8. Calcium Carbonate 400 mg PO QID:PRN reflux
9. DiphenhydrAMINE 25 mg PO DAILY:PRN itching
10. Docusate Sodium 100 mg PO BID
11. Losartan Potassium 50 mg PO DAILY
12. raloxifene 60 mg oral DAILY
13. Sucralfate 1 gm PO TID
14. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Rehabilitation and Nursing Center)
Discharge Diagnosis:
PRIMARY DIATNOSES
Necrotic esophageal ulcer
Esophagitis
Severe protein calorie malnutrition
SECONDARY DIAGNOSES
H pylori gastritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms ___,
It was a pleasure taking care of you at ___.
WHY WAS I IN THE HOSPITAL?
- You were in the hospital because you had pain in your stomach
and chest when eating food due to a large ulcer in your
esophagus.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- We started you on a medication to reduce acid in your stomach.
- We gave you medications that made swallowing more comfortable
- We gave you food that was liquid and easier to swallow.
WHAT SHOULD I DO WHEN I LEAVE?
- You should continue to take your medications as prescribed
- You should continue your liquid diet with lots of
supplementation that we recommend
- You should continue working on your strength
We wish you the best,
Your ___ Care team
Followup Instructions:
___
|
10666359-DS-15
| 10,666,359 | 23,049,125 |
DS
| 15 |
2119-03-29 00:00:00
|
2119-03-31 15:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
bee venom (honey bee)
Attending: ___.
Chief Complaint:
Loss of consciousness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with PMH of seizure, PNES, on VPA, multiple
psychiatric admission due to suicidal attempt, presented to ER
after being found altered at ___ clinic today.
Patient was here for an outpatient EP appointment and was found
in the hallway unresponsive. He did not lose his pulse. He
reported that he felt dizzy while he was walking and his vision
became blurry. He sat down on floor until he felt better. Then
he
stood up. After he stood up he does not remember anything. He
was
found unresponsive and witness to have shaking movement in all
extremities. He was given 2mg of lorazepam at the scene, and
transferred to ED. On his way he had three more episodes of
shaking and his mental status was fluctuating.
Notably, per neurology, the patient was admitted to ___
Neurology service in ___ for EEG characterization of shaking
and
staring spells. Toxic-metabolic and infectious work-up for
factors lowering seizure threshold was all negative. He
underwent
>48 hours of EEG during which he had no clinical/electrographic
seizures or epileptiform discharges, although he had several
clinical events (with no electrographic correlate) which
semiologically were highly suspicious for non-epileptic
seizures.
Given negative EEGs, his standing Keppra was discontinued. As
his
Valproate level was found subtherapeutic (31) on admission, the
dose was uptitrated from 750mg daily to 1000mg daily to reach
therapeutic range. He did not follow up with neurology.
He has had at least 2 other documented ED visits in the
Partner's
___ in ___ for shaking episodes and pseudoseizures.
Past Medical History:
Seizure?
Vertigo
Depression
Bipolar disorder
PTSD
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION EXAM:
VITALS: T 98.3, HR 90, BP 155/97, RR 18, SpO2 99% RA
GENERAL: Well-nourished gentleman, somewhat somnolent, in NAD.
Has multiple staring spells during interview that last
approximately 5 seconds, resolves with sternal rub or repeated
voice prompting
HEENT: NC/AT, dry mucous membranes, EOMI, PERRL(4mm to 3mm), no
scleral icterus
NECK: Supple, no neck stiffness, no JVD
HEART: RRR, normal S1/S2, no m/r/g.
LUNGS: CTAB, breathing comfortably on RA without use of
accessory
muscles
ABDOMEN: Soft, non-tender to palpation, active bowel sounds
EXTREMITIES: No edema, cyanosis or clubbing. 2+ DP
SKIN: Warm and well-perfused
NEURO: Moving all extremities. CN V: decreased sensation in V3
distribution on L side, ___ strength in ___ with normal
sensation, unable to assess strength in UE due to poor
cooperation, increased DTRs but appears delayed. Normal tone, no
rigidity, no clonus.
DISCHARGE EXAM:
VITALS: T 97.7 BP 143/89 HR 64 RR 18 O2 98% RA
GENERAL: Oriented to person and place, somewhat drowsy, staring
spells that resolved with repeated prompting, in NAD
HEENT: NC/AT, MMM, PERRL, EOMI
CV: RRR, normal S1/S2, no m/r/g
RESP: CTAB, no wheezes or crackles.
GI: Normoactive BS, non-tender to palpation, non-distended
EXT/SKIN: Warm and well perfused, edema.
NEURO: Oriented to place and name, but not time, poor
concentration, strength ___ in ___ upper and lower extremities,
normal sensation in ___, 2+ reflexes in ___, no clonus, normal
facial sensation
Pertinent Results:
ADMISSION LABS:
___ 03:00PM cTropnT-<0.01
___ 10:52AM URINE HOURS-RANDOM
___ 10:52AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 10:52AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 10:52AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 08:48AM ___ PO2-154* PCO2-24* PH-7.55* TOTAL
CO2-22 BASE XS-1 COMMENTS-GREEN TOP
___ 08:48AM LACTATE-2.1* K+-5.1
___ 08:48AM O2 SAT-85
___ 08:14AM GLUCOSE-118* UREA N-18 CREAT-1.1 SODIUM-133*
POTASSIUM-6.1* CHLORIDE-97 TOTAL CO2-23 ANION GAP-13
___ 08:14AM estGFR-Using this
___ 08:14AM ALT(SGPT)-27 AST(SGOT)-35 ALK PHOS-73 TOT
BILI-0.3
___ 08:14AM LIPASE-27
___ 08:14AM cTropnT-<0.01
___ 08:14AM ALBUMIN-4.3 CALCIUM-9.2 PHOSPHATE-3.2
MAGNESIUM-2.0
___ 08:14AM VALPROATE-4*
___ 08:14AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 08:14AM WBC-9.3 RBC-4.26* HGB-12.9* HCT-38.8* MCV-91
MCH-30.3 MCHC-33.2 RDW-13.6 RDWSD-45.6
___ 08:14AM NEUTS-51.9 ___ MONOS-5.8 EOS-6.2
BASOS-2.3* IM ___ AbsNeut-4.82 AbsLymp-3.12 AbsMono-0.54
AbsEos-0.58* AbsBaso-0.21*
___ 08:14AM PLT COUNT-254
DISCHARGE LABS:
___ 07:15AM BLOOD WBC-8.5 RBC-4.22* Hgb-12.9* Hct-38.4*
MCV-91 MCH-30.6 MCHC-33.6 RDW-13.8 RDWSD-46.1 Plt ___
___ 07:15AM BLOOD Glucose-96 UreaN-11 Creat-0.9 Na-143
K-4.6 Cl-105 HCO3-23 AnGap-15
___ 07:15AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.2
___ 08:35AM BLOOD Lactate-1.5
MICROBIOLOGY:
___ URINE: URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ BLOOD: Pending
___ BLOOD: Pending
IMAGING:
___ CT HEAD W/OUT CON:
IMPRESSION:
1. No acute intracranial hemorrhage or mass effect.
2. Vague periventricular white matter hypodensity, most
conspicuous in left parietal region. Although this finding is
nonspecific and could reflect changes of mild chronic white
matter microangiopathy, given the patient's age, other entities
including demyelination and/or vasculitis are not excluded. If
further imaging is indicated, MRI of the brain would be of
utility in further assessment.
___ CXR:
IMPRESSION:
No acute cardiopulmonary abnormality. Hyperinflated lungs with
bullous
changes in the lingula suggestive of underlying COPD/emphysema.
___ ECHO:
The left atrial volume index is normal. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF = 60%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Tissue Doppler
imaging suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The ascending aorta is mildly dilated. The number
of aortic valve leaflets cannot be determined. The aortic valve
leaflets are mildly thickened (?#). There is no aortic valve
stenosis. The mitral valve appears structurally normal with
trivial mitral regurgitation. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
Brief Hospital Course:
Mr. ___ is a ___ with PMH of PNES, seizure disorder, and
depression who presented with a syncopal episode followed by
shaking movements concerning for seizure activity.
ACUTE/ACTIVE PROBLEMS:
======================
# Syncopal episode
Patient presented with loss of consciousness preceded by
prodrome of dyspnea, dizziness, diaphoresis, and visual changes.
He has had several syncopal episodes in the recent past and has
been seen in the ED multiple times. He endorses a history of
poor PO intake and multiple episodes of emesis. Most likely
etiology is othostatic hypotension. Patient was treated with IV
fluids. An ECG showed no arrhythmias or ST changes and telemetry
showed no abnormalities. Additionally, he had a stress test and
Holter monitoring in ___ that were negative. A TTE was ordered
and showed normal ejection fraction. Physical therapy evaluated
the patient and believed he was safe to be discharged home but
strongly encouraged the patient to ambulate with his rolling
walker.
# Possible Seizure activity
Following patient's syncopal episode, patient was witnessed
having shaking movements in all four extremities. He has a
history of seizures for which he is treated with Depakote, but
admits to not taking his medication (VPA level 4). He was noted
to have clonus and hyperreflexia in the ED initially concerning
for serotonin syndrome. Neurology was consulted and believed
this abnormal activity was likely due to PNES and did not
require EEG monitoring. A serum and urine toxicology screen was
negative, and electrolyte panel showed a mild hyponatremia but
was otherwise unremarkable. Patient was re-started on his home
VPA and his home citalopram was started a lower dose. His home
bupropion was held. Recommend follow up with outpatient
psychiatrist to discuss these medications.
# Headache
Reports 6 month history of headaches that have worsened over
past ___ wks. A CT head without contrast was negative for
hemorrhage or mass effect. Possible etiologies include
nicotine/caffeine withdrawal vs. migraine. Neurology was
consulted and recommended supportive treatment. The patient was
given Tylenol for his pain.
# Chest pain
Patient reported intermittent episodes of chest pain, sometimes
described as pressure, other times described as sharp pain. On
exam, was reproducible with palpation/movement, and thought to
be musculoskeletal in nature. ECG showed no ST segment changes
and trops were negative. Prior stress test in ___ was negative.
# Nausea/vomiting
Patient reported episodes of emesis ___ episodes/day x8
months), occasionally bloody, and L sided abdominal pain. During
his admission, he had one episode of emesis and was given Zofran
for his nausea. Per OMR, he had recent barium swallow and
gastric emptying study, which were both normal. Recommend
continued OP work-up.
CHRONIC/STABLE PROBLEMS:
========================
# Opioid use disorder
Continued home suboxone
# Chronic Hep C with cirrhosis
Recently diagnosed with cirrhosis, has high viral load and was
prescribed Harvoni but has not started taking it. Should follow
up with OP provider.
# Emphysema
Patient did not endorse any respiratory symptoms during
admission and pulmonary exam without wheezes. His home Spiriva
was held, and it is unclear whether the patient was actually
taking this at home.
# HTN
BP was well controlled during admission. Patient's home
diltiazem was held during admissino. He should follow up with
his PCP to discuss ___ this. It is unclear whether he
takes this medication at home.
# GERD
Home esomeprazole was held as it was unclear whether the patient
was actually taking this medication. This can be re-started if
patient endorses symptoms.
# Depression/PTSD
Follows with psychiatrist and therapist at ___. Home olanzapine
was continued. Home citalopram and bupropion was held due to
initial concern for seratonin syndrome vs. seizure activity. It
is unclear whether the patient was actually taking these
medications, but they can be re-started on discharge. Patient
should follow up with his OP psychiatrist.
TRANSITIONAL ISSUES:
===================
[ ] Patient noted to be unsteady when walking unassisted.
Physical therapy evaluated him and recommended that he ambulate
with his rolling walker. This should continue to be addressed
with patient's PCP. Can consider OP ___.
[ ] Changed medications: Decreased citalopram from 40mg PO daily
to 10mg PO daily
[ ] Recommend OP work-up of peripheral neuropathy with B12, TSH,
MMA, SPEP/UPEP, and HbA1c
[ ] Unclear what medications the patient was reliably taking at
home. This should be discussed with the patient during OP
follow-up with his PCP.
[ ] Chronic headaches should be followed up with PCP
[ ] Chronic nausea and vomiting should be followed up with PCP
ATTENDING STATEMENT: I have seen and examined Mr. ___,
reviewed the findings, data, and discharge plan of care
documented by Dr. ___, MD dated ___ and agree.
___, MD, PharmD
Section of Hospital Medicine
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Influenza Vaccine Quadrivalent 0.5 mL IM NOW X1
Start: ___, First Dose: Next Routine Administration Time
2. BuPROPion XL (Once Daily) 150 mg PO DAILY
3. Vitamin D ___ UNIT PO DAILY
4. Divalproex (EXTended Release) 1000 mg PO BID
5. Nicotine Lozenge 2 mg PO Q8H:PRN craving
6. OLANZapine 5 mg PO BID
7. Diltiazem 30 mg PO DAILY
8. Finasteride 5 mg PO DAILY
9. Tiotropium Bromide 1 CAP IH DAILY
10. Prazosin 1 mg PO DAILY
11. Gabapentin 1200 mg PO TID
12. Ranitidine 300 mg PO DAILY
13. Esomeprazole 20 mg Other DAILY
14. Citalopram 40 mg PO DAILY
15. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL DAILY
Discharge Medications:
1. Citalopram 10 mg PO DAILY
RX *citalopram 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL DAILY
3. BuPROPion XL (Once Daily) 150 mg PO DAILY
4. Diltiazem 30 mg PO DAILY
5. Divalproex (EXTended Release) 1000 mg PO BID
6. Esomeprazole 20 mg Other DAILY
7. Finasteride 5 mg PO DAILY
8. Gabapentin 1200 mg PO TID
9. Nicotine Lozenge 2 mg PO Q8H:PRN craving
10. OLANZapine 5 mg PO BID
11. Prazosin 1 mg PO DAILY
12. Ranitidine 300 mg PO DAILY
13. Tiotropium Bromide 1 CAP IH DAILY
14. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
- Syncope
- PNES
SECONDARY DIAGNOSIS
- Depression
- PTSD
- Opioid use disorder
- HCV
- Hematuria
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulated with assistance - rolling walker.
Discharge Instructions:
Mr. ___,
WHY WERE ___ ADMITTED TO THE HOSPITAL?
- ___ were admitted because ___ lost consciousness
WHAT WAS DONE FOR ___ IN THE HOSPITAL?
- We gave ___ fluids through your vein because ___ were
dehydrated
- We did an ECG to look at your heart rhythm, and the results
were reassuring
- We did an ultrasound of your heart which was reassuring
- The neurologists came and saw ___ and felt that your loss of
consciousness was not caused by a seizure, which is good
WHAT SHOULD ___ DO WHEN ___ GO HOME?
- ___ should use your rolling walker when ___ walking!
- ___ should follow up with your regular providers
- ___ should continue taking your medications, as prescribed,
including your Depakote for your seizures
It was a pleasure taking care of ___.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10666610-DS-12
| 10,666,610 | 21,110,018 |
DS
| 12 |
2159-08-15 00:00:00
|
2159-08-15 16:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Rectal Bleeding
Major Surgical or Invasive Procedure:
Colonoscopy ___
History of Present Illness:
Mr. ___ is an ___ with a history of A-Fib (on dabigatran)and
dementia who presents from his nursing home with rectal
bleeding.
Mr. ___ is a resident ___ at ___
and has significant dementia and hearing loss and therefore
history is very limited. He reports bleeding from his rectum for
the past evening. He cannot quantify or qualify the bleeding. He
denies being in any pain right now, specifically no chest or
abdominal pain. No dyspnea. The patient's healthcare proxy is
his only relative (his niece) who could not provide additional
history as she lives in ___ and has not seen him in years.
In the ED: the patient presented afebrile with a HR 78, BP
127/73, RR 18, and O2sat 98% on RA. His exam was notable for
large maroon stool in his adult diaper, without any large clots
or frank melena. The abdomen was soft and nontender. Labs
revealed a WBC 12.8, Hg 14.9, and hyperkalemia to 6.4
(down-trended to 5.2 on repeat). His BUN/Cr ratio was mildly
elevated >20 (Cr 1.1, BUN 25), and his lactate was 1.6. UA
revealed 10 ketones, trace protein, and 1 hyaline cast but no
e/o infection. A CXR revealed no acute process.
The patient was given metoprolol tartate, fractionated to 6.25
mg q6 for his A-Fib. He received 40 mg pantoprazole given c/f GI
bleed. Dabigatran was held in the setting of GI bleed. The
patient was given 1L IVFs given intermittent RVR in the context
of A-Fib.
Consults: ___, who recommended admission to the floor for
likely lower GIB.
Vitals on transfer: T 98.7, BP 127 / 77, HR 127, RR 20, O2Sat
95 RA
Upon arrival to the floor, the patient was unable to provide a
coherent history d/t dementia. He denied any abdominal pain. He
was aware that he had been having bloody stools. He denied any
difficulty breathing or any pain. His healthcare proxy was
unable to provide any additional history as she has not seen him
in years. Unable to contact his nursing home staff given
after-hours.
==================
REVIEW OF SYSTEMS:
==================
otherwise negative.
Past Medical History:
Dementia
Afib on Pradaxa
History of CVA
"Carotid Surgery"
"Skin Cancer" (s/p resections)
Bipolar Disorder
Alcohol Abuse
Essential HTN
Hypercholesterolemia
Dysphagia
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: T 98.7, BP 127 / 77, HR 127, RR 20, O2Sat 95 RA
GENERAL: Not oriented to place or year. Sitting pleasantly in
bed.
HEENT: No JVD. Neck supple.
CARDIAC: Irregularly irregular rhythm, rapid rate. No murmurs
or gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi
or rales. No increased work of breathing.
BACK: There is a soft, movable lesion on lower back c/w a
lipoma.
ABDOMEN: Normal bowels sounds, non-distended, non-tender to
deep palpation in all four quadrants. No organomegaly.
GU: There is an indirect inguinal hernia with erythema and
tenderness to palpation.
EXTREMITIES: No clubbing, cyanosis, or edema. Lower extremities
are dry. Distal pulses faint but present bilaterally.
SKIN: Warm. No rash.
NEUROLOGIC: No focal deficits.
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 525)
Temp: 98.3 (Tm 98.4), BP: 115/79 (94-131/60-88), HR: 98
(89-108), RR: 20 (___), O2 sat: 97% (94-98), O2 delivery: RA
Fluid Balance (last updated ___ @ 350)
Last 8 hours Total cumulative 0ml
IN: Total 0ml
OUT: Total 0ml, Urine Amt 0ml
Last 24 hours Total cumulative 1260ml
IN: Total 1260ml, PO Amt 1260ml
OUT: Total 0ml, Urine Amt 0ml
GENERAL: Oriented to place but not time. Lying pleasantly in
bed.
HEENT: PERRL, MMM.
CARDIAC: Irregularly irregular rhythm. No murmurs or gallops.
LUNGS: CTAB anteriorly. No wheezes, rhonchi or rales.
Breathing comfortably in room air.
ABDOMEN: Normal bowels sounds, non-distended, nontender to
deep palpation in all quadrants. No guarding or rebound
tenderness.
GU: Left sided large inguinal hernia with no tenderness to
palpation. Irreducible.
EXTREMITIES: Warm and well perfused. No peripheral edema. Distal
pulses present bilaterally.
SKIN: No rash.
NEUROLOGIC: A&Ox1-2. No focal neurological deficits.
Pertinent Results:
ADMISSION LABS:
================
___ 08:50AM BLOOD WBC-12.8* RBC-4.65 Hgb-14.9 Hct-45.5
MCV-98 MCH-32.0 MCHC-32.7 RDW-13.9 RDWSD-50.4* Plt ___
___ 08:50AM BLOOD ___ PTT-34.8 ___
___ 08:50AM BLOOD Glucose-99 UreaN-25* Creat-1.1 Na-137
K-7.0* Cl-98 HCO3-23 AnGap-16
___ 09:20PM BLOOD Calcium-9.3 Phos-3.1 Mg-2.1
IMAGING:
========
+KUB ___
IMPRESSION:
There is no evidence of free intraperitoneal air in supine
position.
Nonetheless, note that upright or left lateral decubitus
projections are the
best projections for detecting free air on radiograph. If
patient is unable
to stand either position, CT without IV contrast may be
considered for
detection of pneumoperitoneum.
+CT ABD & PELVIS WITH CONTRAST ___
IMPRESSION:
Large left inguinal hernia containing proximal-mid sigmoid colon
without
evidence of bowel obstruction or ischemia.
+SCROTAL US ___
IMPRESSION:
1. Large fat and bowel containing inguinal hernia within the
scrotum. Further
assessment with CT is suggested as there was little vascularity
and minimal
peristalsis within one of the bowel loops within this hernia.
2. High-riding right testicle.
3. Normal left testicle.
DISCHARGE LABS:
===============
___ 08:15AM BLOOD WBC-5.4 RBC-3.97* Hgb-12.8* Hct-39.3*
MCV-99* MCH-32.2* MCHC-32.6 RDW-13.7 RDWSD-50.2* Plt ___
___ 08:15AM BLOOD ___ PTT-25.7 ___
___ 08:15AM BLOOD Glucose-81 UreaN-16 Creat-0.9 Na-145
K-4.4 Cl-108 HCO3-28 AnGap-9*
___ 08:15AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.8
Brief Hospital Course:
Mr. ___ is an ___ M with a history of Afib on dabigatran,
advanced dementia, and bipolar disorder who presented from his
nursing home with bright red blood per rectum.
ACUTE ISSUES:
=============
#GI Bleed: The patient presented from his nursing home with 1
day of painless bloody bowel movements. He has not had bloody
bowel movements since ___, has been hemodynamically stable,
and has had a stable H/H. His colonoscopy in ___ was unable to
visualize beyond cecum due to poor bowel prep. Unfortunately his
medical history is limited given his advanced dementia, but he
has no other known risk factors such as AVM, PUD, cirrhosis, or
colon cancer. His bleeding was unlikely mesenteric ischemia
given a normal lactate and absence of severe abdominal pain. The
patient underwent a colonoscopy pre from ___ to ___ and
underwent a colonoscopy on ___ which revealed nonbleeding
diverticulosis, several benign-appearing sessile
polyps (not removed iso GI bleed), and nonbleeding internal
hemorrhoids. No active bleeding was noted in the colon. GI
recommended resuming his home anticoagulation given high CHADs
and risk for stroke, and given that he had mild GI bleeding
without any changes in hemodynamics or Hb. He was observed for
recurrent bleeding after restarting anticoagulation, and his Hb
was stable at 12.8 on the day of discharge.
#Afib: CHADS2VASC ___. The patient was anticoagulated with
dabigatran and rate controlled with metoprolol, at his rehab.
During his hospitalization, he was intermittently tachycardic
with A fib with RVR to 110s, however he was asymptomatic and
fluid responsive. He was encouraged PO intake, and continued on
fractionated metoprolol. He was discharged on his home
metoprolol.
#Chronic inguinal hernia: The patient has a history of an
indirect inguinal hernia which was initially tender to palpation
on admission but shortly resolved. CT abd/pelvis showed no
evidence of obstruction and ischemia. Per ACS, there were no
concerns for incarceration, given that he had no
nausea/vomiting, or obstipation. His symptoms should be
monitored once he leaves the hospital.
#Leukocytosis: The patient had a mild leukocytosis of 12.8k on
admission, which quickly resolved. There were no signs or
symptoms of infection suggesting that it was most likely due to
a stress response. His CXR showed no acute cardiopulmonary
process and UA and UCx were negative UA/UCx. The absence of
abdominal pain was reassuring for GI inflammation or infection.
CHRONIC ISSUES:
===============
# Bipolar Disorder: Continued home valproic acid and quetiapine
fumarate. His QTc was within normal limits.
#Dysphagia: He was on a clear diet during his colonoscopy prep.
There were no acute concerns for dysphagia.
#CV Risk Reduction: The patient's home aspirin was held in the
setting of his GI bleed, but was resumed after his colonoscopy
was unrevealing for an active bleed.
#Insomnia: His home melatonin was held as non formulary, but he
was given ramelteon as needed while inpatient.
#Supplements: Continued home folic acid 1 mg daily
#Constipation: His home bowel regimen was held in the setting of
GI bleed, but can be resumed as an outpatient.
TRANSITIONAL ISSUES:
===================
[]Please address the patient's anticoagulants. His home Pradaxa
and Aspirin were resumed at the time of discharge, given that
his Hb was stable (12.8 on ___.
If bleeding returns on anticoagulation, please involve HCP to
discuss GOC and benefits vs risks of resuming anticoagulation
[]Please recheck CBC in 1 week
[]Please continue to monitor the patient's scrotal tenderness.
CT without evidence of incarceration.
[]Please resume home laxatives. Held as an inpatient in the
setting of his GI bleed.
[]Colonoscopy did reveal multiple benign appearing sessile
polyps. His prep was not sufficient for cancer screening. Please
monitor as needed, although outside the appropriate age range
for screening.
[]Please continue to monitor weights 3 times per week, given
risk for malnutrition
[]Consider re-evaluating dose of Seroquel/ titrating down
**The patient was seen and examined today and is stable for
discharge. Greater than 30 minutes were spent on discharge
planning and coordination.**
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Polyethylene Glycol 17 g PO DAILY
4. Divalproex Sod. Sprinkles 250 mg PO QAM
5. Divalproex Sod. Sprinkles 375 mg PO QHS
6. Senna 8.6 mg PO BID:PRN Constipation - Second Line
7. Dabigatran Etexilate 75 mg PO BID
8. QUEtiapine Fumarate 125 mg PO BID
9. Acetaminophen 325 mg PO TID:PRN Pain - Mild
10. Aspirin 81 mg PO DAILY
11. Melatin (melatonin) 5 mg oral QHS
12. Fleet Enema (Mineral Oil) ___AILY:PRN constipation
13. Magnesium Oxide 400 mg PO DAILY
14. Bisacodyl 10 mg PR QHS:PRN Constipation - First Line
15. Ondansetron 4 mg PO Q6H:PRN nausea/vomiting
Discharge Medications:
1. Miconazole Powder 2% 1 Appl TP TID:PRN groin
RX *miconazole nitrate [Miconazorb AF] 2 % 1 Appl three times a
day Disp #*1 Bottle Refills:*0
2. Acetaminophen 325 mg PO TID:PRN Pain - Mild
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PR QHS:PRN Constipation - First Line
5. Dabigatran Etexilate 75 mg PO BID
6. Divalproex Sod. Sprinkles 250 mg PO QAM
7. Divalproex Sod. Sprinkles 375 mg PO QHS
8. Fleet Enema (Mineral Oil) ___AILY:PRN constipation
9. FoLIC Acid 1 mg PO DAILY
10. Magnesium Oxide 400 mg PO DAILY
11. Melatin (melatonin) 5 mg oral QHS
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Ondansetron 4 mg PO Q6H:PRN nausea/vomiting
14. Polyethylene Glycol 17 g PO DAILY
15. QUEtiapine Fumarate 125 mg PO BID
16. Senna 8.6 mg PO BID:PRN Constipation - Second Line
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
===================
1. Diverticulosis
2. Internal Hemmorhoids
2. Atrial Fibrillation
3. Inguinal Hernia
SECONDARY DIAGNOSES:
====================
1. Advanced Dementia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came to ___ because you were bleeding from your rectum.
Please see more details listed below about what happened while
you were in the hospital and your instructions for what to do
after leaving the hospital.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL:
- Your bleeding was concerning for a bleed in your intestines.
- You had a colonoscopy which showed that you have
diverticulosis, which is an outpouching of your colon, as well
as hemorrhoids.
- Your blood counts also were normal which was reassuring. You
were recommended to restart your blood thinners. Your blood
counts did not drop after restarting them.
- You also had a fast irregular heart rate which was corrected
by fluids. This happened because you were bleeding from your
rectum
- Finally, you had tenderness in your scrotum. You had a scan
which showed that you have a hernia. The surgery team was
consulted and you did not need surgery for this. Your pain also
improved.
- You improved considerably and were ready to leave the
hospital
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL:
- Please follow up with your primary care doctor and other
health care providers (see below)
- Please take all of your medications as prescribed (see
below).
- Seek medical attention if you have a lot of bleeding from
your rectum, have chest pain or palpitations, feel dizzy, or
other symptoms of concern.
It was a pleasure participating in your care. We wish you the
best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10666715-DS-13
| 10,666,715 | 22,108,980 |
DS
| 13 |
2154-07-29 00:00:00
|
2154-07-31 12:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Hypotension, dizziness
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
___ male with a history of aortic stenosis, alcohol
induced cirrhosis complicated by hepatocellular carcinoma,
metastatic s/p multiple ___ ablations most recent in ___ for a
met to the rib presenting with anemia.
Patient has EtOH induced cirrhosis c/b metastatic HCC; s/p TACE
X3 and RFA most recently on ___. Bx-proven HCC mets to right
6th rib; s/p cryoablation on ___. Surveillance CT torso
___ w/innumerable new hypo enhancing lesions throughout the
liver concerning for significant disease progression. Growing
expansile
lytic mass of right middle rib with local involvement of pleura
and
sub muscular chest wall.
As a result of ___ CT torso patient was seen in Liver Tumor
MDC ___ with plans for repeat TACE once optimized, and lans for
cardiologyu visit next week for repeat ECHO; however he was
transferred to ED due to hypotension and symptomatic anemia (hgb
7, from ___, and BP 91/53, per Outpt records usually
systolic 110-120's).
In ED Patient denies fall, trauma, blood in the stool,
hematemesis or hemoptysis. No chest pain, no shortness of
breath, no worsening dyspnea from his baseline.
In the ED, initial vitals were: 97.9 90 115/54 20 100% RA
- Exam notable for:
Negative fast, fecal occult blood test negative
Normal lungs and cardiopulmonary exam
No abdominal pain or tenderness, no flank tenderness
No calf pain or swelling
- Labs notable for:
Hgb 6.7 (from 9.1 ___, WBC 4.8, plt 144, Cr 1.1 (from 0.9
___, ALT 102 AST 66 AP 155 T bili 1.9 Alb 3 Hapto < 10, CEA
4.2 AFP 18.3, INR 1.2
EKG: HR 72 SR leftward axis evidence of LVH
- Patient was given: 1 unit pRBCs
- Vitals prior to transfer: 70 105/48 18 100% RA
Upon arrival to the floor, patient reports that he hasn't
really had symptoms over the past few weeks, denying any
hematemesis, blood in stools or hemoptysis. He reports feeling
more fatigued, describing this as a chronic process, and says he
did feel lightheaded today when he was told he had low blood
pressure. Interestingly, when I asked him about his urine colour
he did endorse his urine not only becoming darker but becoming
"orange colored" in the last few weeks.
Past Medical History:
ETOH Cirrhosis complicated by hepatocellular carcinoma s/p TACE
Hypertension
Aortic stenosis
Hypothyroidism
Gout
Venous stasis and lymphedema
Knee osteoarthritis
TACE ___ and ___
Radiofrequency ablation (___), segments 1 and 7
Cryoablation right 6th rib ___.
Social History:
___
Family History:
No family history of liver disease or malignancy. He has a
father with diabetes. His both parents are deceased. His mother
died of old age and his father died at the age of ___. He has
seven brothers and two sisters. ___ FH of cancer.
Physical Exam:
ADMISSION EXAM
==================
Vital Signs: 98.4 PO 132 / 72 80 18 100 Ra
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, ruddy cheeks,
Neck: Supple. JVP not elevated. no LAD
CV: Regular rate and rhythm. Normal S1+S2, no HJR
Lungs: Clear to auscultation bilaterally, bibsaialr posterior
crackles
Abdomen: Soft, non-tender, non-distended, no fluid wave shift
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE EXAM
====================
Last fever 2300 @ ___
Vital Signs: 98.3 ___ 73 ___ Ra
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, ruddy cheeks
Neck: Supple. JVP not elevated. no LAD
CV: Regular rate and rhythm. grade II systolic murmur heard
best at RUSB with no radiation, early peak
Lungs: Coarse breath sounds, CTAB
Abdomen: Soft, non-tender, non-distended, no fluid wave shift
Ext: Warm, no clubbing, cyanosis, b/l lower extremity edema
Neuro: moving extremities with purpose
Pertinent Results:
ADMISSION LABS
=================
___ 11:48AM WBC-6.0 RBC-2.29* HGB-7.6* HCT-22.8* MCV-100*
MCH-33.2* MCHC-33.3 RDW-16.2* RDWSD-58.4*
___ 11:48AM NEUTS-62.9 ___ MONOS-10.4 EOS-2.0
BASOS-0.7 IM ___ AbsNeut-3.79 AbsLymp-1.42 AbsMono-0.63
AbsEos-0.12 AbsBaso-0.04
___ 11:48AM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-NORMAL
POLYCHROM-OCCASIONAL
___ 11:48AM PLT COUNT-152
___ 11:48AM ___ PTT-35.2 ___
___ 11:48AM CEA-4.2* AFP-18.3*
___ 11:48AM TSH-0.13*
___ 11:48AM HAPTOGLOB-<10*
___ 11:48AM TOT PROT-7.7 ALBUMIN-3.0* GLOBULIN-4.7*
CALCIUM-8.7 PHOSPHATE-3.0 MAGNESIUM-1.7
___ 11:48AM GGT-60
___ 11:48AM ALT(SGPT)-102* AST(SGOT)-66* LD(LDH)-171 ALK
PHOS-155* TOT BILI-1.9* DIR BILI-0.7* INDIR BIL-1.2
___ 11:48AM UREA N-12 CREAT-1.1 SODIUM-133 POTASSIUM-3.8
CHLORIDE-99 TOTAL CO2-22 ANION GAP-16
___ 07:45PM RET AUT-4.3* ABS RET-0.09
IMAGING/STUDIES
===================
RUQUS ___ IMPRESSION:
1. Cavernous transformation of the portal vein. Anterior grade
flow in the hepatic arteries. The right and middle hepatic veins
are patent.
2. Known HCC in the left hepatic lobe status post
chemoembolization.
CXR ___ IMPRESSION:
Comparison to ___. Moderate cardiomegaly. Mild
elongation of the
descending aorta. No. No pleural effusions. There is a new
cortical
disruption of the sixth right rib, with a substantial soft
tissue component.
The presence of a pathological fracture should be excluded by
clinical
correlation and, potentially, further imaging tests.
RENAL ULTRASOUND ___ IMPRESSION:
Probable simple cyst in the lower pole of the left kidney. No
hydronephrosis.
EGD ___
Indications: ___ man with cirrhosis of the liver and
portal hypertension secondary to alcohol complicated by
hepatocellular carcinoma presenting with acute on chronic anemia
and melena.
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. A
physical exam was performed. The patient was administered MAC
anesthesia. Supplemental oxygen was used. The patient was placed
in the left lateral decubitus position and an endoscope was
introduced through the mouth and advanced under direct
visualization until the third part of the duodenum was reached.
Careful visualization of the upper GI tract was performed. The
procedure was not difficult. The patient tolerated the procedure
well. There were no complications.
Findings:
Esophagus:
Other No evidence of esophageal varices.
Stomach: Normal stomach.
Duodenum: Normal duodenum.
Impression: No evidence of esophageal varices.
Otherwise normal EGD to third part of the duodenum
Recommendations: - No findings to explain melena.
- Further care per Inpatient Liver Service.
MICROBIOLOGY
================
___ 3:00 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
DISCHARGE LABS
===============
___ 05:00AM BLOOD WBC-5.2 RBC-2.67* Hgb-8.6* Hct-25.2*
MCV-94 MCH-32.2* MCHC-34.1 RDW-16.0* RDWSD-54.0* Plt Ct-92*
___ 07:45PM BLOOD Neuts-63.2 Lymphs-18.7* Monos-12.6
Eos-3.8 Baso-0.4 Im ___ AbsNeut-3.01 AbsLymp-0.89*
AbsMono-0.60 AbsEos-0.18 AbsBaso-0.02
___ 05:00AM BLOOD Plt Ct-92*
___ 05:00AM BLOOD ___ PTT-36.2 ___
___ 12:45AM BLOOD ___ 07:45PM BLOOD Ret Aut-4.3* Abs Ret-0.09
___ 05:00AM BLOOD Glucose-110* UreaN-13 Creat-0.9 Na-130*
K-3.8 Cl-99 HCO3-23 AnGap-12
___ 05:00AM BLOOD ALT-83* AST-67* LD(LDH)-160 AlkPhos-126
TotBili-2.4*
___ 05:00AM BLOOD Albumin-2.2* Calcium-7.6* Phos-1.9*
Mg-1.9
___ 11:49PM BLOOD calTIBC-90* Ferritn-1388* TRF-69*
___ 11:48AM BLOOD TSH-0.13*
___ 07:55AM BLOOD Free T4-1.4
___ 11:48AM BLOOD CEA-4.2* AFP-18.3*
Brief Hospital Course:
___ year old man with past medical history significant for
alcoholic cirrhosis, complicated by metastatic hepatic cellular
carcinoma, hepatic encephalopathy s/p multiple ___ ablations
admitted from liver clinic for complaints of dizziness,
hypotension and shortness of breath. History notable for
worsening symptoms for ___ weeks and a possibly "a little black"
in his stools. Physical exam notable for positive orthostasis,
tachycardia, soft blood pressures and fever. Labs notable for
Hgb ___ (baseline above ___ and elevated bilirubin. Urine
culture, blood culture with no growth to date. CXR, abdominal
ultrasound, renal ultrasound, CT abdomen and torso with no
concern for infection. Echo completed as this was suppose to be
done outpatient and showed EF 60% and normal biventricular
function and mild AS. In regards to patients fever, he was put
on vancomycin and zosyn for concern for intrabdominal infection
given recent TACE procedure. After 48 hours of coverage and
negative work up, abx were discontinued and patient remained
afebrile and with no symptoms. In regards to his symptoms, they
were attributed to his anemia. Patient was transfused a total of
3uRBC. EGD was done which showed no evidence of bleeding, no
varices. Etiology of anemia ___ be anemia of chronic disease.
Given hx of transfusions, iron studies would not be beneficial
in diagnosis of anemia of chronic disease. On discharge, patient
is functioning back to his baseline, with normal ambulatory
saturations, negative orthostatic vitals.
#Anemia: History notable for worsening symptoms for ___ weeks
and a possibly "a little black" in his stools. Physical exam
notable for positive orthostasis, tachycardia, soft blood
pressures and fever. Labs notable for Hgb ___ (baseline above
___ and elevated bilirubin. Urine culture, blood culture with
no growth to date. Patient was transfused a total of 3uRBC. EGD
was done which showed no evidence of bleeding, no varices.
Etiology of anemia ___ be anemia of chronic disease. Given hx of
transfusions, iron studies would not be beneficial in diagnosis
of anemia of chronic disease. On discharge, patient is
functioning back to his baseline, with normal ambulatory
saturations, negative orthostatic vitals. Of note, per patient,
last colonoscopy was done ___ years ago with no remarkable
findings.
#Fever: Febrile to 101.0 with no localizing symptoms of
infection. Further CT chest, torso did not reveal any
explanation for fever. Given soft blood pressures, initially
covered with vanc/zosyn but then deescalated after 2 days. Did
well with no reoccurrence of fever. Blood culture, urine culture
with no growth.
#ETOH Cirrhosis, HCC: Pt has EtOH induced cirrhosis c/b
metastatic HCC; s/p TACE X3 and RFA most recently on ___.
Bx-proven HCC mets to right 6th rib; s/p cryoablation on
___. Surveillance CT torso ___ showed innumerable new
hypo enhancing lesions throughout the liver concerning for
significant disease progression. Patient was continued on home
lactulose, rifaximin. Continued on home zofran, oxycodone,
compazine.
# Hypotension: Patient presented to the ED from liver clinic due
to symptomatic hypotension to ___ systolic. Resolved with
transfusion. Atributed to anemia. Hypotension was also
concerning for possible occult infection given fever on hospital
day 1, but no clear infectious source on admission.
# History aortic stenosis: Followed by atrius cardiology. On
atenolol only (likely also for cirrhosis). Echo- ___- EF 60%,
LVH, mild AS- mean gradient 15. By last cardiology note he has
mild AS by both exam and echo. Repeat echo was ordered while
inpatient that showed EF 60% and normal biventricular function
and mild AS.
# Painful osteoarthritis: Held home tylenol in setting of
fevers.
# Hypothyroidism: On home levothyroxine. TSH 0.13. FT 4 wnl.
Patient was continued on home levothyroxine. Recommend repeat
TSH in ___ weeks.
# Gout: Continued on home allopurinol.
Transitional issues:
========================
1.Medication changes: None
2.Labs (admission, discharge)
- H/H (6.7,8.6)
- Na (133, 130)
- Total bili (1.9, 2.4)
3. Consider repeat TSH and FT4 in ___ weeks due to abnormal
results. TSH .13, FT4 1.4.
4. Consider repeat iron studies for etiology of anemia 8 weeks
after discharge given recent transfusions.
Code: Full
Contact:
Name of health care proxy: ___
Relationship: daughter
Phone number: ___
___ on Admission:
The Preadmission Medication list ___ be inaccurate and requires
futher investigation.
1. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain - Moderate
2. Lactulose 30 mL PO TID
3. Allopurinol ___ mg PO DAILY
4. Omeprazole 40 mg PO DAILY
5. Simvastatin 40 mg PO QPM
6. Levothyroxine Sodium 150 mcg PO DAILY
7. Tamsulosin 0.4 mg PO QHS
8. Rifaximin 550 mg PO BID
9. Atenolol 25 mg PO DAILY
10. Prochlorperazine 5 mg PO Q8H:PRN nasuea
11. Ondansetron 4 mg PO Q6H:PRN nausea
12. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
2. Allopurinol ___ mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. Lactulose 30 mL PO TID
5. Levothyroxine Sodium 150 mcg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Ondansetron 4 mg PO Q6H:PRN nausea
8. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain -
Moderate
9. Prochlorperazine 5 mg PO Q8H:PRN nasuea
10. Rifaximin 550 mg PO BID
11. Simvastatin 40 mg PO QPM
12. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
=================
Gastrointestinal bleeding
Secondary diagnosis
==================
ETOH cirrhosis
Metastatic ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you here at ___.
What happened while you were admitted?
- You presented with low blood pressures, dizziness, shortness
of breath and a few episodes of black stools.
- Your blood pressures were quite low and you were very
symptomatic, so you were given blood transfusions and you
responded very well to this.
- Blood work was done which showed your hemoglobin level or
blood count was very low. There was a concern you were bleeding
from your gastrointestinal tract.
- You were febrile for 1 day which also made us concerned for
infection. You were given antibiotics for 2 days and an
infectious source was investigated. All your labs, imaging and
cultures looked very reassuring, so the antibiotics were
discontinued and you were monitored very carefully. You remained
without fever.
- An endoscopy was done to investigate the source of possible
bleed and everything actually looked great, no evidence of
bleeding was found.
What to do after discharge?
- Please take your medications as prescribed, this is very
important. Your medications will decrease the risk of
complications from your liver disease, including bleeding,
infection and confusion.
- Please follow up with your hepatologist and primary care
doctor for further management. You ___ have anemia of chronic
disease which can be tested outpatient.
- Please be on the look out for black tarry stools or bloody
stools. If this happens, please call your doctor immediately or
seek medical help.
- Please avoid alcohol, and NSAIDS such as aspirin, motrin,
advil, ibuprofen as this can cause further gastrointestinal
bleeding. We recommend you use Tylenol for aches and pains
instead.
We are so happy to see you feeling better.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10666715-DS-9
| 10,666,715 | 25,070,560 |
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| 9 |
2153-07-23 00:00:00
|
2153-07-25 07:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy (EGD)
History of Present Illness:
___ with hx of EtOH cirrhosis, HLD, HTN, hypothyroidism, gout,
GERD who presents from home with lethargy and confusion. Per
patient and his wife this has been ongoing for ~ 1 month. At
that time, he was admitted to ___ with confusion and
fevers. He was treated for infection of unknown etiology and
then discharged. 1 week later he presented to ___
___ for the same problem and again treated with abx and
discharged. His outpatient hepatologist Dr. ___
(___) adjusted his medications and told him to present
to ___ if his confusion were to return. His wife brings him in
today for worsening confusion and lethargy. She reports he has
been compliant with lactulose and is titrating it to 3BMs daily.
Otherwise denies CP, SOB, abdominal pain, N/V.
On arrival to the ED, vitals afebrile, HR 66, BP 132/70, RR 18
98% RA. Exm notable for 2+ pitting edema and alert and oriented
except to hostpital and date. Labs notable for mild leukopenia
to 3.8, Hgb 9.4, thrombocytopenia to 109. Chem 7 unremarkable.
Lactate 1.5. LFTs only with mild transaminitis with AST to 43.
Bili WNL. No ascites detected on ultrasound so no diag tap
performed. CXR without evidence of PNA. Hepatology contacted in
ED who recommended admission to ET service.
Upon arrival to the floor, patient resting comfortably in bed.
He denies acute complaints. He states that he is aware that his
wife thinks he is more confused and weak than usual but states
"I have my ups and downs like everyone else." He is unable to
clarify anything more regarding his admission. He tells me he no
longer drinks EtOH.
Past Medical History:
-Child's B alcoholic cirrhosis
*c/b hepatocellular carcinoma s/p TACE
*unknown variceal status
-Hypertension
-Hypothyroidism
-Hyperlipidemia
-Gout
-Venous stasis disease and lymphedema
-Obesity
-Anxiety disorder
-Degenerative joint disease of knee
Social History:
___
Family History:
He has a father with diabetes. His both parents are deceased.
His mother died of old age and his father died at the age of ___.
He has seven brothers and two sisters.
Physical Exam:
>> ADMISSION PHYSICAL EXAM:
VITALS: 97.5, 156/81, 80, 20, 99RA
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash.
NEUROLOGIC: A&O to name, hospital. Cannot state year or the days
of the week backwards, however able to state presidents name and
identify some current events. Grossly normal with exception of
mild asterixis
.
>> DISCHARGE PHYSICAL EXAM:
VITALS: Tmax 98.2 BP ___ P 65-105 RR 18 Sat 96-100% RA
GENERAL: Lying comfortably in bed
HEENT: MMM, OP clear, mild palatal jaundice, no scleral icterus.
Telangiectasias on cheeks bilaterally.
CARDIAC: RRR, normal S1/S2, systolic murmur at LUSB
PULMONARY: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Obese. Soft, non-tender, non-distended.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash. No palmar erythema.
NEUROLOGIC: A&O to name, ___, ___. Very mild
asterixis
Pertinent Results:
>> ADMISSION LABS:
___ 01:30PM BLOOD WBC-3.8* RBC-3.10* Hgb-9.4* Hct-29.6*
MCV-96 MCH-30.3 MCHC-31.8* RDW-16.7* RDWSD-57.8* Plt ___
___ 01:30PM BLOOD Neuts-42.2 ___ Monos-10.9 Eos-5.9
Baso-1.1* Im ___ AbsNeut-1.59* AbsLymp-1.49 AbsMono-0.41
AbsEos-0.22 AbsBaso-0.04
___ 01:30PM BLOOD Plt ___
___ 01:30PM BLOOD Glucose-98 UreaN-16 Creat-1.0 Na-136
K-4.4 Cl-103 HCO3-28 AnGap-9
___ 01:30PM BLOOD ALT-20 AST-43* AlkPhos-71 TotBili-0.9
___ 01:30PM BLOOD Albumin-2.5* Calcium-8.9 Phos-3.3 Mg-1.4*
___ 04:25AM BLOOD VitB12-797 Folate-8.1
___ 04:25AM BLOOD TSH-0.22*
___ 04:50AM BLOOD Free T4-1.3
___ 04:25AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 01:37PM BLOOD Lactate-1.5
.
>> DISCHARGE LABS:
___ 06:05AM BLOOD WBC-3.8* RBC-3.12* Hgb-9.8* Hct-29.0*
MCV-93 MCH-31.4 MCHC-33.8 RDW-16.6* RDWSD-55.9* Plt ___
___ 06:05AM BLOOD ___ PTT-42.5* ___
___ 06:05AM BLOOD Glucose-84 UreaN-12 Creat-0.9 Na-135
K-3.7 Cl-106 HCO3-21* AnGap-12
___ 06:05AM BLOOD ALT-27 AST-47* AlkPhos-88 TotBili-1.1
___ 06:05AM BLOOD Calcium-8.9 Phos-3.8 Mg-1.6
.
>> IMAGING:
___ CT Urogram
1. No dilatation of the renal collecting system or evidence of a
renal/perirenal abscess.
2. Limited evaluation of the prostate gland on CT, however no
obvious ___
prostatic collection is identified.
3. Background hepatic cirrhosis with sequelae of portal
hypertension, as
described above.
___. No acute intracranial pathology.
2. Mild, generalized volume loss.
3. Fluid within the paranasal sinuses, suggesting a acute
sinusitis.
___ CXR
Cardiomegaly with mild pulmonary vascular congestion.
___ RUQ U/S
1. Cirrhotic liver. Known treated HCC lesions not visualized.
2. The main portal vein is patent with reversal of flow.
3. Biliary sludge. Gallbladder wall appears diffusely mildly
thickened, may relate to liver disease. Sonographic ___
sign is absent but patient has been medicated.
___ EGD
Impression:No Varicies
Granularity, friability, erythema, congestion, abnormal
vascularity and mosaic appearance consistent with portal
hypertensive gastropathy in the whole stomach
Otherwise normal EGD to third part of the duodenum
Recommendations:Follow-up with endoscopist within ___ years
Brief Hospital Course:
___ with hx of EtOH cirrhosis (NaMELD 14) c/b ___ s/p
transarterial chemoembolization in ___, morbid obesity,
bilateral end stage knee osteoarthritis, HLD, HTN,
hypothyroidism, and GERD who presents with hepatic
encephalopathy.
.
>> ACTIVE ISSUES:
# Hepatic encephalopathy: Patient has a history of hepatic
encephalopathy, on lactulose (titrated to 3 BM/day) and
rifaximin. He presented with worsening confusion and was AOx1-2
on the floor with significant attentional deficits. Infectious
workup was significant for UTI as below as well as acute
sinusitis noted incidentally on head CT. These were treated with
ceftriaxone. The CT was originally performed to assess for signs
of underlying dementia but only demonstrated mild diffuse volume
loss. Other workup was unrevealing: RUQ U/S was negative for PV
thrombus. Patient had a streak of blood in one stool but Hb was
stable, so concern for significant GI bleed exacerbating
encephalopathy was low. His home opioids were held given concern
that they were worsening his encephalopathy, though his mental
status did not improve with opioids held.Lactulose dose was
increased initially to Q2H and then to Q6H. Patient achieved
regular BMs with approx 6 per day. Ceftriaxone was started on
the third day for possible UTI. The next day, his mental status
began to improve, and it continued to improve over the rest of
the hospitalization. Unclear whether this was due to achieving
therapeutic lactulose dosing or the antibiotics. By the time of
discharge, patient was AOX3, appropriate in conversation, with
substantially improved attention.
.
# Urinary tract infection: UA with 56 WBCs, 8 RBCs, 30 prot, 13
hyaline casts, consistent with UTI. Patient was started on
ceftriaxone 1g Q24H. CT urogram was obtained given concern for
abscess, since recent urine culture at ___ grew Strep
anginosus. This was negative for renal abscess or periprostatic
collection. Urine culture grew mixed flora suggestive of
contaminated specimen. Repeat U/A had 62 WBCs but culture did
not grow out any bacteria. During this time, patient was
symptomatically improving considerably, so suspicion was
elevated for chronic prostatitis. Rectal exam was performed and
found no prostatic tenderness. Ultimately, decision was made to
continue antibiotics for two weeks to cover possible chronic
prostatitis vs. complicated UTI. He was transitioned from CTX to
PO cipro prior to discharge.
.
# Child's B ETOH/HCC Cirrhosis: Please see above re: hepatic
encephalopathy. Patient's MELD-Na score was trended, around 13
upon discharge. Patient continued lactulose/rifaxamin as above.
Underwent EGD which did demonstrate a portal gastropathy type
picture without gastric or esophageal varices. No ascites on
exam. Discussed with patient initial plan for weight loss and
alcohol cessation as criteria for liver transplantation, patient
reported at this time is not interested for transplantation and
therefore if decisions changed transplant workup can be
performed as an outpatient.
.
# Leukopenia/Thrombocytopenia: Patient's thrombocytopenia ___ to
cirrhosis, and suspicion for myelosuppression causing leukopenia
from underlying cirrhosis.
.
# Osteoarthritis: Patient with bilateral knee end-stage
osteoarthritis, managed with opiates at home. Patient's opates
were held given concern for exacerbation of hepatic
encephalopathy, and pain managed with Tylenol PRN. Patient did
not require extra doses, and worked with physical therapy.
.
# GERD: Patient was continued on home omeprazole
# Hypertension: Patient was continued on home atenolol 100 mg
daily and quinapril.
# Hyperlipidemia: Patient was continued on home simvastatin
.:
>>TRANSITIONAL ISSUES:
# Encephalopathy: Please encourage patient to titrate lactulose
to ___ BM/day instead of previous 3 BM/day.
# UTI: Given recurrent U/As with 50-60 WBCs, and ~10 RBCs,
please consider further workup for urinary tract infection as
outpatient. He will continue on cipro BID for two weeks to ___
given concern for prostatic type involvement as well and
prolonged course.
# Alcoholic cirrhosis: Patient indicated he is not interested in
transplant evaluation at this time. Please continue to follow up
in clinic.
# OA: Home opioids were held during admission and he was not
discharged with any, given concern for worsening encephalopathy.
Please re-evaluate need for opioids as outpatient.
# Pancytopenia: Slightly low WBC and PLT apparently new on this
admission, with stable anemia. Likely due to alcoholic bone
marrow suppression, but please continue to monitor/evaluate as
outpatient.
# Hypothyroidism: TSH was low at 0.22. Please consider
decreasing dose of levothyroxine and rechecking when more
medically stable.
# Advance directive: Daughter ___ says she has submitted health
care proxy and ___ documentation to Dr. ___, but
there is no documentation in OMR. Please follow up discussion as
outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Prochlorperazine 5 mg PO Q6H:PRN nausea
3. Oxycodone-Acetaminophen (5mg-325mg) 0.5 TAB PO Q4H:PRN pain
4. Allopurinol ___ mg PO BID
5. Simvastatin 40 mg PO QPM
6. Atenolol 100 mg PO DAILY
7. Quinapril 40 mg PO DAILY
8. Lactulose 30 mL PO TID
9. Rifaximin 550 mg PO BID
10. Levothyroxine Sodium 150 mcg PO DAILY
11. Spironolactone 50 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO BID
2. Atenolol 100 mg PO DAILY
3. Lactulose 30 mL PO Q6H
RX *lactulose 20 gram/30 mL 30 mL by mouth every ___ hours
Refills:*1
4. Levothyroxine Sodium 150 mcg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Quinapril 40 mg PO DAILY
7. Rifaximin 550 mg PO BID
8. Simvastatin 40 mg PO QPM
9. Spironolactone 50 mg PO DAILY
10. Ciprofloxacin HCl 500 mg PO Q12H
Please take until ___
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice daily
Disp #*22 Tablet Refills:*0
11. Prochlorperazine 5 mg PO Q6H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Hepatic encephalopathy
2. Acute Cystitis
3. Alcohol Cirrhosis
SECONDARY DIAGNOSIS:
1. Knee osteoarthritis
2. Hypertension
3. Hyperlipidemia
4. GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were hospitalized because of confusion,
which was due to hepatic encephalopathy. In order to understand
why you were getting more confused, we did a CT scan of your
brain that showed no major abnormalities - only a little
shrinking (which is commonly seen with age) and a sinus
infection. We also did a urine analysis which showed that you
had an infection of your urinary tract. A CT scan of your
abdomen was normal. You were treated with an increased dose of
lactulose and an antibiotic called ceftriaxone for the
infection. You will take three days of ciprofloxacin when you go
home and complete your treatment on ___.
It is very important that you take enough lactulose every day to
have 4 to 5 bowel movements per day. Please also use Percocet
sparingly for knee pain as this might contribute to your
confusion. If you start to have symptoms of burning with
urination, or feeling like you need to urinate more frequently,
please call your doctor. Please also call your doctor if you
start feeling more confused.
We wish you the best,
Your ___ Team
Followup Instructions:
___
|
10667056-DS-14
| 10,667,056 | 29,499,447 |
DS
| 14 |
2119-07-25 00:00:00
|
2119-07-25 20:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
diaphoresis, hypotension, syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ M with IgG Myeloma since ___ most recently on velcade,
decadron, pmalyst/zometa started ___, history of chronic hep
C, who presented today for consultation with oncology for
consideration of auto transplant, found to be diaphoretic
hypotensive, and sweating when he arrive to the appointment
toay,
and referred to ED.
He reported in clinic feeling unwell for past few days with
perfuse sweats at home for past 24 hours. No fevers by report.
No shortness of breath; no chest pain, no cough, no sore throat
or rhinorrhea. Endorses decreased PO intake last ___ days though
trying to keep up with PO, but likely minimal due to profound
fatigue. NO HA or localizing weakness but just complete lack of
energy and appetite. ENdorses profound night sweats that
reminded
him of his wife's hot flashes. Symptoms not worse with exertion,
no neck/jaw/arm pain. Does state decreased urinary volume, maybe
some hesitancy, but no dysuria or hematuria. NO blood in stools
or melena.
Came to clinic today for ___ onc eval (seen at ___
previously)
and passed out in clinic on exam bed; brief unresponsive. Pt
states he remembers the entire episode but per provider's report
he had brief LOC. Hypotensive in clinic to SBP ___ with
lighheadedness; Improved to SBP 98 with IV fluids. ___ 175.
EKG
done. BC attempted but could not obtain. Note he has h/o HTN(on
Losartan) and DM(on Metformin). Referred to ED for syncope
workup/infectious workup. In the ED, Patient reports similar
symptoms yesterday which resolved spontaneously. During the past
24 to 48 hours he endorses multiple episodes of diaphoresis
including night sweats. He denies any fever, chills, chest pain,
shortness of breath, nausea, vomiting, cough, bowel
changes. He does report some difficulty initiating a urinary
stream which is new.
ED COURSE:
T 97.8 HR 84 134/66 RR 16 100% RA. UA with large leuks, WBC
111, few bact, epi <1. Lactate 1.5. pt noted to have mild STE
1-2mm in V1-V3 no prior for comparison but denied CP/SOB and
trop
<0.01. Chem with mild hyponatremia up to 134 before transfer,
and
creatinine 1.6 --> 1.3 after fluids. WBC9 with 65% pmns. LFTs
reassuring. Mg 1.8. Ca 9.9. INR 1.2. Hct 37 --> 33.6. He was
given no further fluids or treatment in the ED.
On arrival to the floor he states he feels much improved at this
point, denies headaches, cough, chest pain, still has some
ongoing sweaty and feels warm but improved from prior.
Past Medical History:
PAST MEDICAL
Hypertension, essential
Hepatitis
Diabetes mellitus with renal manifestations, uncontrolled
Colonic adenoma
History of tobacco use
overweight
Osteochondritis dissecans
Multiple myeloma
Vitamin d deficiency
Hyperthyroidism
Low vitamin B12 level
Chronic hepatitis C without hepatic coma
ONCOLOGY HISTORY:
IgG myeloma with IgG level 7 gms, mild inc in free kappa light
chains, 1 cm lesion rt femur, no ben___. Also hx chronic
hep
C.
___: Started Revlimid 25 mg with decadron 20 mg weekly and
monthly zometa
___: IgG level down to 1690 mg/dl. Stopped pulse decadron as
hgb
A1c very high.
___: Zometa held as developed gum pains and off decadron and
IgG
levels good.
___: Restarted Zometa q ___.
___: Zometa on hold due to dental extractions.
___: Revlimid on hold while had dental extractions.
___: Revlimid restarted and developed pruritis and faint
rash.
Advised to stop it. Revlimid dc'd.
___: Rx'd Harvoni for his hep C x 8 wks with undetectable
viral load afterwards.
___: IgG starting to rise. 3.6 gm. CBC normal.
___: IgG up to 5.4 gm. Advised restarting chemo - refusing
decadron. Prefers oral meds. Hep C VL undetectable.
___: Started Pomalyst 4 mg. Complicated by mild pruritis,
resolved with holding the drug, then adding decadron. Rising
IgG
however.
___: Marked rise in IgG to 6410 mg/dl. Agreed to start
Vel/Dex in addition to Pomalyst.
___: Started Velcade, decadron with Pomalyst and zometa.
___: Mild paresthesias. B12 level found to be low although
methylmalonic acid level normal. Started on parenteral and oral
B12.
Social History:
___
Family History:
mother and sister w/ HTN, uncle with DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
Tmax 99.2; BP 144/86; P78, O2 sat 100% on RA
Gen- A&O, NAD, pleasant
HEENT- mucous membranes moist
Chest-cta b/l
CV- RRR
Abd- soft. No masses, tenderness or organomegaly
Ext- no edema.
Neuro: grossly intact
DISCHARGE PHYSICAL EXAM:
99.7 106/70 62 18 100RA
GENERAL: NAD
HEENT: NCAT, MMM, EOMI
CARDIAC: RRR, no murmurs, rubs, or gallops appreciated, normal
S1S2
LUNG: CTAB, no crackles or wheezes appreciated
ABD: soft, non-tender, non-distended, +BS, no rebound or
guarding
EXT: no cyanosis, clubbing, or edema appreciated.
PULSES: DP pulses 2+ bilaterally
NEURO: A&Ox3, strength and sensation grossly intact in bilateral
upper and lower extremities.
Pertinent Results:
LABS ON ADMISSION:
___ 01:50PM WBC-8.6 RBC-4.03* HGB-12.7* HCT-37.0* MCV-92
MCH-31.5 MCHC-34.3 RDW-16.0* RDWSD-54.4*
___ 01:50PM NEUTS-70 BANDS-0 LYMPHS-15* MONOS-15* EOS-0
BASOS-0 ___ MYELOS-0 AbsNeut-6.02 AbsLymp-1.29
AbsMono-1.29* AbsEos-0.00* AbsBaso-0.00*
___ 01:50PM UREA N-16 CREAT-1.6* SODIUM-132*
POTASSIUM-3.8 CHLORIDE-95* TOTAL CO2-24 ANION GAP-17
___ 01:50PM ALT(SGPT)-16 AST(SGOT)-22 LD(LDH)-160 ALK
PHOS-61 TOT BILI-0.5
___ 01:50PM TOT PROT-9.8* ALBUMIN-3.8 GLOBULIN-6.0*
CALCIUM-9.9 PHOSPHATE-4.7* MAGNESIUM-1.8
___ 01:50PM PEP-ABNORMAL B Free K-380* Free ___ Fr
K/L-29.2* b2micro-6.4* IgG-3485* IgA-31* IgM-33* IFE-MONOCLONAL
___ 02:30PM URINE U-PEP-MULTIPLE P IFE-NEGATIVE F
___ 10:00PM URINE RBC-2 WBC-111* BACTERIA-FEW YEAST-NONE
EPI-<1
___ 10:00PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 10:00PM URINE COLOR-Yellow APPEAR-Hazy SP ___
LABS ON DISCHARGE:
___ 07:40AM BLOOD WBC-3.9* RBC-3.34* Hgb-10.3* Hct-30.9*
MCV-93 MCH-30.8 MCHC-33.3 RDW-15.9* RDWSD-54.0* Plt ___
___ 07:40AM BLOOD Neuts-42.9 ___ Monos-22.7*
Eos-5.9 Baso-0.3 Im ___ AbsNeut-1.66# AbsLymp-1.08*
AbsMono-0.88* AbsEos-0.23 AbsBaso-0.01
___ 07:40AM BLOOD Plt Smr-NORMAL Plt ___
___ 07:40AM BLOOD Glucose-165* UreaN-15 Creat-0.9 Na-136
K-4.7 Cl-106 HCO3-29 AnGap-6*
___ 07:40AM BLOOD Mg-2.1
MICROBIOLOGY:
Urine culture ___ (prelim):
GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML
Blood culture ___: pending
Imaging:
CXR ___:
No acute intrathoracic abnormality.
TTE ___:
LVEF = 66%
No cardiac structural abnormality was identified that can
explain the patient's syncope. Mild symmetric left ventricular
hypertrophy with normal biventricular regional/global systolic
function.
The patient has a mildly dilated ascending aorta. Based on ___
ACCF/AHA Thoracic Aortic Guidelines, if not previously known or
a change, a follow-up echocardiogram is suggested in ___ year; if
previously known and stable, a follow-up echocardiogram is
suggested in ___ years.
Brief Hospital Course:
TTE showed no LVH or AV stenosis.
___ M with IgG Myeloma since ___ most recently on velcade,
decadron, pmalyst/zometa started ___, history of chronic hep
C, who presented to the clinic for consultation with oncology
for consideration of auto transplant, found to be diaphoretic
hypotensive, and sweating when he arrive to the appointment
today with syncope. Referred to ED, where he was found to have
UA consistent with UTI.
# complicated UTI with urosepsis- Patient found to have UA
consistent with UTI in ED, consistent with patient's urinary
complaints. Patient meets sepsis criteria as he was hypotensive
on presentation. The patient was started on IV ceftriaxone on
___. The patient's urinary symptoms resolved after treatment
was started. He was transitioned to oral ciprofloxacin on the
day of discharge. As he is male, he meets criteria for a
complicated UTI, so the patient was discharged with a 2-week
course of ciprofloxacin (11 days of cipro 500mg BID in addition
to the three days in the hospital). Urine culture grew GNRs but
was speciation was pending at the time of discharge.
#Hypotension, diaphoresis - Hypotension resolved and patient
felt much better after getting IV fluids and treatment for UTI.
Vital signs were monitored regularly with no further hypotension
as an inpatient. The patient had a TTE that showed normal
biventricular function and no LVH or aortic stenosis, but was
notable for mildly dilated ascending aorta. The patient was
feeling well on the day of discharge.
# Myeloma - most recently on velcade/dex/zometa/pomalyst (last
doses were last ___ and he is currently on the off week of
pomalyst which starts up again this coming ___, referred for
auto transplant evaluation on the day of admission and sent to
ED as per HPI. ___ metastatic XR series shows bilateral femoral
and right tibial small lytic lesions stable c/w MM. Per ___ onc
notes, only a partial response so far to Vel/Dex and Pomalyst,
now with development of paresthesias which are likely early
neuropathy from the Velcade, complicated by his DM and possibly
B12 deficiency although methylmalonic acid level was normal
despite low B12 (79). Outpatient oncology considered switching
to Carfilzomib. On day of admission, IgG 3485, IgA 31, IgM 33
b2micro 6.4, free K/L 29.2. LDH only 160. Urine immunofixation
showed monoclonal IgG kappa band. The patient had a TTE as per
above, which was also a part of his pre-transplant workup. The
patient was discharged with a follow-up appointment arranged
with his primary oncologist.
# HCV - chronic. Patient is s/p Harvoni treatment in ___. VL in
___ checked at ___ was undetectable.
# Anemia - Chronic. Hemoglobin was trended daily. Hemoglobin
dropped from 12.7 to 10.3 during admission but initial labs were
likely hemoconcentrated. No evidence of bleeding. Active type
and screen was maintained but the patient was not transfused.
# ___ - Creatinine was 1.6 on admission. Likely pre-renal, due
to volume depletion. The patient's renal function improved
steadily after resuscitation and was 0.9 on the day of
discharge.
# DM - chronic. The patient's home antidiabetic medications were
held during this admission and he was placed on an insulin
sliding scale. He was given a diabetic diet. He was placed back
on his home antidiabetic medications on discharge.
***Transitional Issues***
[ ] Follow-up blood cultures, speciation of urine culture.
Consider readmission for IV antibiotics if blood cultures are
positive.
[ ] Ongoing treatment of multiple myeloma as per primary
oncologist
[ ] From ___ report: "The patient has a mildly dilated ascending
aorta. Based on ___ ACCF/AHA Thoracic Aortic Guidelines, if not
previously known or a change, a follow-up echocardiogram is
suggested in ___ year; if previously known and stable, a follow-up
echocardiogram is suggested in ___ years."
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. pomalidomide dose ___ ___ DAILY
2. MetFORMIN (Glucophage) 500 mg PO BID
3. Losartan Potassium 100 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every 12 hours
Disp #*22 Tablet Refills:*0
2. Losartan Potassium 100 mg PO DAILY
3. MetFORMIN (Glucophage) 500 mg PO BID
4. pomalidomide 1 dose ORAL DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Sepsis due to gram-negative bacilli UTI
Multiple Myeloma
Acute Kidney Injury
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 the hospital with sweating and low blood
pressure. You were sent to the ED and admitted. We found that
you had an infection in your urininary tract (UTI). We gave you
IV antibiotics for this and you felt much better.
It is safe for you to go home. We are giving you a prescription
for oral antibiotics (ciprofloxacin) to finish treating your
UTI. You should take the first dose tomorrow morning and then
every 12 hours for 11 more days. Please take the entire course
of the medication.
There is a small chance that your blood cultures will come back
positive. If that happens, we will call you with instructions.
You have a follow-up appointment next ___ that is listed
below.
On behalf of your inpatient team, take care and be well.
-Your ___ Care Team
Followup Instructions:
___
|
10667359-DS-21
| 10,667,359 | 27,998,288 |
DS
| 21 |
2171-02-18 00:00:00
|
2171-02-19 18:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Fever, chills
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with PMH Parsonage Turner syndrome presenting with
fevers, malaise, body aches to OSH. Pt didn't feel well
yesterday and developed shaking chills. Also c/o abd pain,
initially suprapubic but now diffuse. Also c/o rib and hip pain.
RIb pain is bilateral at lower ribs and is worse with deep
breaths. No prior diarrhea but at OSH had an episode of loose
stool. No blood in stool.
EXPOSURES:
Has a yard with a garden and many deer nearby. Walks in the
woods near her home.
Friend who went walking with her in the woods had GI sx last
week but recovered. She initially thought she had the same "GI
bug." Otherwise no sick contacts.
Denies recent ingestion of seafood/shellfish/mollusks.
Works as a volunteer at the ___ in the "touch tank" where
she handles aquatic organisms. Denies open skin abrasians or
wounds and states she is "usually very good about washing
hands."
No pets.
Recent travels: ___ in ___. ___ and ___ and ___
in ___. Had a UTI after trip to ___ and a "bad cold"
after trip to ___.
Sailor as a hobby.
AT the ___ pt was hypotensive to ___, febrile to 102, and
noted to have WBC 0.7, 10% bands, 41% PMN (ANC 357), hct 46.1,
dohle bodies present, plats 111, INR 1.1, fibrino ___, cr 1.05,
BUN 23, t bili 2.9, direct bili 0.8, U/A showed 1+ ___, neg
nitrite, and ___ WBC, ___ epis. Lactate 4.0. They gave her 3L Ns
and transferred to ___ due to persistent hypotension not
responsive to fluids.
At ___ initial VS 99.4, 93, 90/60, 17, 96% RA. She was AAOx3,
no meningismus. Pt remained hypotensive in ___ despite
further fluids and was started on levophed. Right IJ placed. Got
6L NS before transfer to MICU. EKG SR at 92, PR 116, Qtc 410,
low voltage, no ischemia. Labs significant for increase in
transaminases (AST 205, ALT 149), INR to 1.6, lactate 3.2, plats
83. Leukopenia improved to 4.4. Given vanc/cefepime/doxy. CT
scan obtained for suprapubic pain showed third spacing and edema
of gallbladder and bowel, likely ___ shock as it was nonfocal.
On arrival to the MICU, VS 99.1, 88, 94/59, 26, 93% RA. Shortly
after arrival to MICU, OSH called to report she had ___
anaerobic bottles growing GNRs.
Past Medical History:
-Parsonage Turner syndrome Dx ___ - per pt had left shoulder
pain, then developed nerve atrophy
-Intermittent tinnitus on left
-small meningioma
-anxiety
-Vitamin D deficiency
Social History:
___
Family History:
noncontributory
Physical Exam:
Admission Exam
Vitals- VS 99.1, 88, 94/59, 26, 93% RA. No pulsus paradoxus
GENERAL: Alert, oriented, no acute distress but appears fatigued
and is speaking in a very soft voice
HEENT: mild scleral icterus and conjunctival injection
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, TTP in upper quadrants bilaterally but neg ___
sign
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no rashes
Discharge Exam
Vitals: 97.6 136/84 67 18 98%RA
GENERAL: Awake, alert, oriented, no acute distress.
HEENT: PERRL. Sclera nonicteric. MMM, no oral lesions.
NECK: Supple, JVP not elevated, no LAD. Prior RIJ CVL site
clean, nontender (line removed ___.
LUNGS: Clear to auscultation bilaterally, no wheezes, decreased
breath sounds at bases b/l. Breathing is nonlabored.
CV: Regular rate and rhythm, normal S1 S2, no murmurs
appreciated.
ABD: BS+. Soft, nondistended, nontender. No rebound or guarding.
No masses or HSM appreciated.
EXT: Warm, well perfused. No ___ edema. Right UE PICC site clean,
nontender.
Pertinent Results:
Admission labs
___ 03:05PM BLOOD WBC-4.4 RBC-4.09* Hgb-12.5 Hct-37.5
MCV-92 MCH-30.6 MCHC-33.4 RDW-12.9 Plt Ct-83*
___ 03:05PM BLOOD Neuts-83* Bands-4 Lymphs-9* Monos-3 Eos-0
Baso-0 ___ Metas-1* Myelos-0
___ 03:05PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 03:05PM BLOOD ___ PTT-33.8 ___
___ 03:05PM BLOOD ___
___ 12:00AM BLOOD FDP-80-160*
___ 03:05PM BLOOD Parst S-NEGATIVE
___ 06:31AM BLOOD Parst S-NEGATIVE
___ 03:05PM BLOOD Glucose-102* UreaN-21* Creat-1.0 Na-143
K-3.4 Cl-114* HCO3-19* AnGap-13
___ 03:05PM BLOOD ALT-149* AST-205* AlkPhos-67 TotBili-2.8*
DirBili-1.4* IndBili-1.4
___ 03:05PM BLOOD Albumin-2.7* Calcium-7.3* Phos-1.2*
Mg-1.3*
___ 09:10PM BLOOD Hapto-82
___ 03:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:31PM BLOOD Lactate-3.2*
Imaging:
CXR IMPRESSION___: Interval placement of right IJ central
venous catheter with tip in the expected location of the SVC.
Interval development of mild pulmonary edema.
CT abd pelvis ___ IMPRESSION: The above-described spectrum of
findings including third-spacing of fluid throughout the abdomen
and pelvis with periportal edema, hyperemia of the bilateral
adrenal glands, and sigmoid mucosal edema is compatible with
underlying shock pathology, with no clear source in the abdomen
or pelvis. The degree of massive gallbladder wall edema could
conceivably be due to underlying fulminant hepatitis, as it
appears slightly out of proportion with the other findings.
Clinical correlation is recommended.
CXR ___ Right internal jugular line tip is at the level of mid
SVC. Heart size and mediastinum are stable. Elevated left
hemidiaphragm is unchanged. There is interval improvement of
interstitial pulmonary edema. Minimal bibasal atelectasis is
still present.
MRCP (MR ABD ___ Date of ___:
IMPRESSION:
1. Gallbladder wall edema as seen on the prior CT is less
prominent then on
the prior exam and is thought to reflect third spacing. No
gallstones are
demonstrated.
2. Small to moderate size right pleural effusion, small volume
of ascites, and subcutaneous edema.
3. Pancreas divisum.
CHEST PORT. LINE PLACEMENTStudy Date of ___:
IMPRESSION:
Tip of the new right PIC line in the mid SVC. Small right
pleural effusion,
new since ___.
Since the mediastinum has been shifted to the right, prior to
the development of moderate right lower lobe atelectasis, the
left lower lobe atelectasis is the result of rather than the
cause of the markedly elevated left hemidiaphragm. Diaphragmatic
elevation could be due to eventration, previous trauma, or
phrenic nerve palsy. Upper lungs are clear. No pneumothorax.
Discharge Labs:
___ 07:59AM BLOOD WBC-6.7 RBC-4.01* Hgb-12.0 Hct-36.1
MCV-90 MCH-29.8 MCHC-33.2 RDW-13.4 Plt ___
___ 07:59AM BLOOD Glucose-125* UreaN-11 Creat-0.7 Na-139
K-4.2 Cl-105 HCO3-25 AnGap-13
___ 07:59AM BLOOD ALT-106* AST-62* AlkPhos-284* TotBili-1.3
___ 07:00AM BLOOD Calcium-8.8 Phos-2.0* Mg-2.0
___ 06:26AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
___ 06:26AM BLOOD HCV Ab-NEGATIVE
___ 03:31PM BLOOD ___ SPOTTED FEVER AB IGG,
IGM-Negative
___ 03:31PM BLOOD ANAPLASMA PHAGOCYTOPHILUM AND EHRLICHIA
CHAFFEENSIS ANTIBODY PANEL (IGM AND IGG) Negative
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
=================================================
___ y/o female with Parsonage Turner syndrome initially presented
to OSH on ___ with a one day history of "flu like symptoms"
with myalgias, fevers, body aches, shaking chills. Found to be
in septic shock and transferred to MICU at ___.
ACTIVE ISSUES:
=================================================
#Polymicrobial septic shock: Patient required ICU level care
with multiple boluses of fluid and pressors. She was started on
broad-spectrum Abx, blood cultures from OSH grew E.coli (2
strains), pseudomonas; blood cx at ___ also grew E coli and
pseudomonas, as well as CLOSTRIDIUM SPECIES NOT C. PERFRINGENS
OR C. SEPTICUM. Given the flora, it was presumed the source was
GI. However, imaging did not reveal any obvious GI source, MRCP
was performed which was normal. After return of micro
sensitivities, PICC was placed (right upper extremity) she was
narrowed to zosyn, discharged to complete a 2-week course (from
time of negative cultures) of zosyn 4.5g q8hrs ___ thru ___.
It was strongly recommended she have repeat imaging and a
colonoscopy to evaluate for potential source or GI malignancy.
# Elevated LFTs: During hospitalization enzymes peaked at ALT
248 AST 224 TBili 3.7. Unclear cause as patient did not have RUQ
symptoms, and both CT and MRCP were unremarkable. Enzymes
trended down prior to admission. She was tested for ___
___ Spotted Fever as well as Anaplasma, both of which were
negative.
# Thrombocytopenia: Was thrombocytopenic on admission so
unlikely to be due to ABx, or HIT. Per patient no known hx of
low plts; PCP records obtained and plt level was 209 in ___.
RMSF and anaplasma negative. Plt count trended up prior to
discharge. She should have a level checked by PCP to ensure
resolution.
# Neutropenia: Was neutropenic on admission in the setting of
polymicrobial septic shock, this was felt likely secondary to
the infection as the next day her ANC returned to normal levels.
TRANSITIONAL ISSUES:
=================================================
- discharged on 2-week course of zosyn 4.5g q8hrs ___ thru
___.
- PICC line should be pulled after completion of ABx course.
- Should have CBC and LFTs drawn at her follow-up PCP
appointment to ensure resolution of thrombocytopenia and
elevated LFTs.
- Needs a colonoscopy as soon as able to evaluate her colon for
source of infection or malignancy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 0.25 mg PO DAILY:PRN neck pain or tinnitus
Discharge Medications:
1. ClonazePAM 0.25 mg PO DAILY:PRN neck pain or tinnitus
2. Acetaminophen 650 mg PO Q8H:PRN pain
3. Piperacillin-Tazobactam 4.5 g IV Q8H
RX *piperacillin-tazobactam 4.5 gram 4.5 gram infusion q8hrs
Disp #*28 Vial Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Bacteremia
Thrombocytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you here at ___
___. You were admitted on ___ and found to have
a serious bacterial infection in your bloodstream. You were
treated with antibiotics. You will need to continue these
antibiotics for at least 2 weeks.
We are not sure of the cause of your infection. Please make sure
to follow-up with your Primary Care Doctor ___ below for
upcoming appointments). You should have a colonoscopy as soon as
you are able, to better evaluate your colon as a source for the
infection.
You were noted to have a low platelet count. This is likely due
to your serious infection and should improve as your infection
resolves. Again, please make sure to follow-up with your Primary
Care Doctor.
___, it was wonderful to meet you. We wish you all the best.
-Your ___ Team
Followup Instructions:
___
|
10667849-DS-10
| 10,667,849 | 28,642,859 |
DS
| 10 |
2121-12-20 00:00:00
|
2121-12-20 13:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Ischemic colitis vs inflammatory colitis, LGIB
Major Surgical or Invasive Procedure:
___: Extended left hemicolectomy with colostomy formation
___: Cardiac catheterization
History of Present Illness:
___ who presented with abdominal pain, bloody diarrhea and
leukocytosis with
elevated serum lactate. She reported that as she attempted to
get out of bed on morning of admission due to rectal bleeding
her legs "gave out" on her and she fell. She was transported to
___ for further evaluation. In the ED she was noted with
progressive tenderness over the course of her resuscitation, and
a lactate that originally went down, but then was noted to
increase. CT imaging was done showing an area of colitis most
prominent in the
area of the splenic flexure. She became intermittently
hypotensive, requiring significant fluid administration to
maintain normotension, and showed signs of
progressive abdominal tenderness. She was, therefore, taken to
the operating room for exploration and definitive management.
On POD 3, Mrs. ___, had episode of SVT with rates of
approximately 150-170, and per her report, was symptomatic with
palpitations, chest discomfort and shortness of breath. The SVT
spontaneously broke without intervention. EKG
was performed overnight after the SVT broke which showed a rate
of ~100 in sinus rhythm with diffuse ST depressions in
I/II/AVF/V4-V6 and 1mm elevation in aVR which is all new from
baseline. No intervention was done at that time. Subsequent EKGs
showed resolution of most of these changes with subtle ST
depressions in the anterolateral precordial leads. Afterwards
she was noted to
have increasing O2 requirements and CXR this AM was consistent
with pulmonary edema and bilateral pleural effusions. She was
diuresed with 10mg IV lasix x1 with improvement in her shortness
of breath. Subsequent labs were notable for CK 489, MB 4,
Trop-T 0.28 with BNP ~22,000. The patient was admitted to ICU
for further management and closer observation.
On ___, a cardiac catheterization was completed and
significant for distal left main and 3-vessel coronary artery
disease. Please see the catheterization report for further
details.
Past Medical History:
HTN, HL, CRI (baseline creat 1.3), Breast cancer, Osteoporosis,
Anx/Dep, Glaucoma
PSH:
Left breast mastectomy (___)
Right mastectomy (___)
TAH (___)
Social History:
___
Family History:
Noncontributory
Physical Exam:
Upon presentation to ___:
Temp: 97.7 HR: 70 BP: 87/53 Resp: 16 O(2)Sat: 98 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, diffuse tenderness
Rectal: brbpr
On discharge:
VS: 98.9 90 122/66 16 96% RA
GEN: A&O, NAD
PULM: Lung sounds diminished at bases bilaterally, otherwise
clear, no crackles/rhonchi
CV: RRR, no m/r/g
ABD: Soft, minimally appropriately tender and midline surgical
incision site, nondistended. Surgical incision dry with
steristrips intact. RLQ stoma pink with liquid stool output.
EXTR: Trace ___ edema, warm pink and well-perfused.
Pertinent Results:
___ 06:20PM BLOOD WBC-10.0# RBC-4.15* Hgb-12.7 Hct-38.3
MCV-92 MCH-30.6 MCHC-33.1 RDW-14.0 Plt ___
___ 07:00AM BLOOD WBC-7.4 RBC-2.96* Hgb-9.1* Hct-26.8*
MCV-91 MCH-30.9 MCHC-34.1 RDW-14.5 Plt ___
___ 01:15AM BLOOD Neuts-89.7* Lymphs-6.9* Monos-3.1 Eos-0.1
Baso-0.3
___ 06:20PM BLOOD Neuts-91.3* Lymphs-5.3* Monos-3.0 Eos-0.1
Baso-0.3
___ 07:00AM BLOOD Plt ___
___ 06:20PM BLOOD Glucose-190* UreaN-34* Creat-2.6*# Na-139
K-4.1 Cl-101 HCO3-23 AnGap-19
___ 01:15AM BLOOD Glucose-200* UreaN-35* Creat-2.4* Na-136
K-3.6 Cl-107 HCO3-17* AnGap-16
___ 05:51AM BLOOD Glucose-95 UreaN-28* Creat-1.6* Na-142
K-3.5 Cl-112* HCO3-21* AnGap-13
___ 07:00AM BLOOD Glucose-153* UreaN-24* Creat-1.3* Na-139
K-3.4 Cl-111* HCO3-21* AnGap-10
___ 11:47AM BLOOD ALT-26 AST-40 AlkPhos-24* TotBili-1.3
___ 06:20PM BLOOD Lipase-26
___ 06:20PM BLOOD cTropnT-<0.01
___ 07:00AM BLOOD Calcium-8.0* Phos-1.9* Mg-2.0
___ Left wrist xray: Intra-articular, impacted, and dorsally
angulated fracture of the distal radius. Ulnar styloid fracture.
___ CT abd/pelvis: Diffuse wall thickening extending from the
mid transverse colon to the sigmoid.
___ CT head: no acute process
___ CT cspine: no fracture
___ TTE:
Conclusions
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. There is mild to moderate regional
left ventricular systolic dysfunction with focal severe
hypokinesis of the entire septum and basal-to-mid anterior wall.
The remaining segments contract normally (LVEF = 35-40 %). The
estimated cardiac index is borderline low (2.0-2.5L/min/m2).
Right ventricular chamber size and free wall motion are normal.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. Moderate [2+] tricuspid regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Regional left ventricular systolic dysfunction c/w
CAD. Moderate mitral regurgitation. Moderate tricuspid
regurgitation.
___ ECG:
Sinus tachycardia with atrial premature beats. Low limb lead
voltage.
ST-T wave abnormalities. Consider ischemia. Since the previous
tracing
of ___ the rate is faster, the ventricular premature beat is
new, atrial premature beat is new, limb lead voltage is lower,
ST-T wave abnormalities are new. Consider ischemia. Clinical
correlation is suggested.
___ Chest x-ray:
AP chest compared to ___:
Lung volumes are appreciably lower, and there is considerably
more
consolidation in both lower lobes as well as mediastinal and
pulmonary
vascular congestion and perihilar opacification suggesting
concurrent
pulmonary edema. Small bilateral pleural effusions are
presumed, increased since ___. Heart size is normal. Right
internal jugular line ends in the region of the superior
cavoatrial junction.
___ Cardiac cath:
FINAL DIAGNOSIS:
1. Ostial and complex distal LMCA and severe 3 vessel coronary
artery
disease.
2. Mild systemic arterial hypertension.
3. Moderate left ventricular diastolic heart failure in the
setting of
know left ventricular systolic heart failure (presumed acute).
4. Reinforce secondary preventative measures against CAD, MI, LV
systolic dysfunction, and hypertension.
Brief Hospital Course:
Ms. ___ was admitted to the Acute Care Surgery team and was
taken to the operating room for extended left colectomy with
transverse colostomy. In the OR she received 4.5L crystalloid
and one unit of cryoprecipitate for a fibrinogen in the ___ and
a slow ooze noted intraoperatively. IV Cipro and Flagyl along
with Vancomycin via the stoma were started. Postoperatively she
was hemodynamically stable and was admitted to the TSICU where
she remained intubated. Over the course of the day her ABG
showed a persistent metabolic acidosis which was felt to be
secondary to under resuscitation and she was bolused and her
basal fluid rate was increased to 125/hr to good effect, her
ABGs improved.
She was also seen by Orthopedics for her left wrist fracture
that was sustained during her fall at home which was what
initially brought her into the hospital. This was reduced and
splinted in the ED prior to her trip to the OR. She will follow
up in Orthopedics clinic in a few weeks after discharge.
On HD#3/POD#1, she was extubated. Her mental status was
appropriate, she was stable off pressors and stable from a
respiratory standpoint on room air. She was transferred to the
floor and doing well overall. She was noted to have bowel
function with ostomy output by POD 3. Wound ostomy consultation
was obtained early on and teaching was initiated with patient.
She was noted with sinus tachycardia since her surgery and was
started on low dose beta blockade with some improvement in her
heart rate from the 110's to 80's-90's. Her electrolytes were
followed closely and repleted accordingly.
On ___ (POD#3) overnight into ___ (POD#4), however, she had an
episode of SVT with rates of approximately 150-170, and had
symptomatic palpitations, chest discomfort and shortness of
breath. EKG showed diffuse ST depressions in I/II/AVF/V4-V6 and
1mm elevation in aVR which is all new from baseline. Subsequent
EKGs showed mostly resolution subtle ST depressions in the
anterolateral precordial leads. Afterwards she was noted to have
increasing O2 requirements and CXR on ___ AM was consistent
with pulmonary edema and bilateral pleural effusions. She was
diuresed with 10mg IV lasix x1 with improvement in her shortness
of breath. Labs were notable for a CK of 489 a troponin of 0.28
with BNP ~22,000.
She was started on a heparin drip, aspirin and continued on
metoprolol. She was transferred to the trauma ICU for further
monitoring but remained hemodynamically stable. Cardiology
evaluated and deemed her appropriate for a catheterization. She
was taken to the cath lab on ___. Findings include distal
left main and 3 vessel coronary artery disease. No intervention
was undertaken at that time (see pertinent results section for
details). She was transferred back to the floor from the ICU s/p
catheterization.
At this time, Mrs. ___ continues on her beta blocker and
ASA. Her home ACEI was resumed on ___. She is currently
hemodynamically stable and feeling well. Her pulmonary edema has
resolved and her oxygenation status is stable on room air. She
is tolerating a regular diet and having output via her ostomy.
She has been started on an appetite stimulant and dietary
supplements given decreased PO intake in her initialy
postoperative course. Her foley catheter has been discontinued
and she is voiding adequate amounts of urine without difficulty.
She has been evaluated by Physical and Occupational therapy and
is being recommended for rehab after her acute hospital stay. On
___ she is afebrile, hemodynamically stable and tolerating a
regular diet. She is being discharged with follow up scheduled
with cardiology, ACS and orthopedics.
Medications on Admission:
BENAZEPRIL 20, HYDROCHLOROTHIAZIDE 12.5, LATANOPROST 0.005 %
Drops - 1 gtt ___, PERPHENAZINE-AMITRIPTYLINE 2'',
ROSUVASTATIN 20 ___, CHOLECALCIFEROL 1000
Discharge Medications:
1. Amitriptyline 10 mg PO HS
2. Perphenazine 2 mg PO DAILY
3. Simvastatin 20 mg PO DAILY
4. Metoprolol Tartrate 12.5 mg PO BID
5. Aspirin 325 mg PO DAILY
6. bimatoprost *NF* 0.01 % ___
* Patient Taking Own Meds *
7. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES AM AND
___
8. benazepril *NF* 20 mg Oral daily
hold for sbp<110
9. Megestrol Acetate 400 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Ischemic colitis
s/p fall: Distal left radius fracture
Non ST elevation myocardial infarction
Acute pulmonary edema
Congestive heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with abdominal pain and were
found to have ischemia (decreased blood supply) to your left
colon. You underwent a resection of this part of your colon.
During your operation you also required that a colostomy be
created so that now you have a bag that will collect any stool
that is produced.
The wound ostomy nurse saw you to provide teaching regarding
your new colostomy.
On the fourth day after your surgery, you experienced a heart
attack. You were also found to be in a rapid heart rhythm. As a
result, you were seen by cardiology and had a diagnostic cardiac
catheterization to evaluate the arteries in your heart. As
recommended, you have been started on aspirin, a beta blocker
(blood pressure medication) and continued on your home ACE
inhibitor (previously "Benezapril"). We did not resume your
home hydrochlorothiazide (diuretic). We recommend that this be
followed up by your primary care physician as well as
cardiology.
You were evaluated by the Physical therapy team and being
recommended for rehab after your hospital stay.
Followup Instructions:
___
|
10667959-DS-18
| 10,667,959 | 24,650,880 |
DS
| 18 |
2136-07-16 00:00:00
|
2136-07-16 19:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Hydrochlorothiazide / Lipitor / Ultram
Attending: ___.
Chief Complaint:
left leg pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a ___ with h/o HTN and AAA presents with L hip pain.
Patient reports pain started ___ days ago, improved over the
past day. The morning pf ___ she went shopping and was able to
ambulate with her cane without difficulty. However, during the
evening, she felt a sharp and sudden pain in the left hip and
was unable to ambulate anymore. She noted that the pain was
unrelated to activity during the day and happened while at rest.
Pt notes that she was recently diagnosed with rheumatoid
arthritis, recieved first corticosteroid injection in finger two
weeks ago. Pt also notes idiopathic edema in feet/ankles (unable
to be clarified by pt or family) and had a thorough cardiac
workup. Pt was on Lasix x 4 days which helped the swelling but
was discontinued given elevated BUN/Cr. Pt notes improved
foot/ankle edema following brief Lasix course but notes that
they are still "not back to normal."
In the ED, pt's vitals were 98 86 140/80 16 99% RA. Cr was
elevated at 1.3 (baseline 0.9-1.1, but 1.3 over last month). CRP
1.5; ESR LENIs were unrevealing for DVTs, XR hip showed no
fractures, CT pelvis was ordered. Initial ED plan was for ___
aspiration of joint given concern for septic arthritis.
On transfer to the floors, pt continues to endorse severe left
hip pain with no other symptoms. Pt is lying in bed with pain
controlled on medications.
Past Medical History:
- Hypertension
- Hyperchloseterolemia
- AAA - infra-renal
- GERD
- Left Renal Mass
-> nodular enhancing solid/cystic left renal mass 16x13mm
- Spinal stenosis
-> with symptoms and signs of radicular compression with an MRI
from ___ disclosing severe spinal stenosis at the L4-L5 level,
grade 1 spondylolisthesis of L4 over L5, severe foraminal
stenosis
at L4-L5 and mild-to-moderate stenosis at L3-L4
- degenerative joint disease of ankles and knees secondary to
severe
mechanical alterations w/ Tricompartmental OA of left knee
thyroid nodules
.
Cardiac Risk Factors: (-)Diabetes, (+) Dyslipidemia and
Hypertension
Social History:
___
Family History:
Non contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.6 173/60 58 18 98% r.a.
General- Alert, oriented, no acute distress and very pleasant
HEENT- Sclerae anicteric, MMM, oropharynx clear.
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB
CV- RRR, S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU- No foley
Ext- warm, well perfused, 2+ pulses, feet mildly swollen b/l, no
pitting edema; unable to lift left leg or bend left knee (right
knee flexion/extension full ROM, ___ strength), unable to
dorsiflex left ankle, able to plantarflex left ankle, able to
dorsi and plantarflex right ankle; right angles
Neuro- AAOx3, CNs2-12 intact
DISCHARGE PHYSICAL EXAM:
VS: 97.2 130-140/50-58 ___ 16 98/RA
General- Alert, oriented, no acute distress but tired appearing
HEENT- Sclerae anicteric, MMM, oropharynx clear.
Neck- supple, JVP not elevated, no LAD
Lungs- clear bilaterally
CV- RRR, S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU- No foley
Ext- warm, well perfused, 2+ pulses, feet mildly swollen b/l;
___ strength of the left leg, but able to dorsiflex and
plantarflex. Right lower extremity strength ___.
Neuro- AAOx3, CNs2-12 intact
Pertinent Results:
ADMISSION LABS:
___ 02:37AM BLOOD WBC-7.5 RBC-3.87* Hgb-11.2* Hct-35.2*
MCV-91 MCH-28.9 MCHC-31.7 RDW-14.2 Plt ___
___ 02:37AM BLOOD ___ PTT-30.3 ___
___ 02:37AM BLOOD Glucose-90 UreaN-37* Creat-1.3* Na-144
K-4.4 Cl-109* HCO3-24 AnGap-15
___ 02:37AM BLOOD Calcium-8.9 Phos-3.7 Mg-1.8
___ 02:37AM BLOOD CRP-1.5
___ 02:37AM BLOOD ESR-29*
DISCHARGE LABS:
___ 07:45AM BLOOD WBC-7.1 RBC-3.44* Hgb-9.6* Hct-31.3*
MCV-91 MCH-27.8 MCHC-30.5* RDW-14.2 Plt ___
___ 07:45AM BLOOD Glucose-79 UreaN-27* Creat-1.2* Na-140
K-4.5 Cl-105 HCO3-26 AnGap-14
___ 07:45AM BLOOD Calcium-9.2 Phos-3.7 Mg-1.8
IMAGING:
Pelvis/Hip XR ___:
IMPRESSION:
No radiographic evidence of fracture. If clinical concern
remains for
radiographically occult fracture, a CT or MRI is recommended.
UNILAT LOWER EXT VEINS LEFT ___
IMPRESSION:
The popliteal vein is compressible with transducer pressure, but
due to
limited patient mobility, augmentation and color flow could not
be assessed. Within these limitations, there is no evidence of
deep venous thrombosis in the left lower extremity veins.
CT PELVIS ORTHO ___ C ___
IMPRESSION:
1. No evidence of fracture or dislocation.
2. Slight asymmetric enlargement of the left iliopsoas and
iliacus muscles compared to the right could be due to muscle
strain, but clinical correlation for underlying coagulopathy or
signs of inflammation or infection is
recommended.
3. Mild bilateral femoroacetabular and sacroiliac joint
degenerative changes, as described above.
4. Severe lumbosacral spine degenerative changes.
5. Stable infrarenal abdominal aortic aneurysm.
6. Fibroid uterus.
7. Atherosclerotic vascular disease.
MR ___ SPINE ___ CONTRAST ___
IMPRESSION:
1. There is abnormal enlargement/ swelling of the left
iliopsoas muscle with T2/STIR hyperintense, concerning for
hematoma, although
infectious/inflammatory process is not entirely excluded. In
addition, there is STIR hyperintense signal at the L1-2 disc
space, which may be degenerative in nature however given the
adjacent signal abnormality of the iliopsoas muscle, early
infection is a differential consideration in the appropriate
clinical context.
2. Multilevel moderate to severe degenerative changes as
described above.
MR HIP ___ CONRAST LEFT ___
(prelim)
IMPRESSION:
1. Diffuse iliacus and psoas muscle asymmetry and
hyperintensity on T2 weighted imaging suggestive of edema; a
focal area of inhomogenous signal is seen within the edematous
muscle statistically is most likely an hematoma in but infection
and focal mass are possibilities in the correct clinical
scenario. CT or MR ___ could be given to differentiate a
fluid-filled mass from a tumor.
MR HIP ___ CONTRAST LEFT ___
FINDINGS:
Again noted is enlargement of the left psoas and iliacus muscle
from the
lumbar region to their insertion at the lesser trochanter with
associated
heterogenous T2 hyperintensity. There are faint areas of T1
hyperintensity within the muscles suggesting the presence of
blood products. On post-contrast images there are small areas of
hypo intensity with surrounding rim of enhancement. This is
best seen in the psoas muscle measuring 12.2 mm x 31.6 mm X 40.8
mm, and in the iliacus muscle measuring 21.3 x 43.4 mm X 35.1
mm. The marrow signal is preserved. Uterine fibroids and
degenerative changes of the lumbar spine are again present.
Foley catheter is seen.
IMPRESSION:
The left psoas and iliacus muscles are enlarged and have
heterogenous
hyperintensity on T2 imaging with faint areas of hemorrhage.
There are also 2 small areas of rim enhancement. Findings are
most compatible with evolving hematomas. Superinfection is
possible but felt less likely due to the report clinical history
of no fever and ESR. If pain continues, followup imaging to
resolution is recommended.
2. No fracture is seen
Brief Hospital Course:
PRIMARY REASON FOR ADMISSION:
This is a ___ with h/o HTN, AAA and newly diagnosed RA (with
recent steroid injection to her finger) who presents with L hip
and leg pain.
ACTIVE ISSUES
#Left Hip and Leg Pain: The patient presented with severe left
hip and leg pain. Initial imaging in the ED was non-diagnostic
so she was admitted to the medicine service to rule out septic
joint. Given her lack of fever, leukocytosis, normal CRP and
only mildly elevated ESR, the likelihood of septic joint was
felt to be low. CT imaging showed a slight asymmetric
enlargement of the left iliopsoas and iliacus muscles compared
to the right and did not reveal any drainable fluid collecton.
Given that her pain continued despite medication, an MRI without
contrast was performed. This similarly showed iliacus and psoas
asymmetry and hyperintensity but also showed a focal area of
inhomogenous signal that could not be characterized without
contrast. She then underwent MRI with contrast that showed two
small areas of rim enhancement that were most consistent with an
evolving hematoma. Her pain was managed with standing tylenol,
lidocaine patches and low-dose oxycodone and baclofen as needed.
Her medications should be titrated while she is at rehab. If she
continues to have pain despite medications and physical therapy,
she should have repeat imaging to confirm resolution of
hematoma.
# Hypertension: She had blood pressures to the 170s on
admission, with pain a likely contributor. Her home amlodipine
10mg was restarted with improvement in blood pressure to the
130s systolic. Her lisinopril was discontinued and could be
restarted per her outpatient providers.
# GERD: Pt has known h/o GERD and she was continued on her home
omeprazole.
TRANSITIONAL ISSUES
- Please titrate pain medications as necessary (discharged on
lidocaine patch, standing tylenol, oxycodone 2.5mg q4h prn pain
and baclofen 5mg TID x 3days. Please make sure to continue bowel
regimen while on pain medications
- If she continues to have pain without improvement would
recommend followup imaging to confirm resolution of hematoma
- Her lisinopril was discontinued on admission. If she becomes
hypertensive, would consider restarting or starting HCTZ along
with her amlodipine
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. Docusate Sodium 100 mg PO DAILY
4. Amlodipine 10 mg PO DAILY
5. Pravastatin 20 mg PO DAILY
6. Omeprazole 20 mg PO BID
7. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID PRN
vaginal itch
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Omeprazole 20 mg PO BID
5. Pravastatin 20 mg PO DAILY
6. Acetaminophen 1000 mg PO TID
7. Baclofen 5 mg PO TID
RX *baclofen 10 mg 0.5 (One half) tablet(s) by mouth three times
a day Disp #*15 Tablet Refills:*0
8. Lidocaine 5% Patch 1 PTCH TD QAM hip pain
RX *lidocaine 5 % (700 mg/patch) apply to affected area qam Disp
#*3 Patch Refills:*0
9. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every four
(4) hours Disp #*15 Tablet Refills:*0
10. Polyethylene Glycol 17 g PO DAILY
11. Senna 8.6 mg PO HS
12. Bisacodyl 10 mg PR HS:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis
left psoas and iliacus muscles sprain and hematoma
Secondary diagnoses:
Hypertension
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted on ___ with left sided leg pain. You had
xrays, CT Scan, and MRIs of your leg that showed a lot of
swelling with some bleeding but no signs of infection or tumor.
This should hopefully with time and pain control.
You will need to continue working with physical therapy to get
your strength back!
We wish you the best,
- Your ___ team -
Followup Instructions:
___
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2171-10-15 14:16:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Difficulty speaking
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ with a history of HTN, hypercholesterolemia,
smoking, and heavy EtOH who presents with aphasia and right
sided
weakness.
According to his wife, the patient was diagnosed with
pericarditis after having chest pain last weekend and was put on
a "mpack". This morning he seemed well, was working on his car
and power-washing it when he injured his right finger (with the
power washer). He appeared pale and said he felt dizzy, which is
typical when he hurts himself. He went to an urgent care at
11:45
where they diagnosed him with air in his finger and "they
squeezed the air out" and gave him some antibiotics. On his way
home he rear-ended another car. There was no damage to either
car
and he was wearing his seatbelt. When his wife asked what
happened he didn't have a good explanation but said he bumped
his
head on the roof of the car (got a bump on the left side of his
head). His wife said he went to the fridge but got nothing out,
then went to the garage. About 10 minutes later (now 1:45) he
walked back in with his shirt off, chest covered in dirt and a
larger abrasion on the right side of his head. When his wife
asked what happened his speech was incomprehensible with made up
words. There was no noticable weakness at that time. They called
___. While at ___ he developed right hemiparesis (unclear time).
At ___ he was seen by neurology at 15:11 and was felt not to be
a
___ candidate because of the hematoma and ?air embolis from the
power washer. When his wife saw him at ___ some words were
right,
some were made up. He knew her but couldn't say her name. He was
___ to ___ for further care.
___ Stroke Scale score was : 9
1a. Level of Consciousness: 0
1b. LOC Question: 2
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 1
5a. Motor arm, left: 0
5b. Motor arm, right: 1
6a. Motor leg, left: 0
6b. Motor leg, right: 1
7. Limb Ataxia: 1
8. Sensory: 1
9. Language: 2
10. Dysarthria: 0
11. Extinction and Neglect: 0
CT already completed at OSH and reviewed on arrival
Past Medical History:
HTN
Hyperlipidemia
Pericarditis diagnosed last week
Heavy ETOH
Social History:
___
Family History:
Brother with brain aneurysm, mother with diabetes
Physical Exam:
Physical Exam:
General: Awake, cooperative, NAD.
HEENT: Small hematoma on the left forehead, abrasion on the
right forehead
Neck: Supple, no nuchal rigidity
Pulmonary: Breathing comfortably
Cardiac: Normal rate, regular rhythm
Abdomen: Soft, NT/ND
Extremities: WWP
Skin: No rash
Neurologic:
-Mental Status: Alert, attentive to exam. Language is fluent
with
majority of speech sensical but with some neologisms. Can follow
verbal commands with some difficulty with complex commands. Able
to repeat simple words but has difficulty with complex words or
multi-word phrases.
-Cranial Nerves:
II: PERRL 3 to 2mm and brisk. Blinks to threat bilaterally.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: Right lower facial droop, mild
VIII: Hearing intact to voice
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline with normal strength
-Motor: Full strength throughout
-Gait: Able to ambulate without difficulty
Pertinent Results:
**********
Laboratory Data:
WBC 11.2 PLT 393
Hct 41.3
Na:143
K:4.2
Cl:106 Glu:91
freeCa:1.14
Lactate:0.9
Cr 0.6
Trop neg
Serum tox neg
EKG: NSR, no ST changes
Non-Contrast CT of Head: Chronic small vessel disease
CTA head and neck: extensive calcification of carotids with what
appears to be soft plaque. Completely occluded right vertebral.
CT C-spine cleared at ___
___ Head MRI
IMPRESSION:
1. Multiple foci of slow diffusion throughout the cerebral
hemispheres common with the largest region involving the left
temporal parietal lobe. These areas demonstrate subtle FLAIR
hyperintensity but no evidence of hemorrhage. Findings are
consistent with acute to early subacute infarction without
evidence of hemorrhagic conversion. There is no significant mass
effect or midline shift. Multiplicity of foci is concerning for
embolic in etiology.
2. Foci of FLAIR hyperintensity within the white matter are
likely sequela of mild to moderate chronic microvascular
ischemic disease.
3. Mild mucosal thickening of the maxillary sinuses with an
air-fluid level in left maxillary sinus.
___ TRANSTHORACIC ECHOCARDIOGRAM
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. No valvular pathology or pathologic flow
identified. No definite structural cardiac source of embolism
identified.
___ TRANSESOPHAGEAL ECHOCARDIOGRAM
IMPRESSION: No intracardiac thrombus. Normal biventricular
cavity size and systolic function. No significant valvular
pathology.
___ CT ABDOMEN/PELVIS Preliminary:
IMPRESSION: 1. Simple left renal cyst. 2. Moderate infrarenal
abdominal aorta atherosclerotic disease with minimal ectasia up
to 2.7 cm at the level of the inferior mesenteric artery. 3. No
suspicious osseous lytic or blastic lesions. Moderate
degenerative changes within the lumbar spine with
anterolisthesis of L5 on S1.
___ CT CHEST:
Official read pending, discussed verbally with ___ prior
to discharge and no evidence of malignancy
Brief Hospital Course:
Mr. ___ was admitted to the ___
___ on ___ after presenting with new-onset speech
difficulty and right-sided weakness concerning for stroke. MRI
showed evidence of multiple ischemic strokes bilaterally,
consistent with an embolic etiology. TTE was suboptimal but did
not identify a cardioembolic source for Mr ___ infarcts.
TEE was also negative for a cardioembolic source. Given a 30+
pack year smoking history, a ___ pound weight loss over the
past year, and no clear source for Mr. ___ infarcts we
performed at CT of the chest, abdomen, and pelvis that was
notable for some lymphadenopathy in the chest but no evidence of
malignancy. There was no evidence of atrial fibrillation on
telemetry monitoring. The etiology of Mr ___ stroke was
unclear at the time of discharge with the differential including
paroxysmal atrial fibrillation, PFO or malignancy. He was
started on full dose aspirin and continued on his statin. His
symptoms improved but did not completely resolve while he was in
the hospital. He continues to have a mixed aphasia. He is able
to follow simple commands and speak in simple words and phrases
but continues to have difficulty with complex commands and
complex words and phrases. He will be transferred to a rehab
center. He will have further diagnostic evaluation as an
outpatient to look for the source of his infarcts, including an
FDG-PET of the entire body, a 30-day Reveal monitor to look for
atrial fibrillation and a hypercoaguable work-up. He will also
be discharged on ___ Hearts monitor.
Medications on Admission:
Crestor unknown dose
Lisinopril 40mg
Aspirin 81mg
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Rosuvastatin Calcium 40 mg PO DAILY
3. Nicotine Patch 14 mg TD DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Multifocal ischemic stroke
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ on ___ with new-onset speech difficulty and right-sided weakness
concerning for stroke. MRI showed evidence of multiple strokes
on both sides of your brain, most likely due to a blood clot
that traveled from somewhere else in your body. We performed a
screening ultrasound of your heart which was normal. A more
detailed ultrasound of your heart was then performed which was
also normal. A CT of your torso to look for cancer as a possible
source of clot was also normal. You were treated with aspirin,
and your symptoms improved while you were in the hospital. You
will be transferred to a rehab center. Please follow up with the
appointments listed below.
You were hospitalized due to symptoms of confused speech and
right sided weakness resulting from an ACUTE ISCHEMIC STROKE, a
condition where a blood vessel providing oxygen and nutrients to
the brain is blocked by a clot. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are: High cholesterol (LDL of 158)
We are changing your medications as follows:
-Increasing aspirin to 325mg daily
-Adding ATORVASTATIN 40mg daily for high cholesterol
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization.
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
worsened language and behavioral changes
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ right handed man with a past
medical history of cryptogenic stroke with residual mixed
aphasia, hypertension and hyperlipidemia who presents with
behavioral changes, worsened language and abulia.
History is gathered from his wife and family who are at bedside.
Mr. ___ was recently hospitalized at ___ from ___ in
the setting of LLE pyoderma gangranosum with superimposed
cellulitis. He underwent extensive evaluation including biopsy
before eventually being discharged on Dapsone and prednisone.
He was at home and doing well until roughly ___, when his
family noticed behavioral changes. Normally he is active,
conversant and ambulatory. He has a residual mixed aphasia,
with
some trouble participating in coversations, but otherwise does
okay. On ___ he was not himself. He was less responsive to
his family and did not go about his day as normal. He produced
minimal language and made more mistakes than normal. Despite
frequent reminders he did not do basic daily tasks. When told
to
go pick his son up, he got in the car, but just sat there
looking
around. He would respond to questions with "okay" before just
standing around. There were no other clearly associated
symptoms
with this.
The next day, this seemed to improve somewhat. However today,
there was again clear behavioral and language alteration. He
just sat on the couch staring forward. When sitting in bed and
attempting to use a urinal, he just repetitively covered and
uncovered himself with the blankets. His wife feels he would
have urinated on himself if she did not hand him the urinal.
When she asked him to do his ABCs, he started with A-B-C- then
trailed off into gibberish (normally he would do these without
problem). At times, he would not respond entirely to his wife.
Due to these changes, he was taken to an OSH ED. There, he had
a
___ noting his prior infarct as well as a possible left
lacunar
infarction. He was subsequently transferred for further
evaluation.
Excluding the above changes, he is otherwise reportedly well and
asymptomatic. No other features suggestive of stroke (numbness,
weakness, etc). There is no history otherwise suggestive of
seizure.
Past Medical History:
HTN
Hyperlipidemia
Pericarditis (___)
Stroke (___)
Heavy ETOH
Pace maker placement
Social History:
___
Family History:
Brother with brain aneurysm, mother with diabetes.
Physical Exam:
Physical Exam:
Vitals: 98.5 66 137/79 16 97% RA
General: Awake, sitting apathetically, NAD.
HEENT: NC/AT, MMM, no lesions noted in oropharynx
Neck: Supple. No nuchal rigidity
Pulmonary: Lungs CTA
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND.
Extremities: WWP. There is a dressed wound on the anterior shin
of his left leg.
Neurologic:
-Mental Status: Alert, oriented x 3. Abulic. Relates none of
his
own history, and sits looking straight ahead when not addressed.
Able to ___ backwards with 1 error, cannot do ___. Language
is
spares and assessment of fluency is limited. He is able to
repeat simple phrases (Happy Birthday), but not more complex
ones
"No ifs, ands or buts" or "I just got to the hospital"). There
were rare paraphasic errors noted. Pt was able to name both high
and low frequency objects. Speech was hypophonic, but not
dysarthric. Able to follow both midline and appendicular
commands. 1 and 2 steps commands are done well, unable to
complete 3 step commands. Pt was able to register 3 objects and
recall ___ at 5 minutes. There was no evidence of apraxia or
neglect. He is able to do luria sequence well. Able to do
simple calculations, but not more complex ones. No Right left
confusion
-Cranial Nerves:
II, III, IV, VI: LEft pupil 0.5mm larger than left, both
briskly
reactive. EOMI without nystagmus. Normal saccades. VFF to
confrontation. V: Facial sensation intact to light touch.
VII: Subtle Right NLFF.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulkthroughout. Fingers on right subtly curl on
PD
assessment.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2+ 1
Plantar response was upgoing vs withdrawal bilaterally
No Grasp
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: deferred
________________________________________
Discharge Exam:
MS: Alert, oriented x 3. responsive, cooperative, responds to
commands. ___ backwards with 2 errors, high frequency naming
intact, low frequency not intact. able to repeat short phrases
but not a sentence, able to follow three step commands.
CN: EOM full, face symmetric, tongue midline
Motor: ___ strength b/l UE and ___
No palmar grasp, jaw jerk, palmomental or snout
No pronator drift, decreased sensation to light touch on LLE,
increased sensation to pinprick on RUE
Pertinent Results:
___ 09:40PM URINE HOURS-RANDOM
___ 09:40PM URINE HOURS-RANDOM
___ 09:40PM URINE HOURS-RANDOM
___ 09:40PM URINE UHOLD-HOLD
___ 09:40PM URINE GR HOLD-HOLD
___ 09:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 06:12PM WBC-9.7 RBC-4.10* HGB-11.9* HCT-37.9* MCV-92
MCH-29.0 MCHC-31.4* RDW-16.2* RDWSD-55.3*
___ 06:12PM NEUTS-84.7* LYMPHS-12.1* MONOS-2.1* EOS-0.4*
BASOS-0.5 IM ___ AbsNeut-8.18* AbsLymp-1.17* AbsMono-0.20
AbsEos-0.04 AbsBaso-0.05
___ 06:12PM PLT COUNT-351#
___ 04:46PM LACTATE-1.6 K+-4.8
___ 04:35PM GLUCOSE-110* UREA N-14 CREAT-0.6 SODIUM-134
POTASSIUM-7.1* CHLORIDE-98 TOTAL CO2-24 ANION GAP-19
___ 04:35PM estGFR-Using this
___ 04:35PM ALT(SGPT)-40 AST(SGOT)-54* ALK PHOS-31* TOT
BILI-0.4 DIR BILI-<0.2 INDIR BIL-0.4
___ 04:35PM cTropnT-<0.01
___ 04:35PM CALCIUM-9.1 PHOSPHATE-3.5 MAGNESIUM-2.3
___ 04:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 04:35PM ___ PTT-25.9 ___
___ 05:08AM BLOOD WBC-10.7* RBC-3.62* Hgb-10.6* Hct-33.5*
MCV-93 MCH-29.3 MCHC-31.6* RDW-15.7* RDWSD-53.3* Plt ___
___ 05:08AM BLOOD Glucose-83 UreaN-21* Creat-0.7 Na-139
K-4.5 Cl-100 HCO3-28 AnGap-16
___ 05:08AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.2
Brief Hospital Course:
Mr. ___ is a ___ right handed man with a past
medical history of cryptogenic stroke with residual mixed
aphasia, hypertension, hyperlipidemia, pyoderma gangrenosum on
dapsone and prednisone, and left superficial femoral artery
stenosis on plavix who presented with reported behavioral
changes described as intermittent abulia. ___ reconfirms old
infarct as well as a possible interval chronic thalamic lacunar
infarction, but no signs of new infarct to cause these new
symptoms. Due to his pacemaker we were unable to complete a MRI
to confirm the lack of a new infarct. But given the number of
his episodes over several days and the lack of new stroke on CT
brain, it is very unlikely that he had a new stroke. EEG was
done and captured one of these events and showed that there was
no seizure activity.
He admitted to feeling depressed sometimes but it was unclear
for
how long this has been occurring. He was frustrated that he
could not return to work. It is possible that his low energy and
abulia are due to depression. Sertraline was started for
presumed depression. Mr. ___ need outpatient follow-up
by his PCP for titration to effect. He was also seen by
dermatology consult for his chronic left lower leg wound. Of
note, his Plavix was discontinued since he had completed his one
month course post op.
Although Dermatology has not left formal recommendations in the
chart, patient and his wife verbalize understanding that it is
their responsibility to call his PCP and ___ in the
morning to follow up on their recommendations. They agree to
this and are requesting discharge home since he is medically
cleared from a neurology perspective.
________________________
Transitional Issues:
- Titration of Sertaline for effect. Started at 25mg daily on
___.
- Follow up with Dermatology for left lower extremity wound
- Discontinued Plavix as per Vascular's recommendations.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Calcium Carbonate 1000 mg PO DAILY
3. Dapsone 100 mg PO DAILY
4. PredniSONE 30 mg PO DAILY
5. Ranitidine 75 mg PO BID
6. Vitamin D 800 UNIT PO DAILY
7. Aspirin 325 mg PO DAILY
8. Rosuvastatin Calcium 40 mg PO QPM
9. Desonide 0.05% Cream 1 Appl TP DAILY
10. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
Discharge Medications:
1. Sertraline 25 mg PO DAILY
RX *sertraline 25 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Aspirin 325 mg PO DAILY
3. Calcium Carbonate 1000 mg PO DAILY
4. Dapsone 100 mg PO DAILY
5. Desonide 0.05% Cream 1 Appl TP DAILY
6. Lisinopril 40 mg PO DAILY
7. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
8. PredniSONE 30 mg PO DAILY
9. Ranitidine 75 mg PO BID
10. Rosuvastatin Calcium 40 mg PO QPM
11. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
encephalopathy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital after acting differently at
home. We monitored you in the hospital. We do not think you had
a new stroke. We obtained an EEG (brain wave study) which
captured one of these episodes and the EEG showed that these are
not caused by seizures. It is possible that depression may be
contributing so we started you on sertraline. Please follow up
with your outpatient doctors to ___ if any further workup needs
to be done and to assess whether or not you see improvement with
the sertraline.
Followup Instructions:
___
|
10668217-DS-21
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DS
| 21 |
2168-02-25 00:00:00
|
2168-02-26 11:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / Nickel
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ year old female with a PMH notable for HTN, DMII,
hyperlipidemia, history of nephrolithiasis, s/p MVA with L2
fracture in ___, who presents with chest pain.
.
Patient reports that on the morning of admission, she developed
a ___ substernal chest pressure without radiation while getting
dressed. Her pain seems to be brought on by exertion and
relieved by rest, though she notes that palpation of her chest
wall reproduced her discomfort. Her chest pain was also
associated with mild dyspnea with exertion. She notes that at
baseline she is without any physical limitations. She denies
fevers, chills, abdominal pain, nausea, vomiting, diaphoresis,
palpitations, orthopnea, PN, heartburn, metallic taste in her
mouth. She took rolaids with minimal benefit. No sick contacts.
Of note, patient reports that she had a similar presentation in
___ for 2 days and underwent stress MIBI at ___ which was
unremarkable for ischemia.
.
She was evaluated at ___ earlier this afternoon and ECG was
reportedly with concern for atrial fibrillation (per report,
unable to view in atrius records). Patient was given aspirin
324mg PO X 1 and sent to ___ ED for further evaluation.
.
In the ED, initial vitals were 97.6, P: 76, BP: 134/94, RR: 20,
O2sat: 99% 2L NC. Labs significant for troponin T < 0.01 X 2,
d-dimer <150, unremarkable urine analysis. Chest radiograph with
no acute process. ECG with normal sinus rhythm and without acute
ischemic changes. Patient was given nitroglycerin 0.4mg SL X 1
without relief, morphine 5mg IV X 1 and 2mg IV X 1. Patient was
initially admitted to ED observation unit but due to
intermittent recurrent chest discomfort and discussion with
on-call ___ cardiology attending, patient was admitted for
further monitoring and workup.
.
On arrival to the floor, patient reports that her pain is only
present with touching her chest. She is walking about the room
without difficulty.
Past Medical History:
1. CARDIAC RISK FACTORS: (+)Diabetes II, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
-CABG: None.
-PERCUTANEOUS CORONARY INTERVENTIONS: None.
-PACING/ICD: None.
3. OTHER PAST MEDICAL HISTORY:
- History of nephrolithiasis
- History of L2 fracture s/p MVA (___) and TLSO
- Asthma
- History of colonic adenoma
- Glaucoma and cataracts
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Father: ___, hypertension. Mother: ___
Cancer, breast Cancer, colon Cancer, diabetes..
Physical Exam:
Admission exam
VS: T: 98.5, BP: 171/93, P: 74, RR: 17, O2sat: 98%RA.
GENERAL: NAD. Morbidly obese. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple. Difficult to appreciate JVD in the setting of
large body habitus.
CARDIAC: Distant heart sounds ___ body habitus, RRR, normal S1,
S2. No m/r/g. No thrills, lifts. No S3 or S4. Pain with
palpation of sternal chest wall. No hematoma or bruising noted.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 1+ pitting edema bilaterally
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Discharge exam
VS: T: 98.2, BP: 146/78, P: 68, RR: 18, O2sat: 99%RA.
GENERAL: NAD. Morbidly obese. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple. Difficult to appreciate JVD in the setting of
large body habitus.
CARDIAC: Distant heart sounds ___ body habitus, RRR, normal S1,
S2. No m/r/g. No thrills, lifts. No S3 or S4. Pain with
palpation of sternal chest wall. No hematoma or bruising noted.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: trace pitting edema bilaterally
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
Admission labs
___ 12:31PM BLOOD WBC-7.3 RBC-4.43 Hgb-12.9 Hct-36.0
MCV-81* MCH-29.1 MCHC-35.8* RDW-12.7 Plt ___
___ 12:31PM BLOOD Glucose-132* UreaN-15 Creat-0.7 Na-141
K-4.4 Cl-102 HCO3-28 AnGap-15
___ 12:31PM BLOOD Calcium-10.1 Phos-4.2 Mg-1.7
Cardiac labs
___ 12:31PM BLOOD cTropnT-<0.01
___ 06:30PM BLOOD cTropnT-<0.01
___ 09:20AM BLOOD CK-MB-2 cTropnT-<0.01
___ 12:31PM BLOOD D-Dimer-<150
Discharge labs
___ 09:20AM BLOOD WBC-7.2 RBC-4.51 Hgb-12.9 Hct-36.7
MCV-81* MCH-28.5 MCHC-35.0 RDW-13.1 Plt ___
___ 09:20AM BLOOD Glucose-146* UreaN-15 Creat-0.7 Na-139
K-4.0 Cl-99 HCO3-29 AnGap-15
___ 09:20AM BLOOD Calcium-9.5 Phos-4.7* Mg-1.7
Studies
Exercise Tc-99m Stress/Rest SPECT from ___
___ on ___ (included for sake of completeness)
HR max 136, 85% age predicted. ___ METS max. Stopped due to
fatigue. RPP ___. No ischemic ECG changes. Image quality
excfellent. Normal LV/RV size and normal tracer uptake. No
regional perfusion defects on stress or rest images. No
Stress Echo ___: EKG: SINUS
HEART RATE: 61 BLOOD PRESSURE: 170/90
PROTOCOL MODIFIED ___ - TREADMILL
STAGE TIME SPEED ELEVATION HEART BLOOD RPP
(MIN) (MPH) (%) RATE PRESSURE
0 ___ 1.0 8 94 174/90 ___
1 ___ 1.7 10 107 182/94 ___ 2.5 12 114 192/94 ___
TOTAL EXERCISE TIME: 7.25 % MAX HRT RATE ACHIEVED: 71
SYMPTOMS: ATYPICAL PEAK INTENSITY: ___
ST DEPRESSION: NONE
INTERPRETATION: This ___ year old IDDM woman was referred to the
lab
from the ER following negative serial cardiac markers for
evaluation of
atypical chest discomfort; following a negative ETT-MIBI at ___
in ___. The patient exercised for 7.25 minutes of a modified ___
protocol and stopped for fatigue. The estimated peak MET
capacity was
5.2 which represents a fair functional capacity for her age. No
arm,
neck, back or chest discomfort was reported by the patient
throughout
exercise. In early recovery, she noted a ___ chest discomfort
similar
to what she has felt in the past which can take hours to
resolve. The
discomfort during this test resolved by minute 10 of recovery.
There
were no significant ST segment changes during exercise or in
recovery.
The rhythm was sinus with rare isolated vpbs. Resting
hypertension with
a blunted hemodynamic response to exercise on beta blocker
therapy.
IMPRESSION: Atypical symptoms in the absence of ischemic EKG
changes at
a high cardiac demand and fair functional capacity. Resting
hypertension
with blunted hemodynamic response. Echo report sent separately.
The patient exercised for 7 minutes and 10 seconds according to
a Modified ___ treadmill protocol ___ METS) reaching a peak
heart rate of 114 bpm and a peak blood pressure of 192/94 mmHg.
The test was stopped because of fatigue. This level of exercise
represents a fair exercise tolerance for age. In response to
stress, the ECG showed no ST-T wave changes (see exercise report
for details). There is resting systolic and diastolic
hypertension. The blood pressure response to stress was blunted.
There was a blunted heart rate response to exercise.
Resting images were acquired at a heart rate of 61 bpm and a
blood pressure of 170/90 mmHg. These demonstrated normal
regional and global left ventricular systolic function. Right
ventricular free wall motion is normal. There is no pericardial
effusion. Doppler demonstrated mild mitral regurgitation with no
aortic stenosis, aortic regurgitation or significant resting
LVOT gradient.
Echo images were acquired within 57 seconds after peak stress at
heart rates of 121-100bpm. These demonstrated appropriate
augmentation of all left ventricular segments. There was
augmentation of right ventricular free wall motion.
IMPRESSION: Fair functional exercise capacity. No ECG or 2D
echocardiographic evidence of inducible ischemia to achieved
workload. Resting hypertension. Abnormal hemodynamic response to
physiologic stress. Mild mitral regurgitation at rest.
Brief Hospital Course:
___ year old female with a PMH notable for HTN, DMII,
hyperlipidemia, history of nephrolithiasis, s/p MVA with L2
fracture in ___, who presents with chest pain.
.
# Chest Pain: Presents with sudden onset chest pain day prior to
admission. Was initially getting ruled out in ED, but due to
persistent pain was admitted. Clinical presentation seemed less
consistent with an acute cardiac process given reproduction with
palpation. Cardiac enzymes negative x3, ECG without acute
ischemic changes, unremarkable stress MIBI at ___ 2 months prior
with similar presentation, and chest radiograph without acute
process. D-dimer < 150 makes PE very unlikely. She had a stress
echo done, and although only got to 75% max HR, it showed no
evidence of ischemia. Her symptoms resolved with
maalox/lidocaine solution. Her CP appears to be more
musculoskeletal or GI in etiology, and unlikely to be cardiac.
However, with her significant cardiac risk factors, she was
started on aspirin 81mg daily for primary prevention of CVD, as
well as omeprazole. Further MSK/GI work-up per PCP.
.
# Diabetes Type II: continued home lantus, and sliding scale.
She takes metformin at home.
.
# Dyslipidemia: Continued home simvastatin.
.
# Hypertension: Continued home atenolol, irbesartan, amlodipine,
and lasix.
.
# History of L2 fracture s/p MVA (___) and TLSO: Stable.
.
# Asthma: Cont home albuterol inhaler.
==========================
TRANSITIONAL ISSUES
# Further ___ chest pain per PCP
___ on ___:
- lantus 36 units SC daily
- atenolol 100mg in AM, 50mg in ___
- metformin 1000mg PO BID
- simvastatin 10mg PO daily
- irbesartan 300mg PO daily
- amlodipine 5mg PO daily
- vitamin D 1000 units PO daily
- albuterol inhaler PRN
Discharge Medications:
1. Lantus 100 unit/mL Solution Sig: 36 units . Subcutaneous once
a day.
2. atenolol 50 mg Tablet Sig: Two (2) Tablet PO QAM (once a day
(in the morning)).
3. atenolol 50 mg Tablet Sig: One (1) Tablet PO Q7PM ().
4. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
5. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. irbesartan 300 mg Tablet Sig: One (1) Tablet PO Daily ().
7. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
One (1) Puff Inhalation Q6H (every 6 hours) as needed for
wheezing.
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*5*
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: atypical chest pain
Secondary: hypertension, high cholesterol, diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
It was a pleasure taking care of you at ___. You were admitted
for chest pain. This was found to not be from your heart. You
had a stress test that showed normal heart function. It is
likely from a musculoskeletal or gastrointestinal cause. You
should seek further management of this pain with your Primary
Care Physician.
The following changes were made to your medications:
* START omeprazole (anti-acid)
* START aspirin 81mg daily (baby-aspirin) for heart health
Followup Instructions:
___
|
10668217-DS-24
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| 24 |
2171-11-21 00:00:00
|
2171-11-21 20:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
lisinopril / Nickel / Ragweed / pollen / wool
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
ERCP
laparoscopic cholecystectomy
History of Present Illness:
___ F presents for evaluation of several days of abdominal
pain. Pt states that pain began on ___, describes as tight
pain across upper part of abdomen, could not identify any
particular trigger, associated with chills and subjective
fevers.
Discomfort was somewhat relieved by rest, however when symptoms
did not resolve she presented to ___ ED on ___, had
workup for chest and abdominal pain which was negative, CT A/P
showed cholecystitis and stable CBD dilatation, CXR WNL, very
mildly elevated LFTS, normal T bili, WBC wnl. Was discharged
after receiving acetaminophen and IV hydration. Pt pain improved
in subsequent days but continued to experience intermittent
subjective fevers and chills until today, when, after eating a
meal (fried plantains and okra), she noticed a return of her
upper abdominal discomfort. Experienced concomitant nausea with
small emesis, also noted to have some dark urine throughout the
day. Pt now presents for further evaluation and workup of her
pain.
Past Medical History:
Her medical history is significant for:
1) hypertension
2) type 2 diabetes with hemoglobin A1c of 7.3% on ___
3) hyperlipidemia
4) asthma on inhalers with no recent flares, no prednisone
taper
5) history of kidney stones
6) chronic low back pain on NSAIDs
7) cholelithiasis by ultrasound study
8) hepatic steatosis by ultrasound study
9) allergic rhinitis
10) colonic adenoma
11) hemorrhoids
12) nephrolithiasis
13) glaucoma
14) amblyopia
15) chondromalacia patellae
16) history of hematuria
17) mal de debarquement (dizziness, motion sickness)
18) history of heart murmur
Her surgical history is noted for:
1) lithotripsy in ___ with stent placement in ___
2) right SLAP tear ___
3) hysterectomy in ___
4) s/p C-section
Social History:
___
Family History:
Father: ___, hypertension.
Mother: ___ cancer, breast cancer, colon cancer, diabetes.
Physical Exam:
Vitals: VSS
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: Clear to auscultation b/l, no respiratory distress
ABD: Soft, nondistended, tender to palpation in right upper
quadrant, well healed scars s/p gastric bypass, no palpable
masses. Incision site is c/d/I, steri strips intact
Ext: no CCE
Neuro: grossly intact
Pertinent Results:
___ 09:11PM BLOOD WBC-7.7 RBC-4.42 Hgb-12.9 Hct-38.0 MCV-86
MCH-29.2 MCHC-33.9 RDW-12.5 RDWSD-38.6 Plt ___
___ 09:11PM BLOOD Neuts-80.6* Lymphs-15.8* Monos-2.6*
Eos-0.3* Baso-0.3 Im ___ AbsNeut-6.23* AbsLymp-1.22
AbsMono-0.20 AbsEos-0.02* AbsBaso-0.02
___ 09:11PM BLOOD Plt ___
___ 09:11PM BLOOD Glucose-148* UreaN-11 Creat-0.9 Na-139
K-3.1* Cl-99 HCO3-28 AnGap-15
___ 09:11PM BLOOD Lipase-56
___ 09:11PM BLOOD ALT-997* AST-444* AlkPhos-310*
TotBili-3.6*
___ 09:11PM BLOOD Albumin-4.4 Calcium-10.6* Phos-2.9 Mg-1.7
___ 04:43AM BLOOD WBC-6.4 RBC-3.90 Hgb-11.1* Hct-33.9*
MCV-87 MCH-28.5 MCHC-32.7 RDW-12.7 RDWSD-39.9 Plt ___
___ 04:43AM BLOOD Plt ___
___ 04:43AM BLOOD Glucose-95 UreaN-15 Creat-0.8 Na-140
K-3.8 Cl-103 HCO3-28 AnGap-13
___ 04:43AM BLOOD ALT-1030* AST-410* AlkPhos-254*
TotBili-1.8*
___ 04:43AM BLOOD Calcium-9.2 Phos-4.2 Mg-1.9
Brief Hospital Course:
The patient presented to the ED for several days of abdominal
pain. The ___ was seen in the ED and then transferred to the ward
for observation. During her time inhouse the decision was made
to undergo a Lap Chole. The patient was taken to the operating
room for a laparoscopic chole for gallstones. There were no
adverse events in the operating room; please see the operative
note for details. Pt was extubated, taken to the PACU until
stable, then transferred to the ward for observation.
Neuro: The patient was alert and oriented throughout
hospitalization Pain was very well controlled.
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 then the patient
was then advanced to a regular diet
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
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 regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. irbesartan 150 mg oral DAILY
2. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID
3. Fish Oil (Omega 3) 1000 mg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Fluticasone Propionate 110mcg 1 PUFF IH DAILY
6. Multivitamins 1 TAB PO DAILY
7. calcium citrate 500 mg oral BID
8. Aspirin 81 mg PO DAILY
9. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
wheezing
10. Cyanocobalamin 500 mcg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Atenolol 100 mg PO DAILY hypertension
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 100 mg PO DAILY hypertension
3. irbesartan 150 mg oral DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID
6. Multivitamins 1 TAB PO DAILY
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Fish Oil (Omega 3) 1000 mg PO DAILY
9. Fluticasone Propionate 110mcg 1 PUFF IH DAILY
10. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
wheezing
11. calcium citrate 500 mg ORAL BID
12. Cyanocobalamin 500 mcg PO DAILY
13. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
14. Fluticasone Propionate NASAL 1 SPRY NU DAILY
15. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
16. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
gallstones
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
You were seen in the hospital for right sided abdominal pain
related to gallstones. We performed an imaging study with the GI
doctors called ___. We also performed a laparoscopic
cholecystectomy. You tolerated these procedures well, tolerated
regular food, and are ready for discharge. You should restart
your home medications when you return home today with the
following 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.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
___
|
10668217-DS-25
| 10,668,217 | 29,765,303 |
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| 25 |
2171-12-01 00:00:00
|
2171-12-04 06:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
lisinopril / Nickel / Ragweed / pollen / wool
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
ERCP
Liver biopsy
History of Present Illness:
___ year old female s/p lap sleeve gastrectomy ___ and lap
CCY ___ for acute cholecystitis. During her last admission
she was seen by hepatology for persistently high LFTs and
scheduled to follow up with an MRCP and clinic visit for
presumed
non-alcoholic fatty liver disease. She now p/w 1 day history of
___ epigastric pain. The pain started in the morning and
radiated to the right and left subcostal region. The pain was
constant, and not relieved by anything. The pain is made worse
with deep inhalation. She denies a history of GERD. She denies
shortness of breath, fever, chills, jaundice, chest pain,
vomiting, diarrhea or constipation. She endorses mild nausea
that
resolved in the morning.
Past Medical History:
Her medical history is significant for:
1) hypertension
2) type 2 diabetes with hemoglobin A1c of 7.3% on ___
3) hyperlipidemia
4) asthma on inhalers with no recent flares, no prednisone
taper
5) history of kidney stones
6) chronic low back pain on NSAIDs
7) cholelithiasis by ultrasound study
8) hepatic steatosis by ultrasound study
9) allergic rhinitis
10) colonic adenoma
11) hemorrhoids
12) nephrolithiasis
13) glaucoma
14) amblyopia
15) chondromalacia patellae
16) history of hematuria
17) mal de debarquement (dizziness, motion sickness)
18) history of heart murmur
Her surgical history is noted for:
1) lithotripsy in ___ with stent placement in ___
2) right SLAP tear ___
3) hysterectomy in ___
4) s/p C-section
Social History:
___
Family History:
Father: ___, hypertension.
Mother: ___ cancer, breast cancer, colon cancer, diabetes.
Physical Exam:
VSS
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: soft, non-tender, non-distended
EXTREMITIES: Warm, well perfused, no edema
Pertinent Results:
___ 06:20PM BLOOD WBC-12.7*# RBC-4.28 Hgb-12.5 Hct-37.2
MCV-87 MCH-29.2 MCHC-33.6 RDW-12.8 RDWSD-39.8 Plt ___
___ 06:20PM BLOOD Glucose-109* UreaN-18 Creat-0.9 Na-145
K-4.6 Cl-104 HCO3-22 AnGap-24*
___ 06:20PM BLOOD ALT-338* AST-456* AlkPhos-233*
TotBili-2.1* DirBili-1.1* IndBili-1.0
___ 06:20PM BLOOD Albumin-4.3
___ 06:05AM BLOOD WBC-4.5 RBC-3.77* Hgb-10.6* Hct-32.8*
MCV-87 MCH-28.1 MCHC-32.3 RDW-12.7 RDWSD-40.0 Plt ___
___ 06:05AM BLOOD ALT-265* AST-83* AlkPhos-280*
TotBili-1.7*
Brief Hospital Course:
The patient presented the ED on ___ with abd pain. She was
found to have persistent transaminitis (LFTs elevated at last
admission in ___. She was admitted for pain management and
evaluation of transaminitis.
She had an ERCP done that showed poor return of contrast through
the hepatic ducts, and balloon dilation was preformed. Her LFTs
improved some after dilation but remained elevated. She was also
evaluated by the hepatology service who recommended liver
biopsy, preformed ___, results pending at time of
discharge.
During her stay, her pain was treated symptomatically and
improved. At the time of discharge, the patient was doing well,
afebrile and hemodynamically stable. The patient was tolerating
a bariatric stage 5 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.
Neuro: The patient was alert and oriented throughout
hospitalization. Pain was very well controlled.
CV: The patient was hypertense during her stay. Her amlodipine
was increased to 5mg and she was asked to follow-up with her PCP
regarding management. She 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.
Of note, patient had CTA chest in ED which found a pulmonary
nodule in the right lobe. Radiology recommended 12 month
follow-up for monitoring. Patient was notified of finding and
PCP (Dr. ___ was contacted.
GI/GU/FEN: Abd pain improved with pain management. Tolerated
regular diet. She experienced some acid reflux and was started
on a PPI.
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 during
this stay and was encouraged to get up and ambulate as much as
possible.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. irbesartan 150 mg oral DAILY
2. MetFORMIN (Glucophage) 500 mg PO BID
3. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID
4. Rosuvastatin Calcium 40 mg PO QPM
5. Aspirin 81 mg PO DAILY
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY
7. Amlodipine 2.5 mg PO DAILY
8. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. irbesartan 150 mg oral DAILY
3. Ciprofloxacin HCl 500 mg PO/NG Q12H Duration: 5 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*6 Tablet Refills:*0
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY
5. MetFORMIN (Glucophage) 500 mg PO BID
6. Rosuvastatin Calcium 40 mg PO QPM
7. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID
8. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth Daily Disp #*30
Capsule Refills:*0
9. Ursodiol 500 mg PO BID
RX *ursodiol 500 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
Transaminitis of unknown source
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented to ___ for abdominal pain and were found to have
elevated liver function tests. The GI team preformed an ERCP and
dilated the ducts in your liver. Your liver blood tests improved
some after this procedure but remained elevated. The
interventional radiology team preformed a liver biopsy in order
to take a cellular look at your liver in hopes to find the cause
of your abdominal pain and elevated labs.
During your hospital stay, you had a chest CT to rule out a
blood clot in your lungs, as you were having shortness of
breath. The CT did not show a blood clot, but it did show a
nodule on your right lung. Your PCP (Dr. ___ was contacted
about this finding. You should follow-up with her and plan on
getting a repeat CT in ___ year to assess for grow of the nodule.
You were also found to have high blood pressure and acid reflux.
Your amlodipine was increased to 5mg daily, and you were started
on omeprazole 20mg daily to help with your acid reflux symptoms.
Please follow-up with your PCP for management of these medical
conditions.
You pain continued to improve and you are being discharged home.
Please call your doctor or return to the ED if you have
persistent abdominal pain, nausea, vomiting, yellowing of your
skin, dark/black urine.
Followup Instructions:
___
|
10668397-DS-10
| 10,668,397 | 22,584,468 |
DS
| 10 |
2127-12-12 00:00:00
|
2127-12-12 08:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OTOLARYNGOLOGY
Allergies:
Penicillins / Ceclor
Attending: ___.
Chief Complaint:
neck abscess
Major Surgical or Invasive Procedure:
S/p transcervical drainage of multiple neck abscesses
History of Present Illness:
___ with IDDM type ___ s/p transcervical drainage of
multiple neck abscesses (retropharyngeal, mediastinal, anterior
neck) likely stemming from pharyngitis (undertreated due to
odynophagia). Hospital course notable for severe pharyngeal
phase dysphagia on videoswallow study ___, status post ___
guided G-tube placement on ___. PICC line placed on ___
for long term antibiotic therapy.
Past Medical History:
IDDM type 1
Family History:
NC
Physical Exam:
Gen: No acute distress
HEENT: Wick in place with minimal purulence. Neck soft, flat.
CV: Hemodynamically stable
Resp: Unlabored breathing on room air
Neuro: Alert and oriented
Pertinent Results:
___ 06:09AM BLOOD WBC-5.9 RBC-3.24* Hgb-10.1* Hct-30.7*
MCV-95 MCH-31.2 MCHC-32.9 RDW-12.7 RDWSD-42.6 Plt ___
___ 06:09AM BLOOD Glucose-201* UreaN-4* Creat-0.6 Na-138
K-3.9 Cl-103 HCO3-22 AnGap-13
___ 06:49PM BLOOD Vanco-16.5
___ 05:25AM BLOOD WBC-3.9* RBC-3.34* Hgb-10.2* Hct-31.3*
MCV-94 MCH-30.5 MCHC-32.6 RDW-12.8 RDWSD-43.2 Plt ___
___ 05:25AM BLOOD Glucose-137* UreaN-7 Creat-0.7 Na-143
K-3.8 Cl-106 HCO3-24 AnGap-13
Brief Hospital Course:
The patient was admitted to the Otolaryngology-Head and Neck
Surgery Service for I&D of multiple neck abscesses. Please see
the separately dictated operative note for details of procedure.
The patient was extubated and transferred to the hospital floor
for further post-operative care. The post-operative course was
uneventful and the patient was discharged to home.
Hospital Course by Systems:
Neuro: Pain was well controlled, initially with IV regimen which
was transitioned to oral/G-tube regimen once G-tube was placed.
Post-operative anti-emetics were given PRN.
Cardiovascular: Remained hemodynamically stable.
Pulmonary: Oxygen was weaned and the patient was ambulating
independently without supplemental oxygen prior to discharge.
HEENT: ___ drains placed intraoperatively were monitored
closely until output was minimal and were removed. Old ___
site was packed with wick BID, with daily packing changes
recommended upon discharge.
GI: Evaluated by SLP who recommended NPO with alternate means of
nutrition due to severe pharyngeal phase dysphagia on
videoswallow study. PEG tube placed by Interventional Radiology
on ___. Diet was advanced as tolerated from continuous tube
feedings to bolus tube feedings. Bowel regimen was given prn.
GU: Patient was able to void independently.
Heme: Received heparin subcutaneously and pneumatic compression
boots for DVT prophylaxis.
Endocrine: Monitored by team from ___.
Adjustments made to insulin regimen as needed.
ID: Received antibiotics per Infectious Disease team
recommendations.
At time of discharge, the patient was in stable condition,
ambulating and voiding independently, and with adequate pain
control. The patient was given instructions to follow-up in
clinic as scheduled. Patient was given detailed discharge
instructions outlining wound care, activity, diet, follow-up and
the appropriate medication scripts.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
2. Pulmicort Flexhaler (budesonide) 180 mcg/actuation inhalation
BID
3. Glargine 10 Units Breakfast
Glargine 10 Units Dinner
Humalog Unknown Dose
Insulin SC Sliding Scale using HUM Insulin
4. Ondansetron ODT 4 mg PO Q8H:PRN nausea
5. OxycoDONE Liquid ___ mg PO Q6H:PRN Pain - Moderate
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg NG Q6H:PRN Pain - Mild
2. Ciprofloxacin HCl 500 mg PO Q12H infection Duration: 4 Weeks
3. Docusate Sodium 100 mg PO BID
4. MetroNIDAZOLE 500 mg PO TID infection Duration: 4 Weeks
5. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
6. Vancomycin 1250 mg IV Q 12H
7. Glargine 8 Units Breakfast
Glargine 3 Units Bedtime
Humalog 3 Units Breakfast
Humalog 3 Units Lunch
Humalog 3 Units Dinner
Humalog 3 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
8. OxycoDONE Liquid ___ mg PO Q4H:PRN Pain - Moderate
9. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
10. Ondansetron ODT 4 mg PO Q8H:PRN nausea
11. Pulmicort Flexhaler (budesonide) 180 mcg/actuation
inhalation BID
12. Outpatient Lab Work
ICD 10 L02.11
___, MD, Infectious Disease
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
WEEKLY: CBC with differential, BUN, Cr, Vancomycin trough, CRP
To be drawn on ___ : AST, ALT, Total Bili, ALK PHOS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Neck abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
- Take antibiotics as prescribed.
- Bolus tube feedings with free water flushes as directed below.
- Change wick packing to neck daily.
- Take Tylenol as needed for pain.
WHEN TO CALL YOUR DOCTOR
Excessive redness of your incision site
Fever greater than 101 degrees Fahrenheit
Sudden excessive swelling of incision site
For questions or problems, please call ___ to speak
to the clinic nurse during clinic hours.
After hours, or on weekends, dial ___ and ask the
operator to page the Otolaryngology resident on-call.
Followup Instructions:
___
|
10668610-DS-4
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| 4 |
2166-09-11 00:00:00
|
2166-09-11 11:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Allergies/ADRs on File
Attending: ___
Chief Complaint:
Stab wound to neck (superficial)
Major Surgical or Invasive Procedure:
Neck exploration and closure of facial
lacerations
History of Present Illness:
___ M intoxicated presents w stab wound to the neck (zone 2).
Unable to recall events.
Past Medical History:
chronic back pain
Social History:
___
Family History:
NC
Physical Exam:
General:
VS T 97.9 68 121/75 22 95% RA
Gen: Well appearing male in NAD, A&Ox3
P: CTAP
CV: RRR
Extremities: pulses palp, no edema. No deformities or step offs.
Mild R shoulder pain on palpation.
HEENT: EOMI, bruising over bridge of nose. no palpable step
offs, no obvious deformities. R lateral nasal side wall stable,
not tender to palp. No rhinorrhea. Small superficial abrasion
and swelling over left occiput. no erythema or signs of
infection. Neck wound dressing clean, dry and intact.
Pertinent Results:
___ 01:57AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 02:13AM ___ PTT-30.7 ___
___ 02:13AM PLT SMR-NORMAL PLT COUNT-449*
___ 02:13AM WBC-13.9* RBC-4.05* HGB-10.8* HCT-35.0*
MCV-86 MCH-26.7 MCHC-30.9* RDW-15.8* RDWSD-48.5*
___ 02:13AM GLUCOSE-125* UREA N-7 CREAT-0.9 SODIUM-133
POTASSIUM-3.7 CHLORIDE-97 TOTAL CO2-19* ANION GAP-21*
Brief Hospital Course:
Mr. ___ was admitted on ___, w neck wound from an assault
earlier Was
reportedly hit with a broken beer bottle. Was briefly seen at
the ___ emergency department but emergently
transferred prior to imaging due to concern for penetrating neck
injury. He was intoxicated and has difficulty providing
a ___ medical history. He reported pain in head and neck
but no chest, abdominal, or back pain. He was intubated as he
was very intoxicated and not cooperaing with plans for CT scan.
Scans showed neck wound penetrating the platysma without active
extravasation. He was taken to the operating room for
exploration. In the OR, a small opening in the platysma was
found with no injury of other structures. The wound was closed
primarily and he was taken to the ICU intubated. He was started
on a phenobarbital taper the next morning and extubated shortly
after without problems. He was started on a regular diet and
Foley was DC'd. Tertiary survey was positive only for mild R
shoulder pain. He was observed overnight and discharged ___.
At the time of discharge, he was tolerating a regular diet with
no difficulty swallowing, his pain was adequately controlled, he
was voiding without difficulty and ambulating independently. He
was expressing his desire to return home.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Stab wound to neck, superficial
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before
your pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10668617-DS-20
| 10,668,617 | 29,781,076 |
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| 20 |
2179-01-22 00:00:00
|
2179-01-26 19:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
simvastatin
Attending: ___
Chief Complaint:
transient vision loss
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ year old man with a history of mechanical
aortic valve replacement in ___ who presents with one
episode of transient vision loss in the right eye. He was at
work
this morning. Around 11am he saw a curtain coming down over the
vision in his right eye. He closed on eye then the other to
confirm it was only in the right eye. It lasted 1 minute then
resolved and his sight quickly returned to baseline. He called
his cardiologist who recommended he come to the ED for TIA
workup
including cardiac echo and vessel imaging.
He is on Coumadin for stroke prevention. His INR goal has been
___ it was subtherapeutic at 1.9. He took 4mg of
Coumadin and rechecked it today, which was 2.1. Since the
amaurosis fugax happened while his INR was >2, the tentative
goal
as discussed between the patient and his outpatient cardiologist
is to increase the INR goal to 2.5-3.5.
He denies weakness, numbness, or other stroke symptoms and feels
at baseline.
Review of Systems:
The pt denies headache, blurred vision, diplopia, dysarthria,
dysphagia, lightheadedness, vertigo, tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech. Denies focal weakness, numbness, parasthesiae. No bowel
or bladder incontinence or retention. Denies difficulty with
gait. The pt denies recent fever or chills. No recent weight
loss. Denies cough, shortness of breath. Denies chest pain or
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies rash.
Past Medical History:
- Bicuspid aortic valve, aortic regurgitation
- Dilated aorta
- Gastroesophageal Reflux Disease
- Hyperlipidemia
- Hypertension
- Aortic valve replacement (mechanical valve) and replacement of
the ascending aorta with a 26-mm Gelweave tube graft ___
- sCHF, EF: 35-40 %
- pericardial effusion w/tamponade in setting of INR ___ s/p
pericardiocentesis
- h/o ocular migraine (looks like kaleidoscope)
Social History:
___
Family History:
- Denies neurologic disease in the family
- pancreatic cancer in father
Physical ___ Exam:
Vitals: 98.1 54 116/73 14 99%
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple.
Pulmonary: clear to auscultation bilaterally
Cardiac: RRR, no murmurs, mechanical valve click
Abdomen: soft, nondistended
Extremities: no edema, warm
Skin: no rashes or lesions noted.
NEUROLOGIC EXAMINATION
-Mental Status: Alert, oriented. Able to relate history without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. There was no
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm bilaterally. VFF to confrontation with
finger
counting in each eye. Funduscopic exam revealed no papilledema.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch in all distributions
VII: No facial droop with symmetric upper and lower facial
musculature bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: full strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline with full ROM right and left
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No tremor noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ ___ ___ 5 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
- Toes were downgoing bilaterally.
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense throughout. No extinction to DSS.
-Coordination: No dysmetria on FNF or HKS bilaterally. Rapid
alternating movements with normal cadence and speed; no
dysdiadochokinesia bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem, on toes, and on heels without
difficulty. Romberg absent.
=================================================
Discharge Exam:
Unchanged
Pertinent Results:
___ 09:15PM BLOOD WBC-5.5 RBC-4.85# Hgb-13.2*# Hct-40.6#
MCV-84 MCH-27.2 MCHC-32.5 RDW-14.0 RDWSD-42.5 Plt ___
___ 09:15PM BLOOD Neuts-45.5 ___ Monos-9.3 Eos-2.4
Baso-0.7 Im ___ AbsNeut-2.49 AbsLymp-2.29 AbsMono-0.51
AbsEos-0.13 AbsBaso-0.04
___ 06:55AM BLOOD ___
___ 09:15PM BLOOD ___ PTT-46.6* ___
___ 09:15PM BLOOD Glucose-89 UreaN-24* Creat-0.9 Na-139
K-4.1 Cl-105 HCO3-21* AnGap-17
___ 06:55AM BLOOD ALT-25 AST-24 LD(LDH)-218 AlkPhos-65
TotBili-0.7
___ 06:55AM BLOOD cTropnT-<0.01
___ 06:55AM BLOOD Albumin-4.2 Cholest-176
___ 06:55AM BLOOD %HbA1c-5.5 eAG-111
___ 06:55AM BLOOD Triglyc-162* HDL-39 CHOL/HD-4.5
LDLcalc-105
___ 06:55AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IMAGING:
CTA Head and Neck (___):
1. Patent circle ___.
2. No evidence of internal carotid artery stenosis by NASCET
criteria.
3. No evidence of infarction.
MRI Head (___)
1. No acute infarction.
2. Punctate chronic microhemorrhages in the right cerebellum and
along
bilateral frontal cortices. The cortical distribution is not
typical for
hypertensive hemorrhages, and amyloid angiopathy is not usually
seen in this
age group. These could be related to the patient's history of
aortic valve
replacement.
ECHO (___)
The left atrium is elongated. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is top
normal/borderline dilated. There is mild global left ventricular
hypokinesis (LVEF = 45 %). Tissue Doppler imaging suggests a
normal left ventricular filling pressure (PCWP<12mmHg). The
aortic root is mildly dilated at the sinus level. A bileaflet
aortic valve prosthesis is present. The aortic valve prosthesis
appears well seated, with normal leaflet/disc motion and
transvalvular gradients. Trace aortic regurgitation (in expected
region for washing jets) is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
a trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of ___, the
findings are similar. Left ventricular function appeared similar
and may have been underestimated due to suboptimal image quality
in the prior study.
Brief Hospital Course:
___ yo male, pmh of AVR s/p mechanical valve, who presents with
transient vision loss. Neuro exam on admission was normal. MRI
negative for stroke. CTA head and neck did not show any
evidence of carotid stenosis. The likely etiology of the embolic
stroke is due to the mechanical valve. TTE without embolus and
similar to prior ECHOs. INR during event was 2.1, so we
recommend his INR goal to be increased to 2.5-3.5, so coumadin
was increased to 3 mg daily on discharge. INR on day of
discharge ws 2.7. LDL (105) and A1c (5.5%) were pending at time
of discharge. He improved to discharge home and to check INR on
___ and to follow up with cardiology neurology and pcp.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 50 mg PO BID
2. Niacin SR 1000 mg PO DAILY
3. Pantoprazole 40 mg PO Q24H
4. Pravastatin 40 mg PO QPM
5. Warfarin 2.5 mg PO 3X/WEEK (___)
6. Warfarin 3 mg PO 4X/WEEK (___)
Discharge Medications:
1. Metoprolol Tartrate 50 mg PO BID
2. Niacin SR 1000 mg PO DAILY
3. Pravastatin 40 mg PO QPM
4. Warfarin 3 mg PO DAILY16
5. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
amurosis fugax, ___ prostetic arotic vavle
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted for transient visual loss in the R eye,
consistant with amurosis fugax. Luckily your symptoms resolved
and you have no neurologic defecits. Your MRI was normal which
ruled out any other strokes.
Your INR was 2.1 at the time of your episode of vision loss, and
we recommend a higher INR goal of 2.5-3.5 to prevent further
episodes of stroke. And echocardiogram was done in the hospital
and showed that your valve is normal. Vessel imaging of your
head and neck did not show any other causes of stroke. You had
an A1C and LDL drawn in the hospital which were pending at time
of discharge, your PCP should follow up on these to also help
modify your stroke risk factors.
Please increase your coumadin to 3 mg daily, and check your INR
on ___, and call your cardiologist to adjust coumadin dosing.
Please also ask your cardiologist to schedule a close follow up
appointment in the next week. Also please call your PCP to
schedule an appointment in the next 2 weeks.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10669269-DS-17
| 10,669,269 | 25,379,634 |
DS
| 17 |
2152-01-22 00:00:00
|
2152-01-22 19:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year-old man with a past medical history of
hypertension and hyperlipidemia who presented with acute onset
left hand weakness, facial droop and dysathria found to have a
right basal ganglia hemorrhage with small amount of
intraventricular extension. Patient reports he was in his usual
state of health, working in the yard, doing heavy lifting and
bending over in the garden earlier in the day yesterday. Around
___, he sat down for dinner and noted acute onset left hand
weakness. He tried to grip a cup and it dropped to the floor.
During this time, he also had a mild sharp occipital headache
about ___ in severity. His wife then noticed that his face
appeared asymmetric and his speech sounded slurred. She called
EMS. In the interim, the patient went to lay down for a nap
because he was feeling so fatigued. He denied any nausea,
vomiting, visual changes or recent trauma.
He presented to an OSH ED where a CT showed IPH in the right
basal ganglia. His systolic blood pressure were elevated to the
170s at that time. He was transferred to ___ for further
intervention.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denies difficulties comprehending speech.
Denies 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
Hyperlipidemia
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 99 P: 71 R: 16 BP: 128/82 SaO2: 95% RA
General: Sleepy but arousable, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, dry MM, no lesions noted
in oropharynx, hypophonic voice
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 C/C/E bilaterally, 2+ radial, DP pulses
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. 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. Smooth pursuit decreased with rightward gaze. VFF to
confrontation.
V: Facial sensation intact to light touch.
VII: Left 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. Left sided
asterxis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ 5 4+ ___ 4 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation
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 up on the left and mute on the right.
-Coordination: Mild intention tremor with bilateral finger to
nose. No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Romberg absent.
======================
DISCHARGE PHYSICAL EXAM:
CN: L sided NLFF
Motor: L wrist extensor 5, finger ext 5-, IO 5, hamstring 5
Coordination: intention tremor, mild L asterixis
Gait: narrow based, steady, neg Romberg
Pertinent Results:
ADMISSION LABS:
___ 03:18AM BLOOD WBC-6.0 RBC-4.56* Hgb-14.8 Hct-43.7
MCV-96 MCH-32.5* MCHC-33.9 RDW-14.2 RDWSD-50.4* Plt ___
___ 03:18AM BLOOD Neuts-58.6 ___ Monos-7.2 Eos-1.2
Baso-0.7 Im ___ AbsNeut-3.53 AbsLymp-1.93 AbsMono-0.43
AbsEos-0.07 AbsBaso-0.04
___ 03:18AM BLOOD ___ PTT-31.3 ___
___ 03:18AM BLOOD Glucose-106* UreaN-20 Creat-1.0 Na-139
K-4.1 Cl-103 HCO3-25 AnGap-15
___ 07:22AM BLOOD CK-MB-2 cTropnT-<0.01
___ 03:18AM BLOOD Calcium-9.2 Phos-3.3 Mg-2.2
___ 07:22AM BLOOD Triglyc-79 HDL-40 CHOL/HD-4.0 LDLcalc-102
___ 07:22AM BLOOD TSH-1.1
___ 07:22AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IMAGING:
Non-Contrast CT of Head ___: Area of intraparenchymal
hemorrhage within the right basal ganglia. A small amount of
hemorrhage also extends into the body and frontal horn of the
right lateral ventricle.
MRI head w/wo contrast on ___: showing unchanged
intraparenchymal hemorrhage within the right basal ganglia. No
abnormal enhancement after contrast administration or other
evidence of underlying mass.
DISCHARGE LABS:
___ 05:05AM BLOOD WBC-6.7 RBC-4.40* Hgb-13.9 Hct-42.5
MCV-97 MCH-31.6 MCHC-32.7 RDW-14.5 RDWSD-51.8* Plt ___
___ 05:05AM BLOOD Plt ___
___ 11:22AM BLOOD Creat-0.9
Brief Hospital Course:
Mr. ___ is a ___ year-old man with a past medical history of
hypertension and hyperlipidemia who presented with acute onset
left hand weakness, facial droop and dysathria found to have a
right basal ganglia hemorrhage with small amount of
intraventricular extension.
# Right basal ganglia hemorrhage: The etiology of the bleed is
likely secondary to hypertension. Given concern for somnelence
and the need for close BP monitoring, he was initially admitted
to the neuro ICU. His blood pressures remained stable on his
home regimen and he was stepped down to the floor soon after
admission. His home aspirin was held. Follow-up imaging showed
showing unchanged intraparenchymal hemorrhage within the right
basal ganglia, without abnormal enhancement after contrast
administration or other evidence of underlying mass. He was
continued on his home lisinopril 20mg PO daily for blood
pressure control, as well as atorvastatin 40mg PO daily. He will
have follow-up imaging in ___ weeks, as well as a neurology
appointment.
Transitional issues:
Patient concerned about stairs at home, however cleared stairs
with physical therapy and nursing services. Will have a home
safety evaluation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Aspirin 81 mg PO DAILY
4. flaxseed oil 1,000 mg oral DAILY
5. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. Lisinopril 20 mg PO DAILY
3. flaxseed oil 1,000 mg oral DAILY
4. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Intracranial hemorrhage of right basal ganglia
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 intracranial bleed,
resulting from an elevated blood pressure, a condition where a
blood vessel providing oxygen and nutrients to the brain is
ruptured and bleeds. 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 issues with its blood supply can result in a
variety of symptoms.
These problems can have many different causes, so we assessed
you for medical conditions that might raise your risk of having
bleeding and stroke. In order to prevent future strokes/bleeds,
we plan to modify those risk factors. Your risk factors are:
- high blood pressure
- high cholesterol
We are continuing your medications as follows:
- Atorvastatin 40 mg daily at bedtime.
- Lisinopril 20 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, please pay attention to
the sudden onset and persistence of these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
Followup Instructions:
___
|
10669294-DS-14
| 10,669,294 | 20,357,943 |
DS
| 14 |
2174-10-30 00:00:00
|
2174-10-31 11:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
NEPHROLITHIASIS, UROSEPSIS/PYELONEPHRITIS
Major Surgical or Invasive Procedure:
___ PROCEDURE:
Cystoscopy, retrograde pyelogram, right ureteral stent
placement, 6 x 24 cm.
FINDINGS: Moderate proximal hydronephrosis, tiny obstructing
stone distal ureter.
History of Present Illness:
___ year old woman who presented with acute onset of right sided
flank pain, nausea and vomiting. UA dirty, she was afebrile and
with normal range WBC, however given persistent tachycardia and
concern for early sepsis, was admitted to urology for
monitoring. Symptoms deteriorated and she was thus taken
urgently to the OR for ureteral stent.
Past Medical History:
MIGRAINE HEADACHES
IRREGULAR MENSES
ACNE
OBESITY
ANXIETY
TUBAL LIGATION
APPENDECTOMY
Social History:
___
Family History:
mother Living ___ HEALTHY
Father ___ MYOCARDIAL
INFARCTION
HEMODYALISIS
DIABETES TYPE II
Other DIABETES TYPE II
MGM ___ DISEASE
Physical Exam:
___ woman, nad
avss
abdominal pain resolved, nt/nd
no CVAT
no l/e p/p/e/c
Pertinent Results:
___ 09:00AM BLOOD WBC-7.3 RBC-3.45* Hgb-9.6* Hct-28.4*
MCV-82 MCH-27.8 MCHC-33.8 RDW-13.5 RDWSD-40.5 Plt ___
___ 07:33AM BLOOD WBC-4.9 RBC-3.57* Hgb-10.0* Hct-30.3*
MCV-85 MCH-28.0 MCHC-33.0 RDW-13.9 RDWSD-43.0 Plt ___
___ 05:20AM BLOOD WBC-9.4 RBC-3.37* Hgb-9.4* Hct-28.1*
MCV-83 MCH-27.9 MCHC-33.5 RDW-13.8 RDWSD-41.5 Plt ___
___ 10:00AM BLOOD WBC-9.0 RBC-4.01 Hgb-11.2 Hct-33.8*
MCV-84 MCH-27.9 MCHC-33.1 RDW-13.8 RDWSD-42.2 Plt ___
___ 10:00AM BLOOD Neuts-58.7 ___ Monos-6.5 Eos-4.1
Baso-0.3 Im ___ AbsNeut-5.25 AbsLymp-2.65 AbsMono-0.58
AbsEos-0.37 AbsBaso-0.03
___ 09:00AM BLOOD Glucose-113* UreaN-8 Creat-0.6 Na-138
K-3.8 Cl-106 HCO3-21* AnGap-15
___ 07:33AM BLOOD Glucose-102* UreaN-5* Creat-0.5 Na-137
K-4.0 Cl-107 HCO3-22 AnGap-12
___ 05:20AM BLOOD Glucose-110* Creat-0.5 Na-138 K-3.2*
Cl-109* HCO3-19* AnGap-13
___ 10:00AM BLOOD Glucose-99 UreaN-10 Creat-0.6 Na-137
K-3.6 Cl-102 HCO3-24 AnGap-15
___ 09:00AM BLOOD Mg-1.8
___ 07:33AM BLOOD Calcium-8.7 Phos-2.4* Mg-2.9*
___ 02:09PM BLOOD Lactate-2.0
___ 10:30AM URINE Color-Yellow Appear-Hazy Sp ___
___ 10:30AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-MOD
___ 10:30AM URINE RBC-118* WBC-137* Bacteri-FEW Yeast-NONE
Epi-<1 TransE-<1
___ 10:30AM URINE Mucous-RARE
___ 10:30AM URINE UCG-NEGATIVE
___ 10:38 am URINE ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 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
___ 12:15 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. ~1000/ML.
___ URINE URINE CULTURE-FINAL INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ URINE URINE CULTURE-FINAL {YEAST} INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ URINE URINE CULTURE-FINAL {PROTEUS
MIRABILIS} INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY WARD
Brief Hospital Course:
Ms. ___ was admitted to urology for observation and
expulsion therapy for her stone but developed fevers and
decompensated quickly so she was urgently taken to the or for
intervention. With a known right ureteral stone she underwent
cystoscopy, retrograde pyelogram, right ureteral stent
placement, 6 x 24 cm. Ms. ___
tolerated the procedure well and recovered in the PACU before
transfer to the general surgical floor. See the dictated
operative note for full details. Overnight, the patient was
hydrated with intravenous fluids and received appropriate
perioperative prophylactic antibiotics and pain was managed.
Over the next several days her antibiotics where adjusted per
culture and sensitivity data. She spiked a fever to 103 on
empiric therapy and started on fluconazole for the yeast in her
urine. Urethral catheter was gradually removed and with pain
under control, regular voiding and afebrile for over 24 hours,
she was prepared for discharge home. At discharge, Ms.
___ had her pain well controlled with oral pain
medications, she was tolerating regular diet, ambulating without
assistance, and voiding without difficulty. She was explicitly
advised to follow up as directed as the indwelling ureteral
stent must be removed and or exchanged and to complete her
course of antibiotics, even though feeling better.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Fever >100, Pain
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg ONE tablet(s) by mouth twice a day
Disp #*22 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg ONE capsule(s) by mouth
twice a day Disp #*60 Capsule Refills:*0
4. Tamsulosin 0.4 mg PO DAILY
RX *tamsulosin [Flomax] 0.4 mg one capsule(s) by mouth daily
Disp #*30 Capsule Refills:*0
5. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain
RX *hydromorphone [Dilaudid] 2 mg ONE tablet(s) by mouth Q4hrs
Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pyelonephritis
PREOPERATIVE DIAGNOSIS: Right ureteral stone.
POSTOP DIAGNOSIS: Right ureteral stone.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or
the indwelling ureteral stent.
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume your pre-admission/home medications EXCEPT as noted. You
should ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor. HOLD ASPIRIN and aspirin containing products for one
week unless otherwise advised.
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control. For pain
control, try TYLENOL FIRST, then ibuprofen, and then take the
narcotic pain medication as prescribed if additional pain relief
is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-You MAY be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative, and available over the counter.
The generic name is DOCUSATE SODIUM. It is recommended that you
use this medication.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks and while
Foley catheter is in place.
IF YOU ARE DISCHARGED HOME WITH A FOLEY CATHETER:
-Please refer to the provided nursing instructions and handout
on Foley catheter care, waste elimination and leg bag usage.
-Your Foley should be secured to the catheter secure on your
thigh at ALL times until your follow up with the surgeon.
-Follow up in 1 week for wound check and Foley removal. DO NOT
have anyone else other than your Surgeon remove your Foley for
any reason.
-Wear Large Foley bag for majority of time, leg bag is only for
short-term when leaving house.
Followup Instructions:
___
|
10669559-DS-7
| 10,669,559 | 21,236,880 |
DS
| 7 |
2167-11-14 00:00:00
|
2167-11-15 05:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Abdominal distension
Major Surgical or Invasive Procedure:
EGD with biopsies, diagnostic and therapeutic paracentesis, bone
marrow biopsy
History of Present Illness:
___ man who states that he has been having ___ weeks of
progressively increasing abdominal distention. The patient was
on vacation in ___ and upon returning home went to see his
primary care doctor who sent the patient to ___. The
patient requested transfer to ___ for more definitive care.
The patient denies chest pain, dyspnea, abdominal pain, fever,
chills, nausea, vomiting, diarrhea. The patient has no history
of alcohol abuse or IVDU. The patient otherwise is without any
blood transfusions in his history to his recollection.
.
In the ___, initial vital signs were pain 0, T 98.0, HR 102, BP
132/68, RR 20 96%. The patient received a diagnostic
paracentesis, which showed 5700 WBCs, so the patient was started
on ceftriaxone 2mg IV. On transfer, the patient's vitals were T
98.8, HR 101 RR16, BP 134/75, 98% on RA, 0 pain.
.
On the medicine floor, the patient is comfortable and reports no
pain. He says that for about one month he has been feeling
nauseated. He thought it was a "stomach bug" because it seemed
to resolve ___ weeks ago. When the patient was away in ___
___ weeks ago, he noticed that his abdomen was expanding. By
___ when he returned to ___ could nto fit well
into his pants. He went to his PCP on ___, which led to his
eventual arrival at ___ and then here. The
patient thinks he may have been producing less urine of late. He
has eaten some sushi and tuna tartare over the last month, but
no raw shellfish. He has tattoos, which he received more than ___
years ago. He denies any blood transfusions or IV drug use.
.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, vomiting, diarrhea, constipation, BRBPR,
dysuria, hematuria.
Past Medical History:
Had a blood clot in his foot ___ years ago, started on baby
aspirin.
Surgical history:
Appendectomy when ___ years old
Adhesions
Gunshot wound on right chest
Social History:
___
Family History:
Brother died on leukemia, another brother of lung cancer,
another brother of brain aneurysm
Physical Exam:
ADMISSION EXAM:
VS - Temp 98.6F, BP 139/89 (127-139/85-89), HR 90, R 18, O2-sat
99% RA
GENERAL - Alert, interactive, in NAD
HEENT - EOMI, sclerae anicteric, no jaundice present near
frenulum under tongue, MMM, oropharynx clear
NECK - Supple, no thyromegaly, no JVD, no carotid bruits
HEART - distant heart sounds, normal S1, S2, no murmurs
auscultated
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - Distended, positive shifting dullness, no pain to
palpation in RUQ, no ___ sign
EXTREMITIES - WWP, no c/c/e, 2+ radial/pedal pulses
SKIN - mutiple moles across abdomen and back, including one on
abdomen, one on back with asymmetric borders, multicolored
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs III-XII grossly intact, muscle
strength ___ throughout, sensation grossly intact throughout
.
DISCHARGE EXAM:
VS - Tc 98.2, Tmax 98.7, BP 126/78 (120-140'/70-80'), HR 94
(60'-90'), 95%RA
Wt on admission 311 lb, yesterday 311 lb down from 313 the day
before yesterday
GENERAL - Pleasant man appears stated age in NAD, comfortable,
appropriate, sitting in chair
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP with white dots
in posterior pharynx.
NECK - supple, no JVD
LUNGS - Appears comfortable. Decreased BS at bases as well, R >
L
HEART - normal rate, distant sounds, no MRG, soft S1-S2
ABDOMEN - Distended and tense but slightly softer than
yesterday, dull to percussion dependently, non tender
EXTREMITIES - WWP, 1+ pitting edema to knees
SKIN - venous stasis changes BLE. No tenderness eythema or
swelling at site of PICC insertion
LYMPH - No cervical, submandiublar, supraclavicular, axillary
or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, no gross
deficit
Pertinent Results:
ADMISSION LABS:
===============
___ 07:48PM BLOOD WBC-7.2 RBC-4.10* Hgb-11.5* Hct-36.5*
MCV-89 MCH-28.1 MCHC-31.5 RDW-14.2 Plt ___
___ 07:48PM BLOOD Neuts-78.0* Lymphs-16.0* Monos-5.6
Eos-0.3 Baso-0.1
___ 05:35AM BLOOD ___ PTT-24.7* ___
___ 07:48PM BLOOD Glucose-118* UreaN-47* Creat-2.2* Na-133
K-4.5 Cl-99 HCO3-21* AnGap-18
___ 07:48PM BLOOD ALT-23 AST-32 CK(CPK)-108 AlkPhos-57
TotBili-0.5
___ 07:48PM BLOOD Lipase-44
___ 07:48PM BLOOD CK-MB-6
___ 07:48PM BLOOD cTropnT-<0.01
___ 07:48PM BLOOD Albumin-3.2* Calcium-8.6 Phos-4.7* Mg-2.3
___ 08:03PM BLOOD Lactate-2.4*
.
MISCELLANEOUS LABS:
===================
___ 07:00AM BLOOD QG6PD-15.8*
___ 07:00AM BLOOD Ret Aut-1.8
___ 07:00AM BLOOD calTIBC-213* Ferritn-308 TRF-164*
___ 07:48PM BLOOD Albumin-3.2*
___ 06:50AM BLOOD UricAcd-15.4*
___ 07:16AM BLOOD HAV Ab-NEGATIVE
___ 05:35AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 07:00AM BLOOD Smooth-NEGATIVE
___ 07:16AM BLOOD ___
___ 07:00AM BLOOD IgG-635*
___ 05:35AM BLOOD HCV Ab-NEGATIVE
___ 07:16AM BLOOD CERULOPLASMIN-Test NEGATIVE
___ HIV Ab negative
SPEP UPEP negative
.
DISCHARGE LABS:
===============
___ 04:35AM BLOOD WBC-6.5 RBC-2.84* Hgb-8.1* Hct-26.5*
MCV-94 MCH-28.7 MCHC-30.6* RDW-14.2 Plt ___
___ 03:29AM BLOOD Neuts-96.6* Lymphs-1.8* Monos-1.1*
Eos-0.5 Baso-0
___ 04:35AM BLOOD ___ PTT-25.8 ___
___ 04:35AM BLOOD ___
___ 04:35AM BLOOD Glucose-146* UreaN-50* Creat-1.3* Na-140
K-5.1 Cl-104 HCO3-28 AnGap-13
___ 04:35AM BLOOD LD(LDH)-907*
___ 04:35AM BLOOD Calcium-7.6* Phos-3.5 Mg-2.3 UricAcd-3.7
___ 08:26PM BLOOD Albumin-2.8* Calcium-7.7* Phos-3.2 Mg-2.3
UricAcd-3.7
.
FLUID ANALYSIS:
===============
URINE:
___ 04:25AM URINE Color-Yellow Appear-Cloudy Sp ___
___ 04:25AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 04:25AM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
___ 04:25AM URINE CaOxalX-OCC Uric AX-MOD
___ 04:25AM URINE Mucous-RARE
___ 04:25AM URINE Osmolal-530
___ 04:25AM URINE Hours-RANDOM UreaN-941 Creat-157 Na-LESS
THAN K-59 Cl-10
___ 11:15AM URINE Osmolal-512
___ 11:15AM URINE Hours-RANDOM UreaN-966 Creat-144 Na-<10
K-34 Cl-<10
.
ASCITES:
========
___ 07:40PM ASCITES TotPro-2.7 Glucose-78 Albumin-1.7
___ 07:40PM ASCITES WBC-5700* RBC-3900* Polys-0 Lymphs-7*
Monos-1* Macroph-1* Other-91*
___ CYTOLOGY
POSITIVE FOR MALIGNANT CELLS, consistent with metastatic
involvement by the patient's gastric plasmablastic neoplasm (see
note).
Note: See also the corresponding cell block specimen
___ for the results of immunohistochemistry studies. In
conjunction with the results of flow cytometry analysis
performed on a subsequent ascitic fluid specimen (___),
the findings support the above diagnosis.
___ 7:40 pm PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 02:36PM ASCITES TotPro-3.1 Glucose-87 LD(LDH)-2395
TotBili-0.4 Albumin-1.9
___ 02:36PM ASCITES ___ Polys-0 Lymphs-2*
Monos-0 Other-98*
.
MICROBIOLOGY:
=============
- Blood cultures: No growth
- Urine culture:
Of ___ URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
______________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 64 I
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
.
Of ___ URINE Site: CLEAN CATCH
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
.
- HELICOBACTER PYLORI ANTIBODY TEST (Final ___:
NEGATIVE BY EIA.
- EBV ___
___ VIRUS VCA-IgG AB (Final ___: POSITIVE BY
EIA.
___ VIRUS EBNA IgG AB (Final ___: POSITIVE BY
EIA.
___ VIRUS VCA-IgM AB (Final ___:
NEGATIVE <1:10 BY IFA.
.
PATHOLOGY/CYTOLOGY:
===================
FLOW CYTOMETRY IMMUNOPHENOTYPING - BONE MARROW
The following tests (antibodies) were performed: ___, FMC-7,
Kappa, Lambda, and CD antigens 3, 5, 10, 19, 20, 23, 45.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield.
B cells comprise 19% of lymphoid-gated events. There is a
slight lambda shift among these events.
T cells comprise 82% lymphoid gated events, express mature
lineage antigens.
INTERPRETATION
Non-specific T cell dominant lymphoid profile; while a
diagnostic immunophenotypic features of involvement by lymphoma
are not seen in specimen a slight lambda shift is seen.
Concurrent bone marrow biopsy reveals atypical cells worrisome
for involvement by an atypical plasma cell / lymphoid
population. Flow cytometry immunophenotyping may not detect all
lymphomas as due to topography, sampling or artifacts of sample
preparation.
Note: This test was performed using analyte specific reagents
(ASRs). These ASRs have not been cleared or approved by the ___
Food ___ Drug Administration (FDA). However, the FDA has
determined that such clearance or approval is not necessary .
This test was developed and its performance characteristics
determined by the Flow Cytometry Laboratory at ___
___, which is licensed by ___ to perform
high complexity tests. This test was used for clinical
purposes; it should not be regarded as for research.
.
.
FLOW CYTOMETRY IMMUNOPHENOTYPING - PERITONEAL FLUID
The following tests (antibodies) were performed: ___, FMC-7,
Kappa, Lambda, and CD antigens 3, 5, 10, 19, 20, 23, 38, 45, 56,
138.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize blast/lymphocyte yield. B cells comprise 3% of
lymphoid-gated events, are polyclonal, and do not express
aberrant antigens. T cells comprise 71% of lymphoid gated
events, express mature lineage antigens. Within the CD45 dim
gate a large population of cells that stain for CD138, CD38 and
CD56.
INTERPRETATION
Immunophenotypic findings consistent with involvement by
CD138/CD56 positive neoplasm.
Note: This test was performed using analyte specific reagents
(ASRs). These ASRs have not been cleared or approved by the ___
Food and Drug Administration (FDA). However, the FDA has
determined that such clearance or approval is not necessary .
This test was developed and its performance characteristics
determined by the Flow Cytometry Laboratory at ___
___, which is licensed by ___ to perform
high complexity tests. This test was used for clinical
purposes; it should not be regarded as for research.
.
SPECIMEN: GASTRIC BIOPSIES.
DIAGNOSIS:
PLASMABLASTIC LYMPHOMA VERSUS PLASMABLASTIC PLASMA CELL MYELOMA.
SEE NOTE.
Note: The differential diagnosis includes primary effusion
lymphoma with tissue infiltration (the so-called solid PEL),
plasmablastic lymphoma, and disseminated plasmablastic plasma
cell myeloma (or plasmacytoma). Based on the immunophenotype,
which is negative for HHV8 LNA, PEL seems unlikely. Though
plasmablastic lymphoma is suggested by the pattern of
infiltration and dissemination, presentation in an apparently
immunocompetent patient is somewhat atypical, making
plasmablastic plasma cells myeloma a distinct possibility.
Further studies may be needed to make this distinction with more
certainty. The results of ___ assay are deemed critical
since the great majority of plasmablastic lymphomas are ___
positive and ___ positive anaplastic plasma cell myeloma is
distinctly rare, if it exist at all [Modern Pathology (___) 18,
80___].
Sections are of multiple gastric biopsies containing antral
mucosa focally extensively infiltrated by a high grade neoplasm
composed of large cells with vesicular nuclei, multiple nucleoli
and moderate amounts of spumous cytoplasm. Frequent mitosis and
apoptotic cells are present, but confluent necrosis is absent.
By immunoperoxidase the neoplastic cells are immunoreactive for
CD45 and CD138, but lack immunoreactivity for cytokeratin
cocktail, CK7, CD20, CD79a, PAX5, and CD30. CD3 and CD5
highlight a small population of infiltrating small lymphocytes.
Kappa and lambda appear largely negative. The MIB-1
proliferation fraction is extremely high approaching 100% in
some areas. HHV8 LNA and EBV LMP1 are negative.
Flow cytometry of ascites fluid revealed that tumor cells
expressed high levels of CD138, CD38 and CD56.
An ___ assay is in progress and results will be provided in an
addendum.
.
BONE MARROW BIOPSY (1 JAR). Procedure Date of ___
Report not finalized.
Assigned Pathologist ___
Please contact the pathology department, ___ ___
PATHOLOGY # ___
BONE MARROW BIOPSY (1 JAR).
.
IMAGING:
========
ABDOMEN U.S. (COMPLETE STUDY) Study Date of ___
FINDINGS: The liver has coarsened and echogenic echotexture with
no focal
liver lesions identified. There is no intra- or extra-hepatic
ductal
dilatation with the common bile duct measuring 4 mm. The
gallbladder is
normal with no evidence of stones or distention. The spleen is
mildly
enlarged at 13 cm. Bilateral kidneys are without hydronephrosis
or stones. A 1.6 x 1.7 x 1.1 cm simple cyst is visualized in the
lower pole of the left kidney.
There is a moderate free abdominal fluid consistent with
ascites.
COLOR AND SPECTRAL DOPPLER WAVE ASSESSMENT: Color and pulse wave
Doppler
examinations demonstrate patent main, right, and left portal
veins with
hepatopetal flow. The right, middle, and left hepatic veins
appear patent
with appropriate flow. The splenic vein appears patent.
IMPRESSION:
1. Moderate free fluid in the abdomen consistent with ascites.
2. Patent hepatic and splenic vasculature.
3. Cirrhotic appearing liver and splenomegaly.
.
CT CHEST, ABD & PELVIS W/O CONTRAST Study Date of ___:
CT CHEST: There is a large non-hemorrhagic right pleural
effusion with
compressive atelectasis. Tiny focal areas of tenting along the
right lung
base (300B, 50 and 2, 40) are nonspecific findings, and could be
followed on subsequent exams. The left lung and right upper lung
remain well aerated. Central airways are patent.
There is no mediastinal, hilar, or axillary lymphadenopathy.
There is,
however, confluent nodular nodal disease in the epicardial
region, replacing normal fat plane (2, 38), likely metastatic
disease. This extends to the anterior pericardium and appears
intimately associated with it (2, 33). Multivessel coronary
arterial disease is present. Note is made of retained contrast
in the mid to lower esophagus, which is nonspecific but could be
seen in the setting of esophageal dysmotility.
CT ABDOMEN: The liver appears small and nodular in contour
suggestive of
cirrhosis. There is a large non-hemorrhagic abdominal ascites.
Non-contrast technique limits visceral assessment. Allowing for
such, no focal liver lesion is appreciated. The gallbladder,
spleen, pancreas, and adrenal glands appear within normal
limits. The kidneys demonstrate no radiopaque stone or
hydronephrosis. Great vessels are normal in caliber. Moderate
atherosclerotic calcifications are seen in the infrarenal aorta
extending into common iliac arteries.
The stomach contains oral contrast, outlining marked diffuse
gastric wall
thickening along the lesser and greater curvatures (2, 62),
which is
concerning for either primary gastric malignancy or linitis
plastica related to secondary neoplastic disease. Small and
large bowel loops appear normal in caliber. Scattered colonic
diverticula are seen predominantly in the sigmoid colon without
evidence of diverticulitis. There is no obstruction, free air,
or extraluminal contrast.
There is diffuse nodular nodal disease in the mesentery, along
the
gastrohepatic ligament and replacing fat planes in the
periportal space and along the lesser gastric curvature. In
addition, there is pronounced omental studding (2, 71) with
nodal masses measuring up to 2 cm. There is discrete and
confluent nodal disease along the celiac and SMA axes. There is
prominent left para-aortic nodal disease measuring up to 2.2 cm
(for example 2, 66) with additional sites of nodular thickening
within the left para-aortic space (2, 77). The aortocaval space
appears relatively spared.
CT PELVIS: The ascitic fluid extends to the pelvis. The bladder,
distal
ureters, and rectum appear unremarkable. The prostate is
enlarged to 6.7 cm. There is no inguinal or pelvic side wall
adenopathy by size criteria.
BONE WINDOW: Note is made of sclerotic changes in the right
parasymphyseal
superior pubic ramus, which is nonspecific and could relate to
prior injury or post-traumatic degenerative change. Moderate
multilevel thoracolumbar spondylosis, disc space narrowing, and
endplate sclerosis appear most pronounced at T12-L1 and L5-S1.
IMPRESSION:
1. Diffuse mural thickening along the lesser and greater
curvatures of the
stomach, concerning for primary or secondary neoplasm (including
gastric
lymphoma). Recommend further assessment by direct visualization
via endoscopy with potential biopsy.
2. Widespread diffuse omental, mesenteric, and retroperitoneal
nodal disease, as well as coalescing epicardial nodular nodal
disease closely associated with the anterior pericardium.
3. Nodular liver contour suggestive of cirrhosis. Large ascites.
4. Large right pleural effusion with compressive atelectasis.
5. Nonspecific focal areas of tenting in the right lung base,
could be
monitored on follow-up exams.
.
TTE ___:
-----------
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. The estimated
cardiac index is normal (>=2.5L/min/m2). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The ascending aorta and
aortic arch are mildly dilated. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Dilated thoracic aorta.
Normal biventricular cavity sizes with preserved global
biventricular systolic function.
If the clinical suspicion for aortic dissection is moderate or
high, a thoracic/chest CT/MRI or a TEE is suggested.
.
TTE ___:
------------
Very limited image quality. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is grossly normal (LVEF>55%). Right
ventricular chamber size and free wall motion are grossly
normal. The aortic valve is not well seen. There is no aortic
valve stenosis. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of ___, there is no apparent change but the technically
suboptimal nature of both studies precludes definitive
comparison.
.
SKELETAL SURVERY ___:
FINDINGS:
SKULL: There are no focal lytic or blastic lesions.
THORACIC SPINE: There are degenerative changes with spurring
particularly at the lower thoracic spine. No compression
deformities or definite lytic or blastic lesions are seen.
LUMBAR SPINE: There is some wedging of the T11 and T12 vertebral
bodies
anteriorly and prominent spurring. There are degenerative
changes with loss of intervertebral disc height worse at L5/S1
as well as anterior spurring. Posterior facet joint arthropathy
of the lower lumbar spine is also identified.
BILATERAL HUMERI: No focal lytic or blastic lesions are present.
AP PELVIS AND BILATERAL FEMORA: There are moderate degenerative
changes of
both hips, left side worse than right. No definite lytic or
blastic lesions are seen within the femurs or within the pelvis.
Vascular calcifications are identified.
IMPRESSION:
Degenerative changes as described above without definite lucent
myelomatous deposits.
Brief Hospital Course:
The patient is a ___ man with past history significant
only for remote history of lower extremity DVT who was
transferred from ___ on ___ after presenting with
abdominal bloating and abnormal labs. In the ___ there, he was
found to have acute kidney injury and ascites. Since transfer
here, has been found to have malignant ascites, most likely
lymphoblastic lymphoma (myc mutation positive) based on gastric
biopsy ___ pending) with widespread nodal disease. He
underwent a bone marrow biopsy on ___, with abnormal cells
seen, formal results pending at this time. Pt received Velcade,
Mesna and cytoxan in addition to steroid pulse. His kidney
function improved to Cr of 1.3 on discharge day which seemed
most likely a pre-renal etiology. He required Rasburicase to
lower his uric acid in addition to allopurinol. His LDH and uric
acid were much better upon discharge compared to admission
values. During his stay, he was found to have new cirrhosis with
splenomegaly. He will be followed for his oncological issues
with Dr ___ at ___ ___ at 10 AM.
.
# Plasmblastic lymphoma vs Plasmablastic myeloma : Patient was
admitted with new onset ascites, with diagnostic tap concerning
for 91% "other" cells. This raised concern for malignancy, which
prompted CT chest/abdomen/pelvis. His CT scan was suggestive of
metastatic cancer, suspicious for gastric primary, with
widespread nodal disease including omentum, mesentery,
retroperitoneal, epicardial and anterior pericardium. Patient
had a TTE which was not suggestive of any impaired cardiac
funtion secondary to epicardial/pericardial involvement. His
cytology and pathology revealled findings suggestive of
lymphoblastic lymphoma with myc mutation positive. Alternative
diagnosis of anaplastic myeloma was also entertained. He was
transferred to the ___ service for continued treatment. He
received Dexamethasone 40 mg IV DAILY for 4 days,
Cyclophosphamide 760 mg IV Q12H on Days 1, 2 and 3. ___,
___ and ___, Mesna 1520 mg IV Days 1, 2 and 3.
___ and ___ (600 mg/m2), Bortezomib 3.3 mg
IV Day 1. (___) (1.3 mg/m2) and 2.6 mg IV Day 4 on
(___) (1.3 mg/m2). Tumor lysis labs were checked every 8
hours. These improved with IVF's initially and upon initial
improvement, IVF's were held given volume overload. His labs
remained stable. He is discharged with neupogen 480 mcg sq
injection daily for 10 days with 2 refills. There was no
allopurinol on discharge.
.
# Ascites: Patient's new onset ascites was thought to be
secondary to malignant ascites. His initially diagnostic tap
revealled 5700 WBC, for which he was started of ceftriaxone.
However, the differential cell count revealled no PMNs, with 91%
other cells so his antibiotics were discontinued. Because of his
renal failure, we did not attempt diuresis, but patient did have
(3L) therapeutic paracentesis with improvement in his symptoms.
His abdomen became less distended during hospital course after
initiation of chemotherapy and did not require additional
paracenteses.
.
# Cirrhosis: Patient had evidence of cirrhosis noted on
ultrasound and CT scan. Patient had no history of previous liver
dysfunction, denied any history of heavy alcohol use though
noted to dirnk alcohol on social history. His LFTs were stable
and his hepatitis panel was negative for hep A, B, and C. His
___ was also negative, and there was no evidence of
hemochromotosis. He had no physical exam findings concerning for
decompensated cirrhosis. Hepatology was consulted while in house
and have recommended liver biopsy for further evaluation. He
does not have evidence of portal hypertension (thrombocytopenia,
varices) or end stage liver disease (hyperbilirubinemia or
coagulopathy). Low albumin likely associated with malignancy.
Instructions were given not to drink any alcohol beverages.
.
# Acute kidney injury: Patient was admitted with creatinine of
2.5 from baseline 1.1. FeNa here 0.1%, which supports that this
is pre-renal from depleted intravascular volume. He received 25g
albumin on admission, 50 g following day, then had 500cc fluid
challenge with no response, which suggests possible hepatorenal
syndrome type physiology. However, liver team didn't feel
strongly about hepatorenal syndrome. His urine sediment was
unrevealing other than uric acid crystals, no evidence of ATN,
only trace protein in urine. There was concern about possible
urate nephropathy contributing to his renal failure, however the
renal team did not feel this was likely given that he was not
oliguric. Diuresis was held given renal failure. Renal function
overall improved gradually with Cr down to 1.3 on discharge day.
SPEP & UPEP negative. Instructions were given to avoid high
potassium diet.
.
# Elevated uric acid: Patient had uric acid crystals on urine
sedimentation. His serum uric acid was elevated initially to
15.5, with worsening to 18. His other electrolytes were normal
so there was no concern for spontaneous tumor lysis. Given that
his uric acid continued to rise, he received 2 doses of
rasburicase during his stay. He was on allopurinol in between
and till discharge day. His uric acid was 3.7 on discharge. No
allopurinol on discharge.
.
# NSVT: He developed asymptomatic 29 beats of NSVT while asleep
___ AM. Cardiology team was consulted. There was a
question from hypoxia (?OSA though no prior diagnosis or sleep
study) versus previous coronary disease. No ventricular
dysfunction seen on Echo, but could not rule out given poor
image quality. Also, EKG with Qs inferiorly, ? previous MI. Tpn
< 0.01. Repeat echo was of poor image quality but didn't show
significant difference from prior or pericardial/myocardial
involvement. Metoprolol 25 mg twice daily was initiated with no
HR > 100 afterwards. He had a very brief few beats of NSVT
following metoprolol initiation but remained vitally stable and
asymptomatic throughout.
.
# Likely oral thrush. Patient reported pain while swallowing
since endoscopy ___. This was managed by fluconazole 200mg
daily and Nystatin swish and spit four times a day and resulted
in resolution of symptoms and signs.
.
.
TRANSITIONAL ISSUES:
- Patient to see Dr. ___ in ___ ___ at
___ on ___ for consultation.
- Pt being discharged with PICC line in place, he has been given
line care instructions.
- Please follow up final bone marrow and gastric biopsy (___)
pathology reports
Medications on Admission:
Aspirin 81 mg daily
Discharge Medications:
1. Neupogen 480 mcg/0.8 mL Syringe Sig: One (1) injection
Injection once a day for 10 days.
Disp:*10 injections* Refills:*2*
2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Malignant Ascites
lymphoma unspecified 202.88,
Acute renal failure
Cirrhosis
oral thrush
Non-sustained Ventricular Tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
It was a great pleasure to participate in your care. You were
admitted to the hospital with abdominal distension. We found
that you have fluid in your abdomen (called ascites) and that
you have cancer in your stomach and lymph nodes. You were
treated with chemotherapy and recommended that you follow-up
with oncology as an outpatient. You will be seen at ___.
During your stay, it was found that your kidneys were not
functioning well. With IV fluids your kidney function slowly but
dramatically improved close to your baseline level but did not
go back to normal values. Kidney doctors were following with you
during your stay.
We also found that you have liver disease and the initial work
up did not help to diagnose the possible etiology. The liver
doctors ___ and recommended liver biopsy at some stage
in the future to help further diagnosis.
In addition, your heart was beating fast without symptoms in a
rhythm called (NSVT). Heart doctors were involved in your care
and recommended to start a new medication called metoprolol
(please see below). Echo was done and did not show abnormal
heart wall motion.
Please make the following changes to your medications:
- Please START Neupogen 480 mcg injection daily
- Please START metoprolol 25 mg twice daily
- Please STOP aspirin 81 mg daily
Please see below for your follow-up appointment at ___.
Followup Instructions:
___
|
10669660-DS-18
| 10,669,660 | 27,520,238 |
DS
| 18 |
2182-12-09 00:00:00
|
2182-12-12 09:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Unresponsiveness
Major Surgical or Invasive Procedure:
Intubation with mechanical ventillation
History of Present Illness:
Mr. ___ is a ___ with intractable paranoid schizophrenia,
hypertension, diabetes mellitus, and cerebrovascular accident
without residual deficits who was found to be unresponsive in
bed at his group home. He has a longstanding history of paranoid
schizophrenia refractory to multiple antipsychotic medications,
with current regimen including PO clozapine and IM risperidone.
He was reported to be denying his medications in the ___ weeks
prior to admission, believing himself to be entirely well and
his medications to be toxic.
On the day prior to admission, he was reportedly in his usual
state of health and took his medications for the day. After
smoking a cigarette, he returned to his room to lie down in bed.
Some time later, he was found unresponsive, including to tactile
stimuli, by his nursing team, who noted him to be flaccid and
drooling, with gurgling and frothing at his mouth, but no
urinary or fecal incontinence. Vital signs at that time included
systolic blood pressure in the ___ and heart rate in the 130s in
association with fingerstick blood glucose of 153.
At ___, labs were notable for sodium of
127, CK of 1593, and negative toxicology screen. EKG was within
normal limits with nonprolonged QTc. Noncontrast head CT head
was negative, as was CTA chest. On transfer to ___ ED, CTA
head and neck were negative. However, he required intubation for
airway protection protection prior to admission to the MICU,
where he was extubated soon after arrival and alert and oriented
x3, calm without complaint.
Past Medical History:
Paranoid schizophrenia
Cerebrovascular accident previously with right-sided paralysis,
dysarthria, dysphagia, and gait abnormality, all resolved
Diabetes mellitus
Hypertension
Hyperlipidemia
Insomnia
Anxiety
Social History:
___
Family History:
Noncontributory.
Physical Exam:
On admission:
Vitals- Afebrile, 110, 134/68, 100% 50%FiO2
___- Intubated, on fentanyl, arousable to vouce
HEENT- PERRLA, anicteric, no facial assymetry
Neck- non elevated JVD
CV- regular, tachycardic, no murmurs
Lungs- Clear on left, diminished breath sounds on right listened
anteriorlly
Abdomen- soft, NT, ND, normal BS
GU- Foley with clear, blood tinged urine
Ext- no edema
Neuro- moves all extremeties, no focal deficits, withdraws to
pain, corneal reflex intact, negative babinski
At discharge:
Vitals- 98.4, 105-106/60-61, 86-88, 18, 97%RA
___- calm, interactive and responsive to questions, no
apparent distress
HEENT- sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP not visualized
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, normal S1 and S2
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding
Ext- warm, well perfused, no clubbing, cyanosis or edema
Skin- clear
Pertinent Results:
On admission:
___ 07:00PM BLOOD WBC-8.1 RBC-4.54* Hgb-12.3* Hct-40.0
MCV-88 MCH-27.1 MCHC-30.8* RDW-14.5 Plt ___
___ 07:00PM BLOOD ___ PTT-29.4 ___
___ 07:00PM BLOOD Glucose-120* UreaN-15 Creat-0.7 Na-130*
K-4.2 Cl-100 HCO3-20* AnGap-14
___ 07:00PM BLOOD CK(CPK)-1328*
___ 07:00PM BLOOD CK-MB-8 cTropnT-<0.01
___ 11:13PM BLOOD CK-MB-9 cTropnT-<0.01
___ 11:13PM BLOOD Calcium-8.3* Phos-3.3 Mg-1.5*
___ 11:28PM BLOOD ___ pO2-55* pCO2-47* pH-7.30*
calTCO2-24 Base XS--3
___ 07:24PM BLOOD Lactate-1.8
___ 07:00PM URINE Color-Straw Appear-Clear Sp ___
___ 07:00PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 07:00PM URINE RBC-14* WBC-0 Bacteri-NONE Yeast-NONE
Epi-0
___ 07:00PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
In the interim:
___ 03:56PM URINE Color-Straw Appear-Clear Sp ___
___ 03:56PM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-TR Bilirub-NEG Urobiln-2* pH-6.5 Leuks-NEG
___ 03:56PM URINE RBC-62* WBC-1 Bacteri-NONE Yeast-NONE
Epi-0
___ 03:56PM URINE Hours-RANDOM UreaN-188 Creat-32 Na-94
K-12 Cl-89
___ 03:56PM URINE Osmolal-376
___ 01:23AM URINE Color-Straw Appear-Clear Sp ___
___ 01:23AM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 01:23AM URINE RBC-6* WBC-2 Bacteri-NONE Yeast-NONE
Epi-0
___ 01:23AM URINE Hours-RANDOM Creat-32 Na-119 K-16 Cl-134
___ 01:23AM URINE Osmolal-433
At discharge:
___ 05:25AM BLOOD WBC-6.6 RBC-4.43* Hgb-11.9* Hct-37.6*
MCV-85 MCH-26.8* MCHC-31.6 RDW-14.3 Plt ___
___ 05:25AM BLOOD Glucose-130* UreaN-12 Creat-0.5 Na-133
K-4.0 Cl-98 HCO3-25 AnGap-14
___ 05:25AM BLOOD Calcium-9.2 Phos-2.5* Mg-1.6
Microbiology:
Blood cultures x2 (___): No growth to date
Urine culture (___): No growth
Imaging:
CTA head/neck with/without contrast (___):
1. No acute intracranial process.
2. Mild calcification at the proximal internal carotid arteries
bilaterally but no evidence of flow limiting stenosis or other
abnormality on CTA head or neck.
3. Prominent thyroid isthmus where nodule is not excluded.
Recommend
ultrasound for further evaluation.
EEG (___):
This is an abnormal EEG due to the presence of a slower than
average background with bursts of generalized slowing consistent
with a mild encephalopathy of toxic, metabolic, or anoxic
etiology. With stimulation, a faster background is produced. No
asymmetries of voltage or frequency are seen, and no
epileptiform activity was captured at the time of this
recording.
ECG (___):
Sinus rhythm at the upper limits of normal rate. Non-diagnostic
Q waves in
leads III and aVF but with T wave abnormalities. Consider prior
inferior wall myocardial infarction. RSR' pattern in lead V1.
Borderline low precordial voltage. Possible early repolarization
pattern in the precordial leads. No previous tracing available
for comparison.
IntervalsAxes
___
___
ECG (___):
Baseline artifact. Sinus tachycardia. Since the previous tracing
the rate is slightly faster. Artifact is more prominent.
Clinical correlation is
suggested.
IntervalsAxes
___
___
Brief Hospital Course:
Mr. ___ is a ___ with intractable paranoid schizophrenia,
hypertension, diabetes mellitus, and cerebrovascular accident
without residual deficits who was found to be unresponsive in
bed at his group home.
Active Issues:
# Loss of consciousness: The cause of his loss of consciousness
was not entirely clear, but was felt in discussion with the
psychiatry service to be most likely oversedation from multiple
antipsychotic medications. IM risperidone monotherapy, with
discontinuation of PO risperidone and PO clozapine, was advised
henceforward to avoid oversedation. Noncontrast head CT was
negative for acute intracranial pathology while CTA chest was
negative for pulmonary embolism or other thoracic pathology.
There was low suspicion for acute coronary syndrome in the
absence of acute ischemic EKG changes or troponinemia, and
cardiac arrhythmia, particularly Torsades in the setting of
multiple QTc prolonging agents, was felt to be unlikely, given
nonprolonged QTc on admission and no further events on
telemetry. In the setting of mild hyponatremia, EEG was negative
for seizure activity. He was reportedly euglycemic when found
unresponsive at his nursing, effectively precluding
hypo/hyperglycemic episode. While he required intubation for
airway protection in the ___ ED, he was extubated soon after
arrival to the MICU and remained alert and oriented x3, calm,
and appropriately interactive without recollection of his reason
for admission throughout the remainder of admission.
# Hyponatremia: Mild hyponatremia to 127 likely reflected
hypovolemic hyponatremia, given improvement to 133 at discharge
following gentle IV hydration.
# Paranoid schizophrenia: As above, oversedation from multiple
antipsychotic medications was felt to be most likely responsible
for transient unresponsiveness. In discussion with the
psychiatry service, IM risperidone monotherapy, with
discontinuation of PO risperidone and PO clozapine, was advised
henceforward to avoid oversedation. Following extubation, he
remained alert and oriented x3, calm, and appropriately
interactive without recollection of his reason for admission
throughout the remainder of admission.
Inactive Issues:
# Diabetes mellitus: Home oral regimen was held in favor of
Humalog insulin sliding scale in house, with resumption of home
glipizide and metformin at discharge.
# Hypertension: Home metoprolol and lisinopril were continued
throughout admission.
# Hyperlipidemia: Home simvastatin was continued.
# GERD: Home omeprazole was continued.
Transitional Issues:
* Avoidance of PO clozapine and PO risperidone is advised by the
psychiatry service to prevent oversedation.
* Thyroid ultrasound is advised for further evaluation of
incidentally noted thyroid isthmus prominence on CTA head/neck.
* Hematuria on multiple urinalyses is presumed secondary to
traumatic Foley insertion, but repeat urinalysis is advised in
the outpatient setting to ensure resolution of hematuria.
* Pending studies: Blood cultures x2 (___).
* Code status: Full.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
2. Clozapine 150 mg PO QAM
3. Clozapine 350 mg PO HS
4. Fleet Enema ___AILY:PRN constipation
5. FoLIC Acid 1 mg PO DAILY
6. GlipiZIDE 10 mg PO BID
7. Lactulose 15 mL PO Q8H:PRN constipation
8. Lisinopril 2.5 mg PO DAILY
9. Metoprolol Tartrate 25 mg PO BID
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Milk of Magnesia 30 mL PO Q6H:PRN constipation
12. Multivitamins 1 TAB PO DAILY
13. Omeprazole 20 mg PO DAILY
14. RISperidone Long Acting Injection 50 mg IM Q2W (MO)
15. RISperidone 12 mg PO HS
16. Acetaminophen 650 mg PO Q6H:PRN pain
17. Simvastatin 40 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. FoLIC Acid 1 mg PO DAILY
3. Metoprolol Tartrate 25 mg PO BID
4. Milk of Magnesia 30 mL PO Q6H:PRN constipation
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO DAILY
7. RISperidone Long Acting Injection 50 mg IM Q2W (MO)
8. Simvastatin 40 mg PO DAILY
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. Lisinopril 2.5 mg PO DAILY
11. Lactulose 15 mL PO Q8H:PRN constipation
12. GlipiZIDE 10 mg PO BID
13. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
14. Fleet Enema ___AILY:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Loss of consciousness
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking part in your care during your admission
to ___. As you know, you were
admitted because you were found unresponsive and unconscious in
your bed at your group home. You were intubated to make sure you
could continue breathing safely, and then mechanically
ventilated (a machine breathed for you for a few hours). You
were transfered to the ICU, where you were extubated. The
psychiatry team evaluated you and decided that the event was
most likely due to too much antipsychotic medication, and they
recommended that you take only Risperdal and not Clozaril.
We wish you all the best in the future.
Followup Instructions:
___
|
10669695-DS-20
| 10,669,695 | 23,053,402 |
DS
| 20 |
2159-08-07 00:00:00
|
2159-08-07 15:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Vytorin ___ / Trilipix / Prinivil / metronidazole
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
___: thoracentesis (1L drained from L lung)
___: pleurX placement
History of Present Illness:
Ms ___ is a ___ yo woman with a history of CAD, hypertension,
hypothyroidism, HL, breast CA s/p tx with tamoxifen, CKD,
dementia, bilateral pleural effusions actively being worked up
as an outpatient who presented with SOB.
The patient was found by her son to bent over table complaining
of weakness and shortness of breath. No chest pain but did
complain of left neck pain that has been going on for the past
few weeks. The patient's son took her blood pressure and noticed
it to be low (SBP < 80) and took O2 sat and found it to be <
90%, so he called EMS.
The patient reported that prior to ___ weeks ago she could climb
one flight of stairs, slowly, but without extreme SOB, but now
she was gasping for air at the top of the stairs. She also
reported increased fatigue. She denied CP, but intermittently
complained of chest pressure. The patient was being worked up as
an outpatient for pleural effusions with active lasix titration.
She was initially taking 40 mg PO QD of lasix, which was started
about 2 weeks prior. She took that dose for about 2 days and
then the PCP recommended decreasing the dose to 20 mg PO QD due
to high UOP on the higher dose.
Despite lasix initiation, the patient continued to have
symptoms, including DOE, orthopnea, PND, and ___ edema, so her
PCP ordered ___ CXR on ___. CXR noted new bilateral pleural
effusions, large on the left and small on the right, with
partial collapse of the left lower lobe. She was started on
emperic PNA tx with levofloxacin and completed 7 day course. She
was also reffered to ___ clinic and was seen there on ___ at
which time the patient and family were offered thoracentesis
verusus watchful waiting, lasix titration, and follow-up in 2
weeks. The patient and family opted to wait, but in the interim
the patient's symptoms worsened.
Initial BP in the field 70/p, HR 78; then HR up to 140s, BP
110s/50s
In the ED, initial vitals were 97.6 134 99/48 23 94% RA. She was
found to have inspiratory crackles diffusely and dry mucous
membranes with some peripheral edema. EKG showed Afib with RVR.
Labs showed leukocytosis to 14k and Cr 2 (baseline 1.4-1.7,
hyponatremia to 128. CXR showed increasing L pleural effusion.
She was given 250cc NS, ceftriaxone and azithromycin and
admitted to medicine. Afib resolved after 250cc bolus per ED
sign out.
On the floor, the patient was more comfortable. She reported
that her breathing was somewhat more labored than usual, but she
did not feel short of breath. She had a new cough that developed
over the prior 2 days, but denied sputum production, hemoptysis,
fever/chills. No lower extremity redness, pain (over baseline).
Past Medical History:
- HTN
- Hyperlipidemia
- CAD
- Constipation
- Hypothyroidism
- Gout
- Depression
- Primary hyperparathyroidism
- h/o invasive ductal carcinoma, dx ___ 1, estrogen
receptor strongly positive, 100% of cells exhibiting nuclear
staining, progesterone receptor positive, HER-2/neu negative.
tx: neo-hormonal therapy (tamoxifen)
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission physical:
VS: 97.6 139/71 74 16 93% RA
GEN: Elderly woman, laying in bed, not using accessory muscles
to breathe, NAD
HEENT: NC/AT, sclera non-ictenic, OP clear, dry MM
NECK: Supple, no JVD
CV: RRR, nl S1 and S2, no MGR
RESP: Decreased breathsounds halfway up the left lung with
scattered crackles at the bilateral lung bases
ABD: +BS, soft, NT, ND, no HSM
GU: No foley
EXTR: WWP, no c/c/e
SKIN: No rashes
NEURO: A&Ox1-2 (knew name and that she was in a hospital, but
not the name of the hospital), CN II-XII grossly intact, full
strength throughout, gait assessment deferred
.
Discharge physical:
VS: 99./ 113/45 64 16 96 3L NC
GEN: Elderly woman, laying in bed right lateral decubitus
position, not using accessory muscles to breathe, NAD
HEENT: MMM, spontaneously opened eyes X1
CV: RRR, nl S1 and S2, no MGR
RESP: no increased WOB, Decreased breathsounds, scattered
crackles bilaterally
ABD: +BS, soft, NT, ND, no HSM
GU: foley draining clear yellow urine
EXTR: WWP,
NEURO: somnolent, not arousable to voice, opens eye
spontaneuosly, purposeful movements in both UE and ___
Pertinent Results:
Admission labs:
___ 08:45AM BLOOD WBC-13.9*# RBC-3.76* Hgb-9.8* Hct-31.7*
MCV-84 MCH-26.1* MCHC-30.9* RDW-15.6* Plt ___
___ 08:45AM BLOOD Neuts-88.3* Lymphs-4.7* Monos-5.5 Eos-1.3
Baso-0.3
___ 06:15AM BLOOD ___ PTT-30.3 ___
___ 08:45AM BLOOD Glucose-115* UreaN-54* Creat-2.0* Na-128*
K-4.8 Cl-95* HCO3-19* AnGap-19
___ 08:45AM BLOOD ALT-11 AST-25 CK(CPK)-39 AlkPhos-106*
TotBili-0.4
___ 08:45AM BLOOD Albumin-3.4* Calcium-10.2 Phos-3.6 Mg-2.1
.
Micro:
All blood/urine/respiratory cultures negative
.
Imaging:
___ EKG
Sinus rhythm. Mildly prolonged Q-T interval. Compared to tracing
#3 the
findings are similar.
TRACING #4
.
___ CXR: Large left pleural effusion, increased compared to
prior, with
presumed subsequent collapse of the left lower lobe and probably
lingula.
Underlying consolidation is not excluded.
.
___ EKG
Atrial fibrillation with a rapid ventricular response. Diffuse
low voltage. Right bundle-branch block. Prior inferior
myocardial infarction. Left anterior fascicular block. Compared
to the previous tracing of ___ atrial fibrillation with a
rapid ventricular response has appeared. Ventricular ectopy is
absent. Otherwise, no diagnostic interim change.
.
___ TTE: The left atrium and right atrium are normal in
cavity size. Normal left ventricular wall thickness, cavity
size, and regional/global systolic function (biplane LVEF = 56
%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). There are three
aortic valve leaflets. The aortic valve leaflets are moderately
thickened. There is mild aortic valve stenosis (valve area
1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is a moderate sized circumferential
pericardial effusion without echocardiographic signs of
tamponade. IMPRESSION: Suboptimal image quality. Moderate
circumferential pericardial effusion without evidence for
tamponade physiology. Mild aortic valve stenosis. Mild mitral
regurgitation. Increased PCWP. If clinically indicated, serial
assessment is suggested.
.
___ TTE: Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets are moderately thickened.
The mitral valve leaflets are mildly thickened. There is a
moderate (1.3-1.7cm) sized circumferential pericardial effusion
that is large (3.0cm) around the right atrium (likely 350-450 ml
fluid). Anterior stranding is visualized within the pericardial
space c/w organization. There are no echocardiographic signs of
tamponade.
.
___ CXR: In comparison with the study of ___, there
has been reaccumulation of a substantial amount of left pleural
effusion. Otherwise little change.
.
___ Pleural fluid: no malignant cells
.
CHEST (PORTABLE AP) Study Date of ___ 10:11 AM
There is cardiomegaly, which is stable. There is a large
retrocardiac
opacity. Bilateral pleural effusions, left greater than right
are seen. The infiltrates bilaterally remain stable. There are
no pneumothoraces.
Calcification in thoracic aorta is present. There is likely a
mild element of fluid overload.
.
Brief Hospital Course:
Ms. ___ is a ___ yo F with h/o CKD stage IV, DM2, Heart
Failure with preserved ejection fraction, CAD, hypothyroidism,
invasive breast CA s/p tamoxifen, and known bilateral pleural
effusions and pericardial effusion, who p/w weakness and dypsnea
on ___, transferred to the MICU on ___ for increased work of
breathing and hypoxemia, and intermittent Afib with RVR,
transferred back to the medicine service for comfort-focused
care and discharge home with hospice.
.
# GOC: After ongoing discussions with family, patient
transitioned from full code to DNR/DNI and subsequently toward
CMO. She was discharged home ___ with minimum medications
necessary for her comfort and hospice care.
.
# Paroxysmal atrial fibrillation: Likely secondary to possible
underlying pulmonary infection and/or volume depletion. The
patient intermittently experienced afib with RVR that was
initially treated with small fluid boluses and IV metoprolol
pushes. In MICU, she was given metoprolol/diltiazem/digoxin for
afib w/RVR. She was in SR most of the time. Initially we thought
about anticoagulation given CHADS 3, but patient was poor
candidate given risk of bleeding, medical comorbidities and
eventually was unnecessary as we shifted focus to end of life
care. On the medical floor, we also stopped the telemetry
monitoring, diltiazem and digoxin. The patient remained
comfortable and was discharged on metoprolol and home hospice.
.
# Hypoactive delirium: Likely in the setting of acute illness,
medications, being in the hospital/ICU, and eventually was also
attributed to approaching end of life. Was noted to have poorer
attention and increased lethargy on floor, which worsened during
MICU course. When she got to the medical floor after MICU stay,
patient was mostly somnolent and not following commands but with
rare spontaneous eye opening. Placed on delirium precautions
with pain control, minimizing tethering, frequent reorientation,
minimize sedating meds and eventually simplified medications to
only the necessary meds when focus shifted to end of life care.
.
# L pleural effusion c/b hypoxia: Initially concerned about
possible CAP vs malignant effusion as patient had h/o breast
cancer vs CHF as patient had DOE, orthopnea and PND. Patient had
no fevers, chills, but did report new cough and had a
leukocytosis. Patient had been emperically tx as outpt for PNA
with levofloxacin on ___ x 7 days without significant change
in symptoms and then finished a 5 day course of Azithromycin
while in the hospital. Had 1L fluid drained from L lung on
___, cytology negative, transudative. TTE on ___ showed
diastolic dysfunction and a pericardial effusion; CHF was
thought to be the likely explanation for pleural effusions and
less likely pna. Patient was transferred to MICU ___,
where she was weaned down to low-flow O2 w/daily lasix and
received L pleurex catheter on ___ ___. She was admitted to the
medical floor ___ and was maintained on ___ NC, pleureX
drained QOD and PRN for symptom control. Discharged home with
PleureX and on 3L oxygen NC.
.
# Pericardial effusion: Large effusion noted on TTE on ___ with
no tamponade physiology. Repeat TTE on ___ unchanged. Patient
carefully monitored and treated symptomatically.
.
# Weakness: Patient had no focal neurologic deficits. Etiology
thought to be related to hypovolemia vs unstable atrial
fibrillation. Improved with fluids initially and worked with ___
with some improvement. However, the patient was in hypoactive
delirium later in the hospital course and hence could not
assess.
.
# Acute-on-chronic CKD: Most likely hypovolemic due to poor PO
intake and diuresis. Fluid status was carefully managed with
fluids vs lasix as patient. Eventually lasix stopped when focus
was on end of life given no PO intake for many days and likely
going forward
.
# Chest pain: Patient has history of CAD with h/o STEMI followed
by PCI and stent to proximal and distal RCA, PTA to OM2 in ___.
Most recent stress was in ___ without evidence of acute
ischemia. Patient now with intermittent CP that lasts only a few
seconds. Non-radiating, non-pleuritic. Likely secondary to
irritation from pleural effusion. Patient had EKG in ED and on
the floor, which is unchanged from prior. Troponins mildly
elevated to 0.02 with max 0.03, but CK/MB flat, likely due to
demand in the setting of AF with RVR and acute-on-chronic CKD.
Patient maintained on telemetry, continued on ASA 325 mg PO QD
and atorvastatin. Nifedipine and olmesartan eventually held
given low SBP and ___. Eventually held all medications and
focused on end of life care.
.
# Hyponatremia: Differential includes hypovolemic hyponatremia
versus SIADH, given large left pleural effusion and question of
malignancy. Cytology from thoracentesis negative. Urine lytes
showed FENa 0.37, likely pre-renal. Patient was hydrated with
caution given pulmonary edema. Improved during MICU course.
.
>> CHRONIC ISSUES
# Hypertension: Patient initially normotensive but had episodes
of soft bp's after metoprolol administration. Held nifedipine
and olmesartan for ___. Eventually held all medications and
focused on end of life care.
.
# Hyperlipidemia: Continued on atorvastatin but Eventually held
all medications and focused on end of life care.
.
# Hypothyroidism: Continued on home levothyroxine but Eventually
held all medications and focused on end of life care.
.
Transitional issues:
# CODE STATUS: DNR/DNI -> CMO
# CONTACT: ___ HCP (son) ___
# Medical list simplified to only comfort-focused meds.
# Patient with pleurX tube to be emptied every other day and as
needed for pt comfort
# Patient will go home on oxygen
# Patient at aspiration risk, NPO in the hospital will take PO
at home for comfort per family wishes
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Benicar (olmesartan) 40 mg Oral daily
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Escitalopram Oxalate 5 mg PO DAILY
7. Levothyroxine Sodium 100 mcg PO DAILY
8. NexIUM (esomeprazole magnesium) 40 mg Oral daily
9. NIFEdipine CR 30 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Tamoxifen Citrate 10 mg PO BID
12. Vitamin D ___ UNIT PO DAILY
13. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
heartburn, indegestion
14. Acetaminophen 325 mg PO Q6H:PRN pain
15. Oxybutynin 10 mg PO DAILY
16. Furosemide 20 mg PO DAILY
Discharge Medications:
1. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
RX *dextran 70-hypromellose [Artificial Tears] ___ drops into
each eye as needed Disp #*1 Bottle Refills:*0
2. Lidocaine 5% Ointment 1 Appl TP DAILY
RX *lidocaine HCl 3 % Apply to area of pleurX catheter daily
Disp #*1 Tube Refills:*0
3. Polyethylene Glycol 17 g PO DAILY:PRN constipation
4. Acetaminophen ___ mg PO Q6H:PRN pain
RX *acetaminophen 500 mg/5 mL 500-1000mg liquid(s) by mouth
every 6 hours Refills:*0
5. Metoprolol Tartrate 25 mg PO BID
Please give as long as pt able to take pills.
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice daily
Disp #*28 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses: Rapid Afib, Hypoactive delirium,
Decompensated diastolic heart failure, pleural effusions
Discharge Condition:
Mental Status: somnolent, opens eyes intermitently
Bedbound
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___. You were admitted
with shortness of breath and were found to have fluid around
your lungs. You also had an abnormal heart rhythm called atrial
fibrillation that caused your heart to beat fast. We drained the
fluid from your lungs and also gave you some new medications to
prevent fluid overload and keep your heart rate normal. You also
needed to spend some time in the intensive care unit for closer
monitoring. A drain was placed around your lung to help drain
the fluid building up.
Through discussions with your family, we focused on treating
your pain and making you comfortable. You will transition back
to home to continue focusing on your comfort with the help of
hospice providers.
Sincerely,
Your ___ medicine team
Followup Instructions:
___
|
10669823-DS-21
| 10,669,823 | 20,115,763 |
DS
| 21 |
2160-11-14 00:00:00
|
2160-11-15 14:53:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin
Attending: ___.
Chief Complaint:
bilateral lower extremity redness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ woman with PMH mild Alzheimers disease, HTN,
Depression, presenting with one week of bilateral leg swelling
and bilateral redness for 1 week. Patient noted swelling that
started in her right leg week ago. The erythema then spread to
her left leg, but never became as bad as her right leg. Right
leg was quite painful, but still able to ambulate. No insighting
scratch or cut. Nothing like this has ever happened before. She
went to her daughter's house in ___ over the weekend, went in the
pool, but the pain did not subside. She did note diffuse
itchiness on her legs, but not in the area of swelling. Her
swelling moved to her upper thighs and she became concerned and
went to her PCP, who sent her to the ED.
In the ED, initial vitals were: 98 62 128/79 18 98% ra.
- Labs were significant for wbc 6.5, Hgb 12.3, Hct 38.1, plt
147. Na 140, K 4.5, BUN 22, Cr 0.8. INR 1. Seen by surgery, who
felt there was low suspicion of necrotizing infection and with
stable vitals.
- Imaging revealed bilateral LENIS negative for DVT. CT lower
extremity prelim read was negative for soft tissue gas, but
mild-moderate edema of right lower extremity next to knee. No
evidence of discrete fluid collection.
- The patient was given flagyl, vanc, zosyn.
Vitals prior to transfer were: 97.7 58 147/76 18 95% RA.
Upon arrival to the floor, 97.5, 150/62, 60, 18, 95RA. Patient
is pleasant, lying in bed, no acute distress. She still has pain
in her right thigh and tenderness to palpation. Denies fever,
chills, recent viral illnesses, sick contacts, chest pain,
shortness of breath, weakness in legs. No history of DVT or PE.
No new medications. Of note, she does have baseline difficulty
with her bowels, with frequent episodes of incontinence for ___
year. Unable to recount all of her medications due to mild
alzheimers. Did not know her daughter's phone number. Records
are in ___ system and could not not be obtained at night.
Will need to be followed up in the morning.
Past Medical History:
asthma
gastroesophageal reflux disease
depression
overactive bladder
hyperlipidemia
insomnia
Social History:
___
Family History:
Son deceased in his ___, had MI with bypass at age ___, daughter
with CAD.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: 97.5, 150/62, 60, 18, 95RA
General: Elderly woman, lying comfortably in bed, Alert,
oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, Both
pupils reactive to light, right pupil slightly smaller in
diameter to left
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: bilateral legs with diffuse erythema from ankle spreading
up to thighs. Right leg with swelling of medial thigh next to
knee, tender to palpation, warm to the touch. Left leg with less
swelling, minimally tender to touch. Erythema has been
demarcated. No crepitus. Multiple small excoriations on lateral
aspect of legs due to scratching.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE PHYSICAL EXAM
========================
Vitals: 98.5,, afebrile overnight 122/49 69 18 93%RA
General: lying in bed, NAD
HEENT: Sclera anicteric, MMM, PERLL
Neck: Supple, JVP not elevated, no LAD
CV: RRR, no murmurs
Lungs: CTAB
Abdomen: + BS, soft, non-tender, non-distended
GU: No foley
Ext: bilateral legs with improved diffuse erythema from ankle
spreading up to thighs. Right leg with swelling of medial thigh
next to knee, tender to palpation, warm to the touch, unchanged
from ___. Left leg with less swelling, minimally tender to
touch. No crepitus. Multiple small excoriations on lateral
aspect of legs due to scratching.
Neuro: symmetrical facial features, appropriate affect, strength
___ throughout
Pertinent Results:
ADMISSION LABS:
================
___ 05:21PM BLOOD WBC-6.5 RBC-4.22 Hgb-12.3 Hct-38.1 MCV-90
MCH-29.1 MCHC-32.3 RDW-13.2 RDWSD-42.7 Plt ___
___ 05:21PM BLOOD ___ PTT-31.4 ___
___ 05:21PM BLOOD Glucose-170* UreaN-22* Creat-0.8 Na-140
K-4.5 Cl-104 HCO3-27 AnGap-14
DISCHARGE LABS:
================
___ 07:45AM BLOOD WBC-6.0 RBC-3.71* Hgb-10.8* Hct-33.3*
MCV-90 MCH-29.1 MCHC-32.4 RDW-13.3 RDWSD-43.5 Plt ___
___ 07:45AM BLOOD Glucose-206* UreaN-15 Creat-0.9 Na-141
K-3.8 Cl-104 HCO3-26 AnGap-15
MICRO:
=======
___ 3:13 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 8:00 pm BLOOD CULTURE x2: No growth at time of
discharge
IMAGING:
=========
BILAT LOWER EXT VEINS Study Date of ___
IMPRESSION:
No evidence of deep vein thrombosis in the bilateral lower
extremity veins.
CT LOW EXT W/O C BILAT Study Date of ___
IMPRESSION:
1. No evidence of necrotizing fasciitis or osteomyelitis.
2. Extensive lower extremity subcutaneous edema, right greater
than left
extending to the ankles.
3. Irregularly thickened bladder. Please correlate clinically
and with UA.
US LOWER EXTREMITY, SOFT TISSUE RIGHT Study Date of ___
IMPRESSION:
1. Subcutaneous edema of the right mid thigh. No evidence of
fluid
collection or gas.
Brief Hospital Course:
___ y F with mild Alzheimers disease admitted with 1 week of
bilateral leg erythema and swelling.
# Bilateral leg swelling and erythema: negative CT and LENIs, as
well as negative soft tissue absecess, and no crepetis on exam.
Most consistent with cellulitis given erythema/warmth, but
atypical that it's bilateral. Per daughter, she scratches her
legs so may have introduced bacteria through small scratch.
Started on vanc/zosyn/flagyl in the ED, briefly switched to vanc
and ceftriaxone before transitioning to PO keflex and bactrim
for a total planned antibiotic course of 7 days. Blood cultures
from admission without growth. She remained afebrile with stable
VS.
# irregularly thickened bladder: findings seen on admission CT.
Has history of urinary incontinence for many years. No symptoms
of UTI, and urine culture without growth.
# Mild Alzheimers: continued on Donepezil 5 mg PO QHS
# HTN: most recently on carvedilol 12.5 mg BID, but HRs in high
50's so she was initially started on 6.25 mg BID. Tolerating
12.5 mg BID on discharge.
# Depression: continued BuPROPion (Sustained Release) 150 mg PO
DAILY, Escitalopram Oxalate 20 mg PO/NG DAILY
# COPD: unclear if taking any COPD medications at home. Lungs
clear on exam. Did not require albuterol during her stay. ___
benefit from further investigation as an outpatient.
# Insomnia: continued traZODone 100 mg PO QHS:PRN insomnia
# GERD: continued omeprazole 20 mg PO DAILY
TRANSITIONAL ISSUES:
====================
# discharged on keflex and bactrim to complete a 10 day course
# Irregularly thickened bladder noted on admission CT: UA
without evidence of infection, but recommen further work-up if
pt symptomatic
# Per ___ records, patient has not been prescribed COPD
medications in years, however per daughter she uses an old
inhaler at home. No wheezing/SOB during admission, but may
warrent further investigation as an outpatient
# Chronic diarrhea: stable during admission, may warrant further
outpatient work-up
# Elevated blood glucose as well as finger sticks in the
___ throughout stay, perhaps in the setting of infection.
Deferred further work-up to PCP
___ on ___:
The Preadmission Medication list is accurate and complete.
1. LOPERamide 2 mg PO QID:PRN diarrhea
2. Omeprazole 20 mg PO BID
3. TraZODone 100 mg PO QHS:PRN insomnia
4. Carvedilol 12.5 mg PO BID
5. Donepezil 5 mg PO QHS
6. BuPROPion (Sustained Release) 150 mg PO DAILY
7. Escitalopram Oxalate 20 mg PO DAILY
8. Atorvastatin 40 mg PO QPM
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. BuPROPion (Sustained Release) 150 mg PO DAILY
3. Carvedilol 12.5 mg PO BID
4. Donepezil 5 mg PO QHS
5. Escitalopram Oxalate 20 mg PO DAILY
6. LOPERamide 2 mg PO QID:PRN diarrhea
7. Omeprazole 20 mg PO BID
8. TraZODone 100 mg PO QHS:PRN insomnia
9. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours
Disp #*28 Capsule Refills:*0
10. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*14 Tablet Refills:*0
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:
Dear ___,
___ was a pleasure caring for you during your recent admission.
You came to the hospital because of leg pain, redness, and
swelling. We made sure that this was not due to a deep infection
or a blood clots in your legs, which it was not. We believe
these symptoms were caused by a cellulitis, or infection of the
skin. We treated you with antibiotics and your symptoms
improved.
Please take your medications as directed and follow-up with your
doctors as ___ below.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10670085-DS-18
| 10,670,085 | 25,603,584 |
DS
| 18 |
2194-03-22 00:00:00
|
2194-03-22 17:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Ampicillin / Ceftin / Bactrim / Zocor / Lopressor / Rezulin
Attending: ___.
Chief Complaint:
left hip infection
Major Surgical or Invasive Procedure:
left hip incision and drainage, placement of articulating
antibiotic spacer in left hip
History of Present Illness:
Patient is a ___ yo F s/p I&D, hardware removal, and
antibiotic spacer placement on ___. She returns for rehab for a
HCT of 22 and sanguinous drainage from the L hip. During her
recent hospitalization she received 3U RBCS for post-operative
anemia with stabilization of her HCT at 24.3. Tissue culture
grew
coagulase negative staph, staphylococcus Lugdunesus, the same
organism found in her prior hip infections. She remained
afebfile
without any signs of sepsis. She was started on IV vancomycin
and
had PICC line placed. She states her pain has been well
controlled and she denies any fevers/chills, nausea/vomitting,
diarrhea. She states the L hip began draining more sanguinous
fluid today.
Past Medical History:
- Coronary artery disease s/p 4 vessel CABG ___: LIMA to LAD,
reverse saphenous vein graft from aorta separately to ramus
intermedius, obtuse marginal, and posterolateral branch of RCA.
- Re-do sternotomy for AVR (___) for critical symptomatic
critical aortic stenosis with bovine AVR
- Carcinoid tumor of right middle lung lobe s/p resection.
- Diabetes mellitus, type 2
- Hypertension
- Hyperlipidemia
- Deep venous thrombosis, ___, on Coumadin X6 months. Stopped
Coumadin, had another ___ placed on Coumadin since, s/p IVC
filter, ___ reports being off of coumadin now
- Oxygen dependent since lung surgery and for obstructive sleep
apnea, uses 2L nasal cannula 02 only at night at home. No Bpap
for obstructive sleep apnea.
- Restrictive lung disease
- carpel tunnel syndrome b/l, ___ s/p decompression
- Chronic Diastolic heart failure (left atrium is mildly
dilated.
LVEF ___
- Anemia of Chronic disease, baseline ___
Social History:
___
Family History:
Denies any family history of blood clot. REports vague family
history o heart attacks.
Her mother was diagnosed with diabetes.
Physical Exam:
AVSS
NAD
sitting up in bed
symmetric chest rise
L hip incision c/d/i
LLE:
Fires ___
SITLT s/s/cp/dp
wwp
2+ cr
1+ dp/pt
Pertinent Results:
___ 02:27PM COMMENTS-GREEN TOP
___ 02:27PM LACTATE-0.7
___ 02:10PM GLUCOSE-96 UREA N-18 CREAT-1.0 SODIUM-137
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-28 ANION GAP-10
___ 02:10PM WBC-8.3 RBC-2.59* HGB-7.7* HCT-23.9* MCV-93
MCH-29.6 MCHC-32.1 RDW-16.7*
___ 02:10PM NEUTS-82.5* LYMPHS-11.9* MONOS-3.5 EOS-1.8
BASOS-0.3
___ 02:10PM PLT COUNT-264
Brief Hospital Course:
The patient was admitted to the Orthopaedic Trauma Service for
repair of a left hip infection. The patient was taken to the OR
and underwent an uncomplicated incision and drainage and
placement of articulating antibiotic space. The patient
tolerated the procedure without complications and was
transferred to the PACU in stable condition. Please see
operative report for details. Post operatively pain was
controlled with a PCA with a transition to PO pain meds once
tolerating POs. The patient tolerated diet advancement without
difficulty and made steady progress with ___.
The patient was transfused 2 units of blood for acute blood loss
anemia.
Weight bearing status: PWB LLE.
The patient received ___ antibiotics as well as
lovenox for DVT prophylaxis, which was switched to subcutaneous
heparin on the day of discharge. The incision was clean, dry,
and intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 2 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge.
Medications on Admission:
1. Aspirin 81 mg PO DAILY
2. Senna 1 TAB PO DAILY:PRN Constipation
3. Docusate Sodium 100 mg PO DAILY Contipation
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Multivitamins 1 TAB PO DAILY
6. Calcium 500 With D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit Oral Twice daily
7. Bromday *NF* (bromfenac) 0.09 % ___ daily
8. Atorvastatin 40 mg PO DAILY
9. Acetaminophen ___ mg PO Q6H:PRN Pain
10. Carvedilol 6.25 mg PO BID
Hold for BP<90 or HR<60.
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Bisacodyl 10 mg PR HS:PRN Constipation
13. Clarithromycin 500 mg PO Q12H Duration: 9 Days
14. Enoxaparin Sodium 40 mg SC DAILY Duration: 19 Days
15. MetRONIDAZOLE (FLagyl) 500 mg PO BID Duration: 9 Days
16. Ondansetron 4 mg IV Q8H:PRN nausea
17. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
Hold for excessive sedation.
RX *oxycodone 5 mg 0.5 (One half) capsule(s) by mouth q6hrs Disp
#*30 Capsule Refills:*0
18. Pantoprazole 40 mg PO Q12H
19. Vancomycin 750 mg IV Q 24H
20. NPH 10 Units Breakfast
NPH 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H pain
standing dose
RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6)
hours Disp #*90 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. Bisacodyl 10 mg PO DAILY:PRN constipation
5. Carvedilol 6.25 mg PO BID
Hold for BP <90 or HR< 60
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
7. Heparin Flush (10 units/ml) 3 mL IV PRN line maintenance
8. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. Multivitamins 1 TAB PO DAILY
11. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 0.5-1.0 tablet(s) by mouth every four to six
(___) hours Disp #*60 Tablet Refills:*0
12. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Senna 1 TAB PO BID
15. NPH 4 Units Breakfast
NPH 4 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
16. Vancomycin 750 mg IV Q 24H
RX *vancomycin 750 mg infuse through PICC line once a day Disp
#*20 Packet Refills:*0
17. Furosemide 40 mg PO DAILY
18. Heparin 5000 UNIT SC TID Duration: 14 Days
RX *heparin (porcine) 5,000 unit/mL inject into abdomen three
times a day Disp #*42 Syringe Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
left hip infection
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:
******SIGNS OF INFECTION**********
Please return to the emergency department or notify MD if you
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.
-Wound Care: You can get the wound wet/take a 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 and/or at your rehab facility. No dressing is needed
if wound continued to be non-draining.
Weigh yourself every morning. ___ your MD if weight goes up by
more than 3lbs.
******WEIGHT-BEARING*******
Partial weight bearing L leg
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
- Take subcutaneous heparin for DVT prophylaxis for 2 weeks
post-operatively.
Physical Therapy:
PWB LLE
Treatments Frequency:
dry to dry; if non draining, no change needed
Followup Instructions:
___
|
10670085-DS-21
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DS
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2194-12-28 00:00:00
|
2194-12-28 17:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ampicillin / Ceftin / Bactrim / Zocor / Lopressor / Rezulin /
Ultram / Flagyl
Attending: ___.
Chief Complaint:
rigors
Major Surgical or Invasive Procedure:
___ - Percutaneous cholecystostomy placed by interventional
radiology
History of Present Illness:
___ with hx of CAD s/p CABG, aortic stenosis s/p bovine AVR, DM2
& h/o left hip septic joint s/p removal of hardware who presents
with rigors. Patient is a poor historian, so history is obtained
primarily from her daughter. Daughter reports that patient was
in her usual state of health until the morning of admission
around 11:00am when the family noticed that her arms, legs and
mouth were shaking; lasted approximately 20 min. Patient was
alert and conversant during this time, however, family was
concerned that she was having a grand mal seizure, so they
called ___.
In the ED, initial VS were T 101, HR 122, BP 153/78, RR 19, SpO2
100% 2L NC. Denied any chest/abdominal pain or urinary symptoms.
Labs were significant for WBC 10.2 with 93% PMNs, anion gap 17,
lactate 3.7, and phosphate 9.9. No evidence of infection on CXR
or urinalysis. Given fever, elevated lactate, and concern for
increased lethargy, in the context of having a bovine valve, the
ED was concerned for endocarditis vs. meningitis. A lumbar
puncture was attempted, but unsuccessful. Patient was given 3L
NS, as well as imipenem 1g IV, vancomycin 1g IV, and acyclovir
500mg IV to cover meningitis and endocarditis. Vital signs on
transfer were
On arrival to the floor, patient states that she feels better.
She is intermittently crying. Patient's daughter states that she
is at her baseline mental status (since last ___) and notes
that she does not appear more lethargic.
REVIEW OF SYSTEMS:
(+) Per HPI, fever, chills, nausea & one episode of vomiting on
the day of admission, constipation for a few days until day of
admission when she had 3 bowel movements, bloating/abdominal
pain which improved after having BMs this afternoon
(-) Denies headache, night sweats, neck stiffness, photophobia,
recent weight loss or gain. Denies rhinorrhea or congestion.
Denied cough or shortness of breath. Denied chest pain or
tightness, palpitations. Denied diarrhea. No recent change in
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
1. Coronary artery disease (4-vessel CABG, ___: LIMA-LAD,
RSVG-RI, OM and PLA of RCA)
2. Critical, symptomatic aortic stenosis with bovine AVR (re-do
sternotomy for wound dehiscence with rib plating, ___
3. Carcinoid tumor of the lung (right middle lobe, s/p
resection)
4. Obstructive sleep apnea (oxygen-dependent since lung
resection; utilizes 2L nasal cannula O2 only at nighttime; no
BiPAP)
5. History of chronic congestive heart failure
6. History of deep venous thrombosis (in ___ twice, s/p IVC
filter placement; no chronic anticoagulation since ___
7. Hypertension
8. Hyperlipidemia
9. Insulin-dependent diabetes mellitus
10. Restrictive lung disease
11. Carpel tunnel syndrome (bilateral decompressions, ___
12. Chronic systolic heart failure (LVEF 40% in ___
13. Anemia of chronic disease (baseline HCT ___
14. Seizure disorder with first convulsive seizure ___
(noted to have multiple episodes of non-convulsive status
epilepticus durng continuous EEG monitoring during that
admission; on keppra now)
PAST PERTINENT SURGICAL HISTORY:
1. s/p right middle lobe resection, VATS for carcinoid tumor
(___)
2. s/p intramedullary rod fixation of left subtrochanteric femur
fracture (___)
3. s/p irrigation debridement left hip joint, arthrotomy,
exchange bipolar component left hip hemiarthroplasty (___)
4. s/p debridement and irrigation of hip abscess, removal of
arthroplasty hardware components, antibiotic spacer placement,
VAC application for wound closure (___)
5. s/p debridement irrigation hip hematoma, removal of
antibiotic spacer and placement of functional antibiotic spacer
and application of surface VAC sponge (___) for left septic
hip joint
Social History:
___
Family History:
Denies significant family history of cardiovascular disease,
early MI, arrhythmia or sudden cardiac death. Father with a
history of lung cancer.
Physical Exam:
ADMISSION EXAM
VS: T 98.8, BP 92/42 (R) 85/35 (L), HR 88, RR 18, SpO2 98% RA,
59.1kg
GEN: alert, oriented to person (occasionally to place, not
usually to time), appears comfortable, but intermittently crying
HEENT: NCAT. EOMI, PERRL, sclerae anicteric. MMM. no LAD. no
JVD. neck supple.
CV: RRR, normal S1/S2, III/VI systolic murmur heard best at
RUSB, no rubs or gallops.
LUNG: CTAB, no wheezes, rales or rhonchi
ABD: soft, mild discomfort to palpation of LLQ, ND, +BS. no
rebound or guarding. neg HSM.
EXT: W/WP, no edema, no C/C. 2+ ___ pulses bilaterally.
SKIN: W/D/I, left hip with well-healed surgical scar
NEURO: CNs II-XII grossly intact. Moving all extremities.
sensation intact to LT.
.
DISCHARGE EXAM
.
V/S: 98.0 98.0 134/62 78 18 97% RA
I/O: 660 / 450 | Inc, perc chole - ___
___: 140, 242, 278, 284
GEN: alert, oriented to person, occasionally to place, appears
comfortable
HEENT: NCAT. EOMI, PERRL, sclerae anicteric. MMM. Mildly
diaphoretic.
Neck: supple, no LAD or JVD
CV: RRR, normal S1/S2, III/VI mid-systolic murmur heard best at
PMI
LUNG: decreased breath sounds at bases; no wheezes, rales or
rhonchi
ABD: +BS, soft, RUQ tenderness is minimal, minimally distended,
no rebound or guarding; percutaneous cholecystostomy tube has
brownish-yellow output with some mild sanguinous drainage
surrounding insertion site. No palpable hematoma, mild
ecchymoses.
EXT: WWP, no ___ edema, 2+ ___ pulses bilaterally
SKIN: W/D/I, left hip with well-healed surgical scar
NEURO: CNs II-XII grossly intact. Moving all extremities.
sensation intact to LT.
Pertinent Results:
ADMISSION LABS:
.
___ 12:30PM BLOOD WBC-10.5# RBC-4.17* Hgb-12.2 Hct-36.2
MCV-87 MCH-29.3 MCHC-33.7 RDW-13.7 Plt ___
___ 12:30PM BLOOD Neuts-93.1* Lymphs-4.2* Monos-2.3 Eos-0.3
Baso-0.1
___ 12:43PM BLOOD ___ PTT-27.8 ___
___ 12:30PM BLOOD Glucose-205* UreaN-31* Creat-1.0 Na-139
K-4.4 Cl-102 HCO3-20* AnGap-21*
___ 08:05AM BLOOD ALT-1104* AST-809* AlkPhos-414*
Amylase-15 TotBili-1.9* DirBili-1.8* IndBili-0.1
___ 12:30PM BLOOD Calcium-9 Phos-9.9*# Mg-1.6
___ 12:37PM BLOOD Lactate-3.7*
.
DISCHARGE LABS:
.
___ 07:33AM BLOOD WBC-4.6 RBC-3.61* Hgb-10.2* Hct-32.9*
MCV-91 MCH-28.3 MCHC-31.1 RDW-14.2 Plt ___
___ 07:33AM BLOOD ___ PTT-29.1 ___
___ 07:33AM BLOOD Glucose-121* UreaN-8 Creat-0.7 Na-140
K-3.8 Cl-110* HCO3-22 AnGap-12
___ 04:30AM BLOOD ALT-226* AST-30 AlkPhos-323* TotBili-1.4
___ 07:33AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.7
___ 08:09AM BLOOD Lactate-1.0
.
MICROBIOLOGY:
___ Blood Culture, Routine-PENDING
___ STOOL C. difficile DNA amplification assay-FINAL;
FECAL CULTURE-PENDING; CAMPYLOBACTER CULTURE - negative
___ Blood Culture, Routine-PENDING
___ Blood Culture, Routine-PENDING
___ Blood Culture, Routine-PRELIMINARY {GRAM NEGATIVE
ROD(S)}; Aerobic Bottle Gram Stain-FINAL; Anaerobic Bottle Gram
Stain-FINAL (2 morphologies)
___ Blood Culture, Routine-PENDING
___ URINE CULTURE-FINAL {ENTEROCOCCUS SP.}
___ Blood Culture, Routine-PRELIMINARY {ESCHERICHIA
COLI}; Aerobic Bottle Gram Stain-FINAL; Anaerobic Bottle Gram
Stain-FINAL
IMAGING:
___ CT ABD/PELVIS: 1. Distended gallbladder with
cholelithiasis. Minimal wall thickening in the setting of
anasarca. No adjacent fat stranding to suggest inflammation.
Overall, no evidence for cholecystitis. No intrahepatic biliary
ductal dilation.
2. Stranding and thickening of the rectum thought to represent
proctitis. 3. A 1.2 cm right lower lobe enhancing nodule
raising suspicion for metastatic disease. 4. Unchanged
appearance of the left femur. 5. Small bilateral pleural
effusions.
___ EUS: Small amount of blood in the stomach, most likely
from stress ulcers. No active bleeding noticed. Multiple small
erosions were noted in the first and second portion of the
duodenum. Non-bulging, normal major papilla. EUS was performed
using a linear echoendoscope at ___ MHz frequency. The common
bile duct was found to be of normal caliber, 3.3mm, with no
shadowing foci or dilatation. The gallbladder was dilated with a
thickened wall. The pancreatic parenchyma was normal, with a
''salt and pepper'' appearance. The pancreatic duct was not
found to be dilated. Given the above, non dilated CBD with no
evidence of stones/sludge, and no pus from the papilla, a
decision was made not to proceed with ERCP.
___ RUQ u/s: 1. Cholelithiasis with findings suspicious for
acute cholecystitis although gallbladder wall edema may
represent ___ spacing related to patient's low albumin level of
2.1 and recent aggressive fluid resuscitation. Further
evaluation with urgent HIDA scan is recommended. 2. No
biliary dilation. 3. Splenomegaly.
___ HIDA scan: GB does not fill after 60 minutes of scan
suggesting cystic duct obstruction
___ CXR: Low lung volumes with probable bibasilar
atelectasis. Probable small right pleural effusion.
Brief Hospital Course:
IMPRESSON: ___ with PMH significant for CAD s/p CABG, AS s/p
bovine AVR, DM2 & septic left hip joint s/p removal of hardware
who presented with rigors, found to have E.coli bacteremia with
presumed biliary source complicated by Enterococcal urine
colonization, who improved with antibiotic treatment.
.
# E.coli sepsis with presumed biliary source: Admitted with
rigors and LFT abnormalities with clinical picutre concerning
for sepsis. She had evidence of biliary obstruction and
abdominal pain that likely reflected transient biliary
obstruction with a cholelith that passed. HIDA imaging was
positive and there was concern for cholecystitis and gallbladder
inflammation as well. She was volume resuscitated and received
broad spectrum antibiotics. Blood cultures speciated a sensitive
E.coli and she was transitioned to Cipro IV for 2-weeks. She
received a percutaneous cholecystostomy tube on ___ as
requested by general surgery. She had some mild serosanguinous
oozing at the drain insertion site which resolved with a
pressure dressing and surgicel placement. Her hemodynamics
remained stabled and her hematocrit was stable; thus she did not
require transfusion. Her rigors resolved, her abdominal pain
improved, her LFTs improved and she was discharged on PO Cipro
for a 2-week course. She was tolerating diet with minimal pain
at discharge. She will need follow-up with surgery in two weeks,
and they will consider cholecystectomy at that time.
.
# Enterococcus in the urine: U/A without evidence of infection,
likely represents colonization as she remained asymptomatic and
improved with treatment of her biliary infection. She initially
received 4-days of Vancomycin and with discontinuation she
remained stable.
.
# IDDM2: Fingersticks were low on admission in the setting of
sepsis. She was maintianed on an insulin sliding scale without
issues.
.
# OSA: Patient does not use CPAP at home, but does
intermittently use 2L NC.
.
# CAD: No current symptoms. Continued daily aspirin dosing. Held
atorvastatin given transaminitis and bilirubinemia. Cardiac
enzymes were trended and were negative.
.
# HLD: Held atorvastatin given transaminitis and bilirubinemia.
.
# AOCM: Hematocrit at baseline this admission.
.
# Hx seizures: continued home Keppra dosing without issues.
.
TRANSITIONAL ISSUES:
1. A 1.2 cm right lower lobe enhancing nodule of the lung was
noted this admission on imaging, raising suspicion for
metastatic disease.
2. Will complete 14-days total of oral Cipro from the time of
percutaneous cholecystostomy placement.
3. Continue insulin sliding scale and consider changing back to
insulin 70/30 if necessary.
4. Will need perc chole removal and follow-up with ACS in clinic
to consider cholecystectomy.
5. Resume atorvastatin when LFTs normalize.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO HS
2. Multivitamins 1 TAB PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. LeVETiracetam 500 mg PO BID
5. Docusate Sodium 100 mg PO BID Hold for loose stools
6. bromfenac 0.09 % ___ 1gtt OD qhs
7. Calcium Carbonate 1250 mg PO HS
8. 70/30 10 Units Breakfast; 70/30 3 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
9. Aspirin EC 81 mg PO DAILY
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Calcium Carbonate 1250 mg PO HS
3. Docusate Sodium 100 mg PO BID
4. LeVETiracetam 500 mg PO BID
5. Vitamin D 1000 UNIT PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. bromfenac *NF* 0.09 % ___ 1gtt OD qhs
8. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
9. Acetaminophen 1000 mg PO Q8H pain
10. Ciprofloxacin HCl 750 mg PO Q12H Duration: 19 Doses
started ___, ending ___
11. Polyethylene Glycol 17 g PO DAILY
12. Senna 1 TAB PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. E.coli bacteremia from a presumed biliary source
2. Vancomycin-sensitive Enterococcal urinary tract infection
SECONDARY DIAGNOSIS:
1. Insulin-dependent diabetes mellitus
2. Coronary artery disease
3. Obstructive sleep apnea
4. Anemia of chronic disease
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 ___,
___ was a pleasure taking care of you during your stay at ___.
You were admitted to the hospital with rigors and fever and
found to have bacteremia (bacteria in your blood) and a urinary
tract infection. You received IV fluids and antibiotics and your
abdominal pain complaints improved. You had a percutaneous
cholecystostomy (gallbladder drain) placed this admission which
will need to stay in place for several weeks, until you see the
surgeons to discuss. You will continue on oral antibiotics for a
total of 2-weeks. You are being discharged to a rehabilitation
facility to improve your strength and receive nursing care.
It is important that you take all of your medications as
prescribed and keep all of your follow up appointments.
Followup Instructions:
___
|
10670085-DS-22
| 10,670,085 | 24,639,588 |
DS
| 22 |
2195-01-03 00:00:00
|
2195-01-05 22:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ampicillin / Ceftin / Bactrim / Zocor / Lopressor / Rezulin /
Ultram / Flagyl
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Stress myocardial perfusion imaging (___)
History of Present Illness:
___ with hx of CAD s/p CABG ___, aortic stenosis s/p bovine
AVR, DM2 & h/o left hip septic joint s/p removal of hardware
with recent admission for E. coli bacteremia thought to be of
biliary source presenting with chest pain. Patient brought in
by ambulance after awakening from sleep with chest pain at
04:00. Patient reports chest pressure bilaterally. Patient
reports pain lasted for approximately 15 minutes then resolved
with nitroglycerin. She thinks this is similar pain she
experienced prior to getting her CABG in ___. She did
experience similar chest pain in ___, presented and had a
low probability MIBI so was managed medically. In the
intervening period she has not experienced significant chest
pain similar in character to this.
In the ED, initial vitals were 98 82 129/59 16 98%.
In the ER, the patient's labs revealed Ddimer of ___, troponin
of 0.04, CKMB of 2. Due to the patient's elevated Ddimer, she
had a CTA of the chest to evaluate for PE, which was negative.
Her EKG was with Q waves in the inferior leads and no current
ST-T wave changes.
She denied radiation in the ER, although by report she endorsed
radiation to her left arm at triage. Patient received asa 324mg
and ntg x2 prior to arrival in the ambulance. At time of
evaluation in the ER, patient was chest pain free. She only
received Keppra in the ER, and the ER physicians wanted to order
a stress MIBI which is not possible from the ER on ___, so
she was admitted.
ED Vitals prior to transfer: HR 73 BP 112/43 RR 16 SaO2 100% on
RA
On review of systems, she denies any prior history of stroke,
TIA, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. She denies recent fevers, chills or rigors. She denies
exertional buttock or calf pain. All of the other review of
systems were negative.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
- Coronary artery disease
* CABG (___): LIMA-LAD, TSVG-RI, TSVG-OM, and PLA of RCA.
* Unstable angina ___, stress MIBI with fixed defect
- Chronic systolic heart failure (LVEF 40% in ___
- History of critical aortic stenosis. S/p bovine AVR (___)
- Hypertension
- Dyslipidemia
- Diabetes mellitus, type II
- Carcinoid tumor of the lung (right middle lobe, s/p
resection)
- Obstructive sleep apnea (oxygen-dependent since lung
resection; utilizes 2L nasal cannula O2 only at nighttime; no
BiPAP)
- Restrictive lung disease
- History of deep venous thrombosis (in ___ twice, s/p IVC
filter placement; no chronic anticoagulation since ___
- Carpel tunnel syndrome (bilateral decompressions, ___
- Anemia of chronic disease (baseline HCT ___
- Seizure disorder with first convulsive seizure ___ (noted
to have multiple episodes of non-convulsive status epilepticus
durng continuous EEG monitoring during that admission; on keppra
now) Thought to be due to some antibiotic ? and tramadol
PAST PERTINENT SURGICAL HISTORY:
- s/p right middle lobe resection, VATS for carcinoid tumor
(___)
- s/p intramedullary rod fixation of left subtrochanteric femur
fracture (___)
- s/p irrigation debridement left hip joint, arthrotomy,
exchange bipolar component left hip hemiarthroplasty (___)
- s/p debridement and irrigation of hip abscess, removal of
arthroplasty hardware components, antibiotic spacer placement,
VAC application for wound closure (___)
- s/p debridement irrigation hip hematoma, removal of
antibiotic spacer and placement of functional antibiotic spacer
and application of surface VAC sponge (___) for left septic
hip joint
Social History:
___
Family History:
Denies significant family history of cardiovascular disease,
early MI, arrhythmia or sudden cardiac death. Father with a
history of lung cancer.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T 98.1 BP 146/62 HR 76 RR 12 SaO2 98% on RA
FOBT: Negative, performed by me.
GENERAL: Chronically ill appearing women in no apparent
distress.
HEENT: EOMI, MMM
NECK: JVP ~8cm H2O
CARDIAC: RRR, loud click over RSB. Midline sternotomy
LUNGS: CTAB
ABDOMEN: Nontender, nondistended
RECTAL: Normal rectal tone. Large, hard stool present.
EXTREMITIES: Some ulcerations on legs
SKIN: Stage 1 pressure ulcer on sacrum
PULSES:
Right: 2+ DP, ___
Left: 2+ DP, ___
NEURO: A&Ox3. Moves all four extremities spontaneously,
although LLE with more difficulty than RLE. Upper extremity
strenth intact bilaterally.
DISCHARGE PHYSICAL EXAMINATION:
VS: T 97.9 BP 146/73 HR 86 RR 12 SaO2 100% on RA
Weight: 55.9kg
I/O: NR, biliary drain.
GENERAL: Chronically ill appearing women in no apparent
distress.
HEENT: EOMI, MMM
NECK: JVP ~8cm H2O
CARDIAC: RRR, loud click over RSB. Midline sternotomy
LUNGS: CTAB
ABDOMEN: Nontender, nondistended. Cholecystostomy drain
present, clean/dry/intact.
EXTREMITIES: Some ulcerations on legs
SKIN: Stage 1 pressure ulcer on sacrum
PULSES:
Right: 2+ DP, ___
Left: 2+ DP, ___
NEURO: Moves all four extremities spontaneously, although LLE
with more difficulty than RLE. Upper extremity strenth intact
bilaterally.
Pertinent Results:
___ 05:35AM BLOOD WBC-7.9# RBC-3.49* Hgb-10.2* Hct-30.8*
MCV-88 MCH-29.2 MCHC-33.2 RDW-14.9 Plt ___
___ 07:35AM BLOOD WBC-6.0 RBC-3.48* Hgb-10.1* Hct-31.5*
MCV-91 MCH-29.1 MCHC-32.1 RDW-15.0 Plt ___
___ 07:35AM BLOOD ___ PTT-74.4* ___
___ 05:35AM BLOOD Glucose-219* UreaN-16 Creat-0.8 Na-145
K-3.9 Cl-106 HCO3-28 AnGap-15
___ 07:35AM BLOOD Glucose-341* UreaN-25* Creat-0.9 Na-142
K-4.2 Cl-105 HCO3-26 AnGap-15
___ 05:35AM BLOOD CK(CPK)-13*
___ 03:30PM BLOOD ALT-67* AST-25 LD(LDH)-191 CK(CPK)-16*
AlkPhos-389* TotBili-0.7
___ 07:35AM BLOOD ALT-61* AST-19 LD(LDH)-137 AlkPhos-363*
TotBili-0.6
___ 05:35AM BLOOD cTropnT-0.04*
___ 03:30PM BLOOD CK-MB-2 cTropnT-0.03*
___ 07:35AM BLOOD Albumin-3.1* Calcium-8.7 Phos-4.1 Mg-1.9
Cholest-PND
___ 05:35AM BLOOD ___
CTA CHEST (___)
FINDINGS: The imaged portions of the thyroid gland are normal.
There is no axillary lymphadenopathy. In the mediastinum, there
are multiple enlarged lymph nodes. For example, in the right
paratracheal region, there is a 13-mm lymph node (2, 18). In
the prior exam, it measured 8 mm. Another adjacent lymph node
measures 11 mm (2, 21). It previously measured 6 mm. There is
no hilar lymphadenopathy.
The heart is enlarged. There is no evidence of right heart
strain. There is no pericardial effusion. The thoracic aorta
is normal in course and caliber. There is no evidence of
dissection or acute aortic pathology. Moderate atherosclerotic
disease is noted along its course. Atherosclerotic disease is
also noted within the coronary arteries. Atherosclerotic
calcifications are also noted along the aortic and mitral
valves.
The main pulmonary vein is normal in size without evidence of
pulmonary
hypertension. The pulmonary arteries are patent to the
subsegmental levels. There is no evidence of pulmonary
embolism.
Evaluation of the pulmonary parenchyma is somewhat limited by
respiratory
motion. Within the limitations, no discrete nodule is
identified. There are basilar enhancing consolidations, which
are likely atelectasis. There is mild septal thickening, which
is nonspecific, but likely from mild pulmonary edema. There are
moderate-sized bilateral pleural effusions. They are
nonhemorrhagic. On the right, a portion of the effusion is
loculated. Effusion is also tracking along the fissures. There
is no pneumothorax.
This exam is not tailored to evaluate the subdiaphragmatic
structures. Within the limitations, the imaged portions of the
liver, spleen, and stomach are normal. There is a small hiatal
hernia.
OSSEOUS STRUCTURES: There is a stable compression fracture of
T4. No new
fracture is identified. The patient is status post a
sternotomy, with an
unchanged appearance of the sternum. The associated wires and
hardware are stable. No new rib fracture is identified. Older
deformities of the lateral right eighth and ninth ribs are
unchanged.
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic pathology.
2. Minimal enlargement in the bilateral nonhemorrhagic pleural
effusions with loculated components and associated atelectasis.
Stable cardiomegaly with minimal pulmonary.
3. Enlarged mediastinal lymph nodes, of uncertain etiology,
possibly
reactive. Recommend a follow-up CT of the chest in 6 months,
but preferably when the patient does not have a CHF
exaccerbation.
STRESS TEST
===========
The image quality is adequate but slightly limited by arms being
down.
Left ventricular cavity size is top normal with an EDV of 107mL.
Rest and stress perfusion images reveal uniform a moderate
sized, fixed defect involving the inferior wall. This defect is
slightly less evident on the prior study of ___, where it
appeared moderate to severe but partially reversible.
Gated images reveal hypokinesis of the inferior wall.
The calculated left ventricular ejection fraction is 46%.
IMPRESSION: Moderate, fixed perfusion defect of the inferior
wall with
accompanying inferior wall hypokinesis.
Brief Hospital Course:
___ with PMH significant for CAD s/p CABG, AS s/p bovine AVR,
DM2 & septic left hip joint s/p removal of hardware who had
recent admission with e.coli bacteremia due to presumed biliary
source presenting with unstable angina.
#) UNSTABLE ANGINA: No ECG changes. Ruled out for MI with flat
biomarkers and no recurrent chest pain. While trending cardiac
biomarkers, she was started on a heparin gtt and clopidogrel, as
well as metoprolol, and aspirin. Given recent endoscopy with
some evidence of bleed, we tested her stool which was gauaic
negative. Her heparin gtt and clopidogrel were stopped after
she ruled out for MI.
Given signficant cardiac history and known reversible defect on
prior stress, obtained a stress myocardial perfusion study shich
showed a fixed defect.
- Full dose Aspirin 325mg daily x 1 month, then down to 81mg QD
- Started atorvastatin 80mg QD. Would check LFTs and CKs in two
weeks to ensure tolerance given prior elevated CKs with
simvastatin.
- Started metoprol then transitioned to carvedilol. Would
follow-up tolerance to carvedilol as an outpatient as below.
- Continue risk factor reduction as per PCP
#) PRIOR E. COLI SEPSIS: Presumed biliary source. Alkaline
phosphatase persistently elevated but transaminases were
trending toward normal; thus, statn was started.
- Continued on ciprofloxacin 750 mg PO Q12H, started ___,
ending ___
#) SEIZURE DISORDER: Continue home levetiracetam dosing.
Touched base with outpatient neurologist who had planned to
initiate lacosamide, but had advised to keep the patient on her
home levetiracetam here.
#) DIABETES MELLITUS: Poorly controlled, A1c 8%. Continued on
HISS while here.
#) OSA: No CPAP at home, but uses 2L NC at night
- O2 PRN O2 sat of < 92% on RA
#) AOCM: Hematocrit at baseline this admission. FOBT negative
#CODE: Full Code
#CONTACT: Daughter/HCP ___ ___
TRANSITIONAL ISSUES
===================
[ ] Trend incidental mediastial lymphadenopathy with follow-up
CT scan
[ ] Re-check CK values in 2 weeks. Now on atorvastatin.
Patient previously had elevated CK on simvastatin.
[ ] Follow-up tolerance of beta-blocker carvedilol. Had
previously had "adverse drug reaction" of hyptension while on
metoprolol.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LeVETiracetam 500 mg PO BID
2. Aspirin EC 81 mg PO DAILY
3. Calcium Carbonate 1250 mg PO HS
4. Docusate Sodium 100 mg PO BID
5. Vitamin D 1000 UNIT PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. bromfenac *NF* 0.09 % ___ 1gtt OD qhs
8. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
9. Acetaminophen 1000 mg PO Q8H pain
10. Ciprofloxacin HCl 750 mg PO Q12H
started ___, ending ___
11. Polyethylene Glycol 17 g PO DAILY
12. Senna 1 TAB PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H pain
2. Aspirin EC 81 mg PO DAILY
3. Calcium Carbonate 1250 mg PO HS
4. Ciprofloxacin HCl 750 mg PO Q12H Duration: 4 Days
Started ___, ending ___
5. Docusate Sodium 100 mg PO BID
6. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
7. LeVETiracetam 500 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. Polyethylene Glycol 17 g PO DAILY
10. Senna 1 TAB PO BID
11. Vitamin D 1000 UNIT PO DAILY
12. Atorvastatin 80 mg PO DAILY
13. bromfenac *NF* 0.09 % ___ 1gtt OD qhs
14. Carvedilol 6.25 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Unstable angina
Coronary artery disease
Dementia
Cholecystitis
Diabetes mellitus, type 2
Dyslipidemia
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 Ms. ___,
It was a pleasure taking care of you at ___. You were
admitted for chest pain which was suspicious for a heart source.
Fortunately, you did not have a heart attack. However, given
your medical history of heart problems, we obtained a stress
test which showed a fixed blood flow defect. Please keep your
scheduled follow-up appointments as below.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10670085-DS-26
| 10,670,085 | 24,878,940 |
DS
| 26 |
2195-10-18 00:00:00
|
2195-10-18 20:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ceftin / Bactrim / Zocor / Lopressor / Rezulin / Ultram / Flagyl
/ Keppra / Compazine
Attending: ___.
Chief Complaint:
fever, dysuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS: ___ with history of gastric ulcers,
CAD s/p CABG, AVR with bovine valve not on anticoagulation, HTN,
DM, recent admission for urosepsis c/b e.coli bactermia and
NSTEMI, presents with 4 days of dysuria, increased frequency,
rigors and low grade fevers today to 100.0F, per daughter. ___
culture was obtained by ___ yesterday, and processed at ___
___, reportedly showing a urinary tract infection. No
antibiotics given as an outpatient. Patient and family deny
cough, congestion, sore throat, nausea, vomiting, or diarrhea.
Possibly has some left flank pain. Her last bowel movement was
yesterday and was formed. During her previous admission, her
NSTEMI sypmtoms consisted of shortness of breath.
In the ED intial vitals were: 99.3 75 115/54 20 100%RA. Labs
were significant for lactate 2.1, Cr 1.6, BUN 44, hct 32, WBC
10.1 (90%N). Blood cultures x2 sent. Urine not tested, patient's
daughter refused straight cath. CXR shows hardware from previous
surgery, enlarged heart, no obvious focal area of consolidation.
Patient was given tylenol and ceftriaxone. Vitals prior to
transfer were: 100.4 104 117/44 18 96% RA.
On the floor, patient is comfortable. No chest pain, shortness
of breath, lightheadedness, abdominal pain or suprapubic pain.
Her last episode of rigors was yesterday afternoon.
Review of Systems:
(+) as above
(-) night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, hematuria.
Past Medical History:
- Coronary artery disease
* CABG (___): LIMA-LAD, TSVG-RI, TSVG-OM, and PLA of RCA.
* Unstable angina ___, stress MIBI with fixed defect
- Chronic systolic heart failure (LVEF 40% in ___. Estimated
Dry Weight 150lbs.
- History of critical aortic stenosis. s/p bovine AVR (___)
- Hypertension
- Dyslipidemia
- CKD
- Diabetes mellitus, type II
- Carcinoid tumor of the lung (right middle lobe, s/p resection)
- Obstructive sleep apnea (oxygen-dependent since lung
resection; utilizes 2L nasal cannula O2 only at nighttime; no
BiPAP)
- Restrictive lung disease
- History of deep venous thrombosis (in ___ twice, s/p IVC
filter placement; no chronic anticoagulation since ___
- Carpel tunnel syndrome (bilateral decompressions, ___
- Anemia of chronic disease (baseline HCT ___
- Seizure disorder with first convulsive seizure ___ (noted
to have multiple episodes of non-convulsive status epilepticus
durng continuous EEG monitoring during that admission; on keppra
now) Thought to be due to some antibiotic ? and tramadol
PAST SURGICAL HISTORY:
- s/p right middle lobe resection, VATS for carcinoid tumor
(___)
- s/p intramedullary rod fixation of left subtrochanteric femur
fracture (___)
- s/p irrigation debridement left hip joint, arthrotomy,
exchange bipolar component left hip hemiarthroplasty (___)
- s/p debridement and irrigation of hip abscess, removal of
arthroplasty hardware components, antibiotic spacer placement,
VAC application for wound closure (___)
- s/p debridement irrigation hip hematoma, removal of antibiotic
spacer and placement of functional antibiotic spacer and
application of surface VAC sponge (___) for left septic hip
joint
Social History:
___
Family History:
Denies significant family history of cardiovascular disease,
early MI, arrhythmia or sudden cardiac death. Father with a
history of lung cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - 99.0, 91/43, 100, 18, 96% 2L
GENERAL: NAD, lying flat, breathing comfortably
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, hirsuitism, good dentition, nontender supple
neck, no LAD, no JVD
CARDIAC: tachy, RR, S1/S2, ___ murmur, no gallops or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles lying flat
ABDOMEN: obese, mildly distended, +BS, nontender in all
quadrants, no rebound/guarding, no hepatosplenomegaly. Bluish
hue over abd c/w old ecchymoses. No suprapubic tenderness.
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Vitals: 98.3/97.6 98/48 76 20 100% 2L sleeping (on RA during my
exam)
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, hard to evaluate JVP because patient has thick
neck
Lungs: Bibasilar crackles, otherwise CTAB with good air movement
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic
ejection murmur best at LLSB
Abdomen: normoactive bowel sounds, soft, obese, non-tender,
non-distended, no rebound tenderness or guarding, could not
appreciate organomegaly but exam limited by body habitus
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Warm, dry
Neuro: Mental status wnl, speech fluent and coherent, adequate
historian, Moving all extremities with full strength
Pertinent Results:
ADMISSION LABS:
___ 11:00PM BLOOD WBC-10.1# RBC-3.76* Hgb-10.5* Hct-32.1*
MCV-85 MCH-28.0 MCHC-32.7 RDW-15.0 Plt ___
___ 11:00PM BLOOD Neuts-89.7* Lymphs-5.6* Monos-4.2 Eos-0.3
Baso-0.2
___ 08:00AM BLOOD ___ PTT-30.7 ___
___ 11:00PM BLOOD Glucose-105* UreaN-44* Creat-1.6* Na-137
K-4.6 Cl-98 HCO3-23 AnGap-21*
___ 08:00AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.4*
___ 11:07PM BLOOD Lactate-2.1*
DISCHARGE LABS:
___ 08:30AM BLOOD WBC-4.2 RBC-3.56* Hgb-9.7* Hct-31.1*
MCV-87 MCH-27.3 MCHC-31.2 RDW-15.0 Plt ___
___ 08:30AM BLOOD Glucose-281* UreaN-28* Creat-1.3* Na-138
K-4.7 Cl-97 HCO3-28 AnGap-18
___ 08:30AM BLOOD ALT-91* AST-21 AlkPhos-332* TotBili-0.4
PERTINENT LABS/MICROBIOLOGY:
********OSH labs from ___
___ UA - Leuk esterase 3+, pH 7.5, ketones negative, WBC >
100, bacteria 1+
___ URINE CULTURE ___ labs) - Prot. mirabilis >100,000
cfu/mL
AMPICILLIN Sensitive MIC
CEFAZOLIN Sensitive MIC
CEFOXITIN Sensitive MIC
CEFTAZIDIME Sensitive MIC
CEFTRIAXONE Sensitive MIC
CEPHALOTHIN Sensitive MIC
CIPROFLOXACIN Sensitive MIC
Cefuroxime - Oral Sensitive MIC
Cefuroxime- I.V. Sensitive MIC
GENTAMICIN Sensitive MIC
LEVOFLOXACIN Sensitive MIC
NITROFURANTOIN Resistant MIC
TETRACYCLINE Resistant MIC
TOBRAMYCIN Sensitive MIC
TRIMETHOPRIM/SULFAMETHOXAZOLE Sensitive MIC
___ labs while inpatient********
___ 08:00AM BLOOD calTIBC-215* Ferritn-3267* TRF-165*
___ 08:00AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.4* Iron-25*
___ 09:52AM URINE Color-Yellow Appear-Hazy Sp ___
___ 09:52AM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
___ 09:52AM URINE RBC-3* WBC-65* Bacteri-FEW Yeast-NONE
Epi-3 TransE-<1
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ <=0.5 S
___ 06:25AM BLOOD ALT-557* AST-465* AlkPhos-562*
TotBili-1.6*
___ 06:00PM BLOOD ALT-476* AST-306* AlkPhos-563*
TotBili-1.1
___ 07:20AM BLOOD ALT-344* AST-156* AlkPhos-506*
TotBili-0.8
___ 07:30AM BLOOD ALT-228* AST-54* AlkPhos-409* TotBili-0.6
___ 08:30AM BLOOD ALT-168* AST-32 AlkPhos-386* TotBili-0.5
___ 07:55AM BLOOD ALT-126* AST-24 AlkPhos-361* TotBili-0.4
IMAGING:
___
FINDINGS:
There is normal in echogenicity without evidence focal mass.
These
gallbladder appears distended. Wall was mildly thickened, but
improved
compared with the prior ultrasound. Multiple small stones are
noted. There is no evidence pericholecystic fluid in it was a
negative sonographic ___ sign. There is no significant intra
or extrahepatic biliary ductal dilatation with the CBD measuring
1.9 mm. The visualized portions of the pancreas are
unremarkable without evidence of the mass or ductal dilatation.
D main portal vein was widely patent hepatopetal flow.
Visualized portions of the aorta an IVC are unremarkable.
IMPRESSION:
Cholelithiasis without sonographic evidence of cholecystitis.
Brief Hospital Course:
Ms. ___ is a ___ with history of gastric ulcers, CAD s/p
CABG, sCHF (LVEF 35-40%), AVR with bovine valve not on
anticoagulation, HTN, DM, recent admission for UTI with
resultant e/coli bacteremia, who presented with rigors and
dysuria and was admitted for sepsis with urinary tract
infection. She was stabilized, narrowed to PO antibiotics, and
is now being discharged home on a 10 day course of ciprofloxacin
(ending ___ and 14 day course of amoxicillin (ending
___.
---------------
ACTIVE ISSUES:
---------------
# SEPSIS:
# URINARY TRACT INFECTION: Patient has a history of urosepsis
with cipro resistant e.coli and pansensitive klebsiella,
complicated by e/coli bacteremia and was admitted 1 month prior
for this reason. She presented again with fevers, tachycardia,
symptoms concerning for recurrent UTI (dysuria, increased
frequency), and reports of a positive urine sample drawn by ___
the day prior to presentation. Her ___ culture ultimately grew
pan-sensitive proteus >100,000 colonies and her ___ urine
culture grew ampicillin-sensitive enterococcus. Most likely, she
had polymicrobial UTI. Initially, she was treated with IV
ceftriaxone, which was broadened empirically to IV ciprofloxacin
after noting transaminitis and IV vancomycin after noting urine
positive for enterococcus. For the first few days of admission,
she continued to have low-grade fevers to 100.3, dysuria, and
night sweats as well as transient hypotension to SBP ___. By
___, she was noted to be improved without fevers or night
sweats, with stable hemodynamics, and was switched from IV to PO
ciprofloxacin. On ___, she was switched from IV vancomycin
to PO amoxicillin. Although OMR records an ampicillin allergy,
upon further discussion with the daughter, this may have been
mistakenly recorded due to a language barrier. Also, she
received 2 doses of IV ampicillin ___ with no noted
adverse reaction. She tolerated 2 doses of PO amoxicillin while
inpatient ___ without any adverse reactions. Prior to
discharge, blood cultures were NGTD, patient had been afebrile
>72 hrs, and hemodynamics were stable. She will continue
ciprofloxacin PO 500mg Q12H for a 10 day course until ___
for her proteus UTI and amoxicillin PO 500mg Q8H for a 14 day
course until ___ for her enterococcus UTI. The long course
of antibiotics is for presumed pyelonephritis since the patient
had left flank pain prior to presentation that resolved after
antibiotics.
# TRANSAMINITIS: Her LFTs were noted to be elevated in 400s-500s
at the beginning of the admission. RUQ Ultrasound did not show
any abnormality and patient did not have any RUQ tenderness,
nausea, vomiting, or abdominal pain (she had mild epigastric
pain transiently prior to admission but not while inpatient).
They trended down without intervention. Hepatitis B and C screen
was negative. Most likely etiology of transaminitis was thought
to be shock liver from hypotension due to sepsis prior to
presentation. On discharge, LFTs were: ALT 91, AST 21, AlkPhos
332, Tbili 0.4 and continuing to trend down.
# CHRONIC SYSTOLIC HEART FAILURE: LVEF ___ was 35-40%.
Estimated dry weight 150 pounds and was 151 lbs prior to
discharge. The patient's lungs were clear and she had no
peripheral edema so was deemed euvolemic. She was restarted on
torsemide 40mg daily and metoprolol XL 25mg QHS and tolerated
this well without hypotension >24 hrs prior to discharge. The
daughter was very concerned about low blood pressures;
therefore, she was counseled that she can check her mother's
blood pressure prior to giving torsemide or metoprolol. If SBP <
100 or HR < 60, she can hold either medication and call her PCP
to further discuss the blood pressure regimen.
# CORONARY ARTERY DISEASE
# HYPERTENSION
# HYPERLIPIDEMIA: Admission ECG showed <1mm depressions, which
likely represent from demand ischemia since patient is
asymptomatic. She continued to have no chest pain or dyspnea
during this admission. She was not given aspirin ER 81 mg daily
given history of complicated upper GI bleeds ___ multiple ulcers
and per PCP ___. She was continued on atorvastatin 40mg
daily. Initially, home metoprolol was held while septic but was
restarted after infection was under control and BPs remained
stable. She was continued on nitroglycerin 0.3 mg SL prn but did
not require this while inpatient. Additionally, she was not
given aspirin while inpatient per PCP preference and since this
was not a preadmission medication, given her history of
complicated GI bleeds. However, the patient has high cardiac
risk and no recent GI bleeds, so we recommend that the question
of restarting aspirin 81mg daily be reconsidered by her PCP.
# ACUTE RENAL FAILURE:
# CHRONIC KIDNEY DISEASE STAGE 3: Acute renal failure with Cr of
1.6 on presentation resolved to Cr of 1.1 (baseline) after fluid
resuscitation. Prior to discharge Cr was 1.3 likely due to some
mild hypovolemia but can be followed as an outpatient.
# DIABETES MELLITUS TYPE II, not well-controlled (A1C 8.2
___:
# INSULIN-DEPENDENT DIABETES: Insulin NPH was decreased from AM
dose of 14 to 10units and 4 units to 2 units QPM due to low
blood sugars of ___ initially. Blood glucose rose to 200s the
day prior discharge, so she will be discharged on her home
insulin regimen.
---------------
CHRONIC ISSUES:
---------------
# Anemia of chronic disease: Slightly above baseline at 32 on
admission, possibly hemoconcentrated from infection. Iron level
low 25 but transferrin/TIBC 76%. Ferritin high. So diagnosis is
c/w anemia of chronic disease and supplemental iron may not help
given high transferrin/TIBC. Hematocrit remained stable around
30 on discharge. Despite history of GI bleed, there was no
evidence of active GI bleeding while inpatient.
# Dyspepsia: She was continued on home pantoprazole ER 40 mg
daily
# OSA: Continued on nighttime O2 (2L NC)
# OA/right knee pain: Continued on Lidoderm 5 % (700 mg/patch)
adhesive patch Qday right knee. Acetaminophen was held while
inpatient to prevent masking fever. It was not restarted on
discharge given elevated LFTs on admission. The decision to
restart this medication can be made with the patient's PCP.
---------------
TRANSITIONAL ISSUES:
---------------
# SEPSIS/UTI: Urine culture were positive for proteus and
enterococcus. Blood cultures were negative. Upon discharge, the
patient will continue ciprofloxacin PO 500mg Q12H for a 10 day
course until ___ for her proteus UTI and amoxicillin PO
500mg Q8H for a 14 day course until ___ for her enterococcus
UTI. The long course of antibiotics is for presumed
pyelonephritis since the patient had left flank pain prior to
presentation that resolved after antibiotics. She will follow up
with her ID physician ___ after discharge.
# ACUTE RENAL FAILURE: The patient's Cr was elevated to 1.6 on
admission but trended down to 1.1 with fluid resuscitation. It
was 1.3 on discharge likely because of mild hypovolemia, and can
be trended by the outpatient PCP to ensure resolution of acute
renal failure.
# TRANSAMINITIS/SHOCK LIVER: Transaminitis is most likly
secondary to hypovolemic and septic shock prior to arrival as
they continued to trend down over the course of the patient's
admission. HepB and HepC screen was negative. The patient was
counselled to stop Tylenol, while her liver enzymes are
elevated. She can discuss with her PCP ___ to resume
Tylenol. LFTs can be followed up by her outpatient PCP.
# CAD: The patient has CAD and is s/p CABG ___ and NSTEMI
during her last admission; therefore, she is at high cardiac
risk. We recommended that she discuss with her PCP whether or
not to restart aspirin 81mg daily. Although she has a history of
complicated GI bleeds, she currently does not have evidence of
GI bleeding.
# COUGH: The patient complained of a dry cough, treated
symptomatically with guaifenesin prn and cepastat lozenges prn.
CXR ___ was not remarkable. The patient gave a history of
URI symptoms prior to admission so etiology was thought to be
most likely viral URI. Resolution of cough should be followed by
her outpatient PCP.
# Code: Full
# Emergency Contact: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. NPH 14 Units Breakfast
NPH 4 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
2. Lidocaine 5% Patch 1 PTCH TD QAM right knee
3. Multivitamins 1 TAB PO DAILY
4. Nitroglycerin SL 0.3 mg SL ASDIR
5. Acetaminophen 650 mg PO ASDIR
6. Atorvastatin 40 mg PO DAILY
7. Calcium Carbonate 500 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Docusate Sodium 100 mg PO BID:PRN constipation
10. Metoprolol Succinate XL 25 mg PO HS
11. Pantoprazole 40 mg PO Q24H
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Senna 8.6 mg PO DAILY:PRN constipation
14. Torsemide 40 mg PO DAILY
15. bromfenac 0.07 % ophthalmic Qhs
16. ___ (cranberry extract) 500 mg oral BID
17. Nystatin Cream 1 Appl TP BID breasts
18. Guaifenesin 10 mL PO Q6H:PRN cough
Discharge Medications:
1. Atorvastatin 40 mg PO DAILY
2. bromfenac 0.07 % ophthalmic Qhs
3. Calcium Carbonate 500 mg PO DAILY
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Guaifenesin 10 mL PO Q6H:PRN cough
6. Lidocaine 5% Patch 1 PTCH TD QAM right knee
7. Metoprolol Succinate XL 25 mg PO HS
Hold for systolic blood pressure < 100 or HR < 60
8. Multivitamins 1 TAB PO DAILY
9. Nystatin Cream 1 Appl TP BID breasts
10. Pantoprazole 40 mg PO Q24H
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Senna 8.6 mg PO DAILY:PRN constipation
13. Torsemide 40 mg PO DAILY
Hold for systolic blood pressure < 100 or HR < 60.
14. Vitamin D 1000 UNIT PO DAILY
15. Cepastat (Phenol) Lozenge 1 LOZ PO Q2H:PRN cough or sore
throat
RX *phenol [Cepastat] 14.5 mg Take 1 lozenge Up to every 2 hours
Disp #*90 Lozenge Refills:*0
16. Ciprofloxacin HCl 500 mg PO Q12H
Last dose is on ___
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth Every 12 hours
Disp #*5 Tablet Refills:*0
17. ___ (cranberry extract) 500 mg oral BID
18. Nitroglycerin SL 0.3 mg SL ASDIR
19. Amoxicillin 500 mg PO Q8H
last day = ___
RX *amoxicillin 500 mg 1 capsule(s) by mouth Every 8 hours Disp
#*30 Capsule Refills:*0
20. NPH 14 Units Breakfast
NPH 4 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
------------------
PRIMARY DIAGNOSES
------------------
Urinary tract infection
Sepsis
Hypotension
Shock liver
------------------
SECONDARY DIAGNOSES
------------------
Chronic systolic congestive heart failure
Coronary artery disease
Acute renal failure
Chronic kidney disease, stage III
Diabetes mellitus type II, insulin dependent
Anemia
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 during your hospital stay.
You were admitted to the hospital because you had fever, rigors,
and pain upon urination. You were found to have a urinary tract
infection. At first this was treated with IV antibiotics. After
a few days, you no longer had fevers, your blood pressures
became stable, and you no longer had nighttime sweats or chills.
At this point, your blood cultures were negative, so we felt it
was safe to switch you from IV to PO antibiotics. You will be
discharged with 2 antibiotics: ciprofloxacin and amoxicillin.
Your last day of ciprofloxacin will be ___ for 10 total days,
and your last day of amoxicillin will be ___ for 14 total days.
You were restarted on your blood pressure and heart medications
(lisinopril and metoprolol) before discharge and your blood
pressure was stable. When you are at home, you can continue to
check your blood pressure. If your systolic blood pressure is
less than 100 (the top number) or your heart rate is less than
60, please call your primary care physician to ask if you should
continue taking lisinopril and/or metoprolol.
We also stopped Tylenol while your were in the hospital because
your liver enzymes were high. You should discuss with your PCP
___ you can restart Tylenol.
Please continue to follow up with your primary care physician.
You are now being discharged to home with ___ and ___ services.
Your ___ Team
Followup Instructions:
___
|
10670085-DS-28
| 10,670,085 | 21,322,925 |
DS
| 28 |
2196-12-18 00:00:00
|
2196-12-19 15:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ceftin / Bactrim / Zocor / Lopressor / Rezulin / Ultram / Flagyl
/ Keppra / Compazine / darbepoetin alfa
Attending: ___.
Chief Complaint:
nausea/tremor
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ hx CAD s/p CABg ___, AS s/p bovine AVR ___, CHF, DVT
s/p IVC filter, IDDM, restrictive lung disease, seizures on
keppra, lung carcinoid s/p R middle lobe resection, UGIB, hx
UTIs p/w nausea since last night, insomnia, and abdominal pain.
She states that last night, she noticed acute onset of nausea
after taking Robutussin and Tums. She then developed mild
epigastric abdominal pain with no radiations, last for hours,
characterized as a dull pain, better with food, with 2 episodes
of rigors however no fevers. She had 2 incontinent BMs that were
formed with blood upon wiping her bottom. She also has been
complaining of a dry cough over the last ___s 1.4
lb weight loss since yesterday. This AM, her pulse was noted to
be 124 at home, which prompted her visit to the ED.
Of note, patient was in ICU in ___ for
hypercarbic-hypoxemic respiratory failure and likely sepsis from
urinary source. Cultures in past typically grew fairly sensitive
E. coli, Klebsiella, and proteus (Enterococcus on couple of
occasions). Patient has been bacteremic in the past with E.
coli.
In the ED, initial vital signs were: 98.5 110 121/51 20 97%RA.
Labs were notable for WBC 10.6 (92.2%PMNs), H/H 7.8/26.1, Cr 1.3
(baseline 1.1), ALT 682, AST 1188, ALP 497, lipase 442, trop
<0.01, lactate 2.9, U/A with large ___ and >182 bacteria, 11 epi.
CXR showed mild pulmonary edema, tiny bilateral pleural
effusions with no convincing sign of PNA. CT abd/pelvis showed
cholelithiasis, no evidence of obstruction or diverticulitis.
Patient was given Zosyn x 1 and IVF. Vitals on transfer 98.5 105
125/50 18 97% RA.
Upon arrival to the floor, patient states that she overall feels
okay. Denies any current abdominal pain or nausea. Denies any
dysuria or urinary frequency. Otherwise with no other
complaints.
Past Medical History:
- Coronary artery disease
* CABG (___): LIMA-LAD, TSVG-RI, TSVG-OM, and PLA of RCA.
* Unstable angina ___, stress MIBI with fixed defect
- Chronic systolic heart failure (LVEF 40% in ___. Estimated
Dry Weight 150lbs.
- History of critical aortic stenosis. s/p bovine AVR (___)
- Hypertension
- Dyslipidemia
- CKD
- Diabetes mellitus, type II
- Carcinoid tumor of the lung (right middle lobe, s/p resection)
- Obstructive sleep apnea (oxygen-dependent since lung
resection; utilizes 2L nasal cannula O2 only at nighttime; no
BiPAP)
- Restrictive lung disease
- History of deep venous thrombosis (in ___ twice, s/p IVC
filter placement; no chronic anticoagulation since ___
- Carpel tunnel syndrome (bilateral decompressions, ___
- Anemia of chronic disease (baseline HCT ___
- Seizure disorder with first convulsive seizure ___ (noted
to have multiple episodes of non-convulsive status epilepticus
durng continuous EEG monitoring during that admission; on keppra
now) Thought to be due to some antibiotic ? and tramadol
PAST SURGICAL HISTORY:
- s/p right middle lobe resection, VATS for carcinoid tumor
(___)
- s/p intramedullary rod fixation of left subtrochanteric femur
fracture (___)
- s/p irrigation debridement left hip joint, arthrotomy,
exchange bipolar component left hip hemiarthroplasty (___)
- s/p debridement and irrigation of hip abscess, removal of
arthroplasty hardware components, antibiotic spacer placement,
VAC application for wound closure (___)
- s/p debridement irrigation hip hematoma, removal of antibiotic
spacer and placement of functional antibiotic spacer and
application of surface VAC sponge (___) for left septic hip
joint
Social History:
___
Family History:
Denies significant family history of cardiovascular disease,
early MI, arrhythmia or sudden cardiac death. Father with a
history of lung cancer.
Physical Exam:
ADMISSION EXAM:
=====================
Vitals: 98.8 101/58 97 18 98%RA
Weight: 71.9 kg (admission)
General: WDWN ___ female. Obese. Alert, oriented in NAD. Lying
comfortably in bed
HEENT: EOMs in tact. Sclera anicteric. Dry MM.
Neck: supple, no appreciable JVD, no LAD
CV: RRR. S1/S2. ___ SEM at RUSB. no gallops/rubs
Lungs: CTAB
Abdomen: soft, obese. +BS. mild RUQ pain, no guarding/rebound.
no appreciable HSM
GU: no foley, no CVA tenderness
Ext: wwp. 2+ pulses. trace ___ edema bilaterally
Neuro: no gross focal deficits.
Skin: no rashes, no skin breakdown
DISCHARGE EXAM:
=======================
Vitals: 97.9 (99.0) 113/52 (103-130/40-70) 70 (70-90) 18 100%2L
FSBS: ___
General: NAD. Lying in bed in NAE.
HEENT: Sclera anicteric.
Neck: JVd ~14 cm
CV: RRR. S1/S2. ___ SEM at RUSB. no gallops/rubs
Lungs: CTAB
Abdomen: soft, obese. +BS. no appreciable tenderness.
Ext: wwp. 2+ pulses. trace ___ edema bilaterally
Neuro: no gross focal deficits.
Skin: no rashes, no skin breakdown
Pertinent Results:
ADMISSION LABS:
====================
___ 12:35PM BLOOD WBC-10.6# RBC-3.24* Hgb-7.8* Hct-26.1*
MCV-81* MCH-23.9* MCHC-29.8* RDW-16.7* Plt ___
___ 12:35PM BLOOD Neuts-92.2* Lymphs-2.3* Monos-5.3 Eos-0.2
Baso-0.1
___ 12:35PM BLOOD Glucose-371* UreaN-33* Creat-1.3* Na-133
K-4.9 Cl-95* HCO3-23 AnGap-20
___ 12:35PM BLOOD ALT-682* AST-1188* CK(CPK)-44
AlkPhos-497* TotBili-1.3
___ 12:35PM BLOOD Lipase-442*
___ 12:35PM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-2246*
___ 02:03PM BLOOD Lactate-2.9*
PERTINENT LABS:
====================
___ 07:30AM BLOOD ___
___ 05:24AM BLOOD ALT-586* AST-585* AlkPhos-449*
TotBili-2.0*
___ 01:55PM BLOOD DirBili-1.7*
___ 06:20AM BLOOD ALT-407* AST-235* AlkPhos-421*
TotBili-2.4*
___ 07:00AM BLOOD ALT-281* AST-99* CK(CPK)-42 AlkPhos-410*
TotBili-1.5
___ 07:30AM BLOOD ALT-354* AST-300* AlkPhos-381*
TotBili-1.5
___ 07:00AM BLOOD ALT-266* AST-161* AlkPhos-367*
TotBili-1.0
___ 11:49PM BLOOD cTropnT-0.17*
___ 06:24AM BLOOD CK-MB-8 cTropnT-0.21*
___ 01:55PM BLOOD CK-MB-6 cTropnT-0.19*
___ 06:20AM BLOOD cTropnT-0.25*
___ 05:26PM BLOOD CK-MB-4 cTropnT-0.25*
___ 07:00AM BLOOD CK-MB-3 cTropnT-0.27*
___ 06:24AM BLOOD calTIBC-334 ___ Ferritn-35 TRF-257
___ 06:24AM BLOOD Iron-15*
___ 12:20AM BLOOD Lactate-1.4
___ 06:35AM BLOOD Lactate-1.1
DISCHARGE LABS:
=====================
___ 07:00AM BLOOD WBC-4.1 RBC-3.92* Hgb-9.9* Hct-31.2*
MCV-80* MCH-25.2* MCHC-31.7 RDW-17.0* Plt ___
___ 07:00AM BLOOD Glucose-171* UreaN-27* Creat-1.2* Na-143
K-4.2 Cl-105 HCO3-28 AnGap-14
___ 07:00AM BLOOD ALT-266* AST-161* AlkPhos-367*
TotBili-1.0
___ 07:00AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.1
IMAGING:
======================
ECG (___):
Sinus tachycardia. Possible old inferior wall myocardial
infarction. Compared to the previous tracing of ___ no
change.
ECG (___):
Sinus rhythm. Consider prior inferior wall myocardial
infarction, although the small Q wave in lead aVF is
non-diagnostic. Possible septal myocardial infarction of
indeterminate age. Non-specific ST-T wave abnormalities.
Compared to the previous tracing of ___ ventricular rate is
slower.
CXR (___):
Severe cardiomegaly, thickening of the pleural margins, and
pulmonary vascular congestion are chronic. There is probably no
pulmonary edema or new pleural effusion.
RUS U/S (___):
1. Slightly limited assessment of the hepatic parenchyma without
evidence of focal lesion.
2. Cholelithiasis without evidence of cholecystitis.
3. Mild splenomegaly.
TTE (___):
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 4.0 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.8 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.2 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.1 cm
Left Ventricle - Fractional Shortening: *0.26 >= 0.29
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Right Ventricle - Diastolic Diameter: 4.0 cm <= 4.2 cm
Right Ventricle - Free Wall Thickness: 0.7 cm < 0.8 cm
Aorta - Sinus Level: 2.9 cm <= 3.6 cm
Aorta - Ascending: 2.8 cm <= 3.4 cm
Aorta - Arch: 2.5 cm <= 3.0 cm
Aortic Valve - Peak Velocity: *2.4 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *24 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 12 mm Hg
Aortic Valve - LVOT diam: 2.0 cm
Mitral Valve - E Wave: 1.4 m/sec
Mitral Valve - A Wave: 1.2 m/sec
Mitral Valve - E/A ratio: 1.17
Mitral Valve - E Wave deceleration time: 180 ms 140-250 ms
TR Gradient (+ RA = PASP): *46 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of ___.
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Lipomatous hypertrophy of the
interatrial septum. No ASD by 2D or color Doppler. Normal IVC
diameter (<=2.1cm) with >50% decrease with sniff (estimated RA
pressure ___ mmHg).
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
global systolic function (LVEF>55%). [Intrinsic LV systolic
function likely depressed given the severity of valvular
regurgitation.] No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion. RV
hypertrophy.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR
well seated, normal leaflet/disc motion and transvalvular
gradients. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Moderate mitral annular calcification. Severe (4+) MR.
___ VALVE: Moderate to severe [3+] TR. Moderate PA
systolic hypertension. Given severity of TR, PASP may be
underestimated due to elevated RA pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor apical views.
Echocardiographic results were reviewed by telephone with the
houseofficer caring for the patient. Right pleural effusion.
Conclusions
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is ___
mmHg. There is mild symmetric left ventricular hypertrophy with
normal cavity size and global systolic function (LVEF>55%).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of mitral regurgitation.] Right
ventricular chamber size and free wall motion are normal. The
right ventricular free wall is hypertrophied. The diameters of
aorta at the sinus, ascending and arch levels are normal. A
bioprosthetic aortic valve prosthesis is present. The aortic
valve prosthesis appears well seated, with normal leaflet motion
and transvalvular gradients. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Severe (4+) mitral regurgitation is seen.
Moderate to severe [3+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. [In the
setting of at least moderate to severe tricuspid regurgitation,
the estimated pulmonary artery systolic pressure may be
underestimated due to a very high right atrial pressure.] There
is a trivial/physiologic pericardial effusion.
IMPRESSION: Well seated, normal functioning bioprosthetic aortic
valve. Severe mitral regurgitation. Moderate pulmonary artery
hypertension. Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
Moderate to severe tricuspid regurgitation.
Compared with the prior study (images reviewed) of ___,
the severity of tricuspid regurgitation is now increased, the
estimated PA systolic pressure is now much higher, and global
left venticular systolic function is improved.
MICROBIOLOGY:
====================
Blood Culture, Routine (Final ___: NO GROWTH x 2
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
___ with multiple co-morbidities, recurrent UTIs and recent
admission for E. coli bacteremia presenting with transient
abdominal pain c/w choledocholithiasis c/b demand ischemia.
#NSTEMI: Patient with elevated troponin with unchanged EKG. Most
likely Type II NSTEMI, potentially from anemia/demand with Hb
7.3. Patient was given 1U pRBCs with improvement of symptoms.
However, patient continued to have intermittent episodes of
chest pain with mild elevations in troponins that improved with
SL nitro. Patient was not given heparin due to GI bleeding risk
from prior admissions. Cardiology was consulted who recommended
initiating beta-blockade with metoprolol for anti-anginal
effect. Patient's BP remained stable in the 110-120s with HRs in
the 70-80s. Patient's chest pain resolved upon discharge. Her
spironolactone was discontinued in favor of uptitration of
metoprolol.
#SOB/Congestion: Unclear etiology. CXR not impressive for volume
overload. ___ be manifestation of symptomatic anemia that
resolved with transfusion. Patient was given guifenecin and PRN
nebs with resolution of dyspnea.
# Chronic Systolic and diastolic CHF: EF 35-40% from TTE in
___. Dry weight 160 pounds. Weight at increased 5 kg while
inpatient with evidence of elevated JVP. Patient was given IV
lasix with good diuresis and improvement of volume status. She
was transitioned to daily torsemide for further diuresis.
Spironolactone was discontinued as above.
#choledocholithiasis: Patient presented with mild epigastric,
RUQ abdominal pain found to have transaminitis and elevated
lipase. Pain subsided and thought to be from choledocholithiasis
leading to transaminitis and gallstone pancreatitis. Patient's
abdominal pain improved spontaneously and LFTs downtrended. RUQ
showed no evidence of cholelcystitis.
#microcytic anemia: Fe/TIBC = 4% consistent with iron deficiency
anemia. Patient was initiated on ferrous sulfate with aggressive
bowel regimen. H/H remained stable after transfusion and
initiation of iron supplementation.
CHRONIC ISSUES
# h/o critical AS: s/p bovine AVR (___)
# Hypertension: as above
# Diabetes mellitus, type II: continued home regimen of 33U
___ with HSSI
# Obstructive sleep apnea: oxygen-dependent since lung
resection; utilizes 2L nasal cannula O2 only at nighttime
# Seizure disorder: stable and not on anti-epileptics.
Transitional Issues:
-consider outpatient surgical evaluation for cholecystectomy to
discuss risk/benefits of procedure
-f/u LFTs as outpatient
-can increase metoprolol as BP and HR tolerates written for 25
mg daily of succinate
-discharge weight: 79.8 kg
-code: full
-contact: ___ (daughter) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Docusate Sodium 100 mg PO BID
3. Multivitamins 1 TAB PO DAILY
4. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
5. Pantoprazole 40 mg PO Q24H
6. Senna 8.6 mg PO BID:PRN constipation
7. Spironolactone 12.5 mg PO DAILY
8. Torsemide 5 mg PO QOD
9. Vitamin D 1000 UNIT PO DAILY
10. Humalog ___ 33 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
11. Prolensa (bromfenac) 0.07 % ophthalmic BID
12. Nystatin Cream 1 Appl TP BID
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. Docusate Sodium 100 mg PO BID
3. Humalog ___ 33 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
4. Multivitamins 1 TAB PO DAILY
5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
6. Nystatin Cream 1 Appl TP BID
7. Pantoprazole 40 mg PO Q24H
8. Senna 17.2 mg PO HS
9. Torsemide 5 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
12. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
13. Guaifenesin ER 1200 mg PO Q12H
RX *guaifenesin [Mucinex] 1,200 mg 1 tablet(s) by mouth twice a
day Disp #*28 Tablet Refills:*0
14. Lactulose 15 mL PO DAILY:PRN constipation
RX *lactulose 10 gram/15 mL (15 mL) 15 mL by mouth daily:PRN
Refills:*0
15. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth
daily Refills:*0
16. Prolensa (bromfenac) 0.07 % ophthalmic BID
17. Metoprolol Succinate XL 25 mg PO DAILY
hold dose if heart rate <60 or blood pressure less than 90/50
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
-choledocholithiasis
-Type II non-ST elevation myocardial infarction
-iron deficiency anemia
-chronic systolic and diastolic heart failure
Secondary Diagnosis:
-hypertension
-diabetes mellitus
-obstructive sleep apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You came to the hospital because of
abdominal pain. Your labs showed that your most likely had a
gallstone that became stuck, causing you to have abdominal pain.
The stone most likely passed and your abdominal pain improved as
did your liver function labs.
You also experienced episodes of shortness of breath/chest pain.
You were found to have anemia which most likely contributed to
your symptoms for which you were given blood and iron. Your
chest pain improved and your EKG did not show any changes
concerning for a heart attack. You still had intermittant
episodes of chest pain for which you were seen by the cardiology
team who suggested further changes in your medication. Your
blood pressure remained stable with these medication changes.
We repeated an echocardiogram here which demonstrated that your
heart function was stable and you had no evidence of a large
heart attack.
Please follow-up with your appointments listed below and
continue taking your medications as instructed.
Wishing you the best,
Your ___ team
Followup Instructions:
___
|
10670085-DS-29
| 10,670,085 | 29,281,063 |
DS
| 29 |
2197-05-21 00:00:00
|
2197-05-22 13:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ceftin / Bactrim / Zocor / Lopressor / Rezulin / Ultram / Flagyl
/ Keppra / Compazine / darbepoetin alfa
Attending: ___.
Chief Complaint:
Left Hip and Leg Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with h/o CAD (s/p CABG), aortic stenosis (s/p bovine
AVR), HTN, DM2, OSA (on home nighttime 2L O2), prosthetic joint
infection (s/p multiple revisions and washouts) who p/w left hip
pain ___. Patient has a complex left hip surgical history.
Patient had history left subtrochanteric fracture (___) c/b
prosthetic joint infection status post multiple revisions
including a left hip prosthesis with Girdlestone c/b by multiple
washouts, most recently ___. Per report patient was able
to perform ADLs at home, but had recently noted acute onset of
baseline left hip pain ___. She was unable to ambulate
and was advised to present to ED. Patient was has no recent
history of trauma or falls. Upon presentation to ED patient was
seen by orthopedics who did not feel that she had osteomyelitis
or septic joint and thus did not proceed with joint aspiration.
Past Medical History:
- Coronary artery disease
* CABG (___): LIMA-LAD, TSVG-RI, TSVG-OM, and PLA of RCA.
* Unstable angina ___, stress MIBI with fixed defect
- Chronic systolic heart failure (LVEF 40% in ___. Estimated
Dry Weight 150lbs.
- History of critical aortic stenosis. s/p bovine AVR (___)
- Hypertension
- Dyslipidemia
- CKD
- Diabetes mellitus, type II
- Carcinoid tumor of the lung (right middle lobe, s/p resection)
- Obstructive sleep apnea (oxygen-dependent since lung
resection; utilizes 2L nasal cannula O2 only at nighttime; no
BiPAP)
- Restrictive lung disease
- History of deep venous thrombosis (in ___ twice, s/p IVC
filter placement; no chronic anticoagulation since ___
- Carpel tunnel syndrome (bilateral decompressions, ___
- Anemia of chronic disease (baseline HCT ___
- Seizure disorder with first convulsive seizure ___ (noted
to have multiple episodes of non-convulsive status epilepticus
durng continuous EEG monitoring during that admission; on keppra
now) Thought to be due to some antibiotic ? and tramadol
PAST SURGICAL HISTORY:
- s/p right middle lobe resection, VATS for carcinoid tumor
(___)
- s/p intramedullary rod fixation of left subtrochanteric femur
fracture (___)
- s/p irrigation debridement left hip joint, arthrotomy,
exchange bipolar component left hip hemiarthroplasty (___)
- s/p debridement and irrigation of hip abscess, removal of
arthroplasty hardware components, antibiotic spacer placement,
VAC application for wound closure (___)
- s/p debridement irrigation hip hematoma, removal of antibiotic
spacer and placement of functional antibiotic spacer and
application of surface VAC sponge (___) for left septic hip
joint
Social History:
___
Family History:
Denies significant family history of cardiovascular disease,
early MI, arrhythmia or sudden cardiac death. Father with a
history of lung cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.7 75 118/55 20 100% 2L NC
FSG: 195
General: alert, oriented, anxious
HEENT: sclera anicteric, MMM, oropharynx clear
Lungs: bibasilar crackles; no wheezes, rhonchi
CV: regular rate and rhythm, systolic ejection murmur
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: Left hip without erythema or ecchymosis. Non-tender to
palpation. Slight bulge on lateral aspect of upper thigh warm,
well perfused, 2+ pulses, 1+ pitting edema to mid calf L>R
Neuro: AAOx2 (place, name), CNs2-12 intact, motor function
grossly normal
DISCHARGE PHYSICAL EXAM:
Vitals: T: 98.6 Tm: 98.6 HR: 76 BP: 112/50 RR:18 O2: 100% 2L
NC
Weight: 72.0 kg (___) <- 72.3 kg (___) <- 71.1 kg (___)
<-73.0 kg (___) <- 72.8 kg (___) <- 75.4 kg (___)
General: alert, in no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear
Lungs: CTAB
CV: regular rate and rhythm, ___ holosystolic murmur right
sternal border. JVP not elevated.
Abdomen: soft, non-tender, non-distended, bowel sounds present
GU: no foley
Ext: Left hip without erythema or ecchymosis. Non-tender to
palpation. Slight bulge on lateral aspect of upper thigh warm,
well perfused, 2+ pulses. Pain on hip flexion, abduction,
adduction and rotation.
Skin: no sacral desquamation, ulceration; no ulceration of heels
Psych: AAOx2-3 (name, place, knows month but not year)
Pertinent Results:
==================
ADMISSION LABS:
==================
___ 08:00PM BLOOD WBC-8.6 RBC-3.72* Hgb-9.4* Hct-30.7*
MCV-83 MCH-25.3* MCHC-30.6* RDW-17.3* RDWSD-51.7* Plt ___
___:00PM BLOOD Neuts-75.1* Lymphs-14.2* Monos-9.3
Eos-0.9* Baso-0.3 Im ___ AbsNeut-6.44* AbsLymp-1.22
AbsMono-0.80 AbsEos-0.08 AbsBaso-0.03
___ 08:00PM BLOOD ___ PTT-31.7 ___
___ 08:00PM BLOOD Glucose-67* UreaN-39* Creat-1.3* Na-139
K-4.4 Cl-100 HCO3-28 AnGap-15
___ 08:00PM BLOOD Albumin-4.1 Calcium-9.7 Phos-4.4 Mg-2.0
___ 08:00PM BLOOD CRP-3.2
___ 08:18PM BLOOD SED RATE- 31
==================
INTERVAL LABS:
==================
___ 05:40AM BLOOD WBC-5.6 RBC-3.25* Hgb-8.2* Hct-26.7*
MCV-82 MCH-25.2* MCHC-30.7* RDW-17.3* RDWSD-51.8* Plt ___
___ 06:58AM BLOOD WBC-5.5 RBC-3.34* Hgb-8.5* Hct-28.4*
MCV-85 MCH-25.4* MCHC-29.9* RDW-17.6* RDWSD-54.0* Plt ___
___ 07:15AM BLOOD WBC-5.5 RBC-3.39* Hgb-8.5* Hct-28.9*
MCV-85 MCH-25.1* MCHC-29.4* RDW-17.4* RDWSD-53.7* Plt ___
___ 05:31AM BLOOD WBC-5.7 RBC-3.17* Hgb-8.1* Hct-27.3*
MCV-86 MCH-25.6* MCHC-29.7* RDW-17.1* RDWSD-54.0* Plt ___
___ 07:00AM BLOOD WBC-5.2 RBC-3.13* Hgb-8.0* Hct-27.2*
MCV-87 MCH-25.6* MCHC-29.4* RDW-17.1* RDWSD-54.1* Plt Ct-
___ 06:58AM BLOOD CRP-9.4*
___ 07:15AM BLOOD CRP-11.5*
___ 05:31AM BLOOD CRP-11.7*
___ 06:05AM BLOOD CRP-10.1*
___ 05:40AM BLOOD CK-MB-2 cTropnT-<0.01
==================
DISCHARGE LABS:
==================
___ 07:40AM BLOOD WBC-4.8 RBC-3.14* Hgb-7.9* Hct-26.5*
MCV-84 MCH-25.2* MCHC-29.8* RDW-16.8* RDWSD-51.4* Plt ___
___ 07:40AM BLOOD Plt ___
___ 07:40AM BLOOD Glucose-151* UreaN-37* Creat-1.3* Na-138
K-4.9 Cl-99 HCO3-28 AnGap-16
___ 07:40AM BLOOD Calcium-9.2 Phos-5.2* Mg-2.0
==================
IMAGING:
==================
___ (PORTABLE AP)
IMPRESSION:
Mild interstitial pulmonary edema and small pleural effusions
have increased since the prior.
___ HIP & FEMUR
IMPRESSION:
Chronic deformity at the left proximal femur without acute
fracture or
definite signs of osteomyelitis.
==================
MICRO:
==================
BLOOD CULTURE ___:
Blood Culture, Routine (Final ___: NO GROWTH.
URINE CULTURE ___:
(Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| PROTEUS MIRABILIS
| |
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- 4 S <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S 1 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
Brief Hospital Course:
___ with history of prosthetic joint infection (c/b by multiple
revisions and washouts), presents to the emergency room with
progressively worsening left hip pain with hospital course c/b
urinary tract infection and pulmonary edema.
# Left Hip pain:
Patient has complex left hip history (fracture in ___, infected
hardware, multiple revisions now s/p Girdlestone procedure)
presenting with acute worsening of pain ___. Patient
presented to the ED after she was unable to ambulate at home due
to recent onset left hip pain. In the ED she received an x-ray
hip/femur which showed chronic deformity at the left proximal
femur without acute fracture or definite signs of osteomyelitis.
She was evaluated by Orthopedic surgery who did not think this
was osteomyelitis or inflammatory joint disease given her lack
of fever, normal WBC, and normal CRP. Her hip/leg pain was
thought to be secondary to her known joint disease and chronic
pain.
Patient's pain was managed with tylenol ___ mg TID and
oxycodone 5 mg TID-QID after lengthy discussion with patient and
family regarding the risks and benefits of opiate pain
medications. Her CRP increased from 3.2 (___) to 11.7 (___)
but remained stable with CRP of 10.1 (___). Her ESR 31 (___)
was slightly above upper limit of normal. We considered whether
this could represent an infectious/inflammatory joint process
versus her known urinary tract infection. Upon discussion with
orthopedic surgery this was not concerning for inflammatory or
infectious process.
We continued to monitor her and did not proceed with joint
aspiration or surgical intervention. During her admission she
had improved pain control with mild improvement in her range of
motion. Physical therapy was consulted and recommended long term
acute care rehab facility. Patient and family declined discharge
to rehab but agreed to 24 hour care at home with Hoyer lift. She
was discharged with home ___.
# Hypoxia
Patient has a complicated cardiac history with CAD s/p CABG and
AVR. Most recent echo with EF 55% and severe MR. ___ has h/o
chronic dyspnea, OSA and is on home nighttime O2. On admission,
patient endorsed dyspnea worse than baseline. Her exam on
admission was notable for bibasilar crackles. Her oxygen
saturation was 96%RA-100%2L NC. Given her SOB, we considered
whether this could be PE given her distant history of DVTs,
however thought this was thought to be less likely given her
lack of tachycardia without e/o R heart strain on EKG. CXR
(___) showed increased pulmonary edema and effusions. Her
pulmonary edema was potentially exacerbated by her fluid bolus
on admission (~200 ml) but was likely acute on chronic. She
received 20 mg IV lasix with improvement in her clinical exam
and SOB. She was then transitioned to her outpatient regimen of
torsemide 10 mg QOD and then to torsemide daily to maintain
euvolemia. She continued to have stable clinical exams
throughout her admission. The patient was discharged home on
daytime oxygen requirement of 2L with plan to wean by home
services. Her chronic bedtime oxygen requirement of 2L remained
stable.
# Cognitive disorder/altered mental status:
Patient initially presented with mild agitation and confusion
including orientation x ___ with short-term memory deficits.
This was initially thought to be delirium in the setting of her
UTI and hip pain. Her UTI and pain were treated. Her orientation
and agitation improved, however she continued to have difficulty
with short term memory, continued inability to remember year,
anxiety and repetition of her medical conditions. She however
did not have waxing and waning consciousness or attention that
would be more consistent with delirium or encephalopathic
process. She did not have any focal neurological findings. Per
collateral with family, patient appeared more confused than
usual. Her presentation may represent underlying dementia that
should be followed up by her outpatient providers.
# Urinary Tract infection: Patient with history of recurrent
UTIs and a history of bacteremia from these infections. Patient
has urinary incontinence at baseline. Admission urinalysis
showed 33 WBCs with cultures that grew Klebsiella and proteus
sensitive to ceftriaxone. She received a 7 day course of IV
ceftriaxone. Blood cultures were negative at the time of
discharge.
# CKD III: In the ED, patient was found to have Creatinine of
1.3, increased from her baseline Creatinine ___. This was
initially thought to be pre-renal in setting of poor PO intake.
She was started on fluids at admission but this was subsequently
stopped due to dyspnea (see above). During her admission her
creatinine increased to 1.5 (___) thought to be in the
setting of her diuresis. Upon discharge patient had stable
creatinine of 1.3.
# T2DM:
Continued home insulin regimen.
# Constipation: Patient did not have bowel movement for several
days while inpatient. This was thought to be due to decreased PO
intake initially, then secondary to oxycodone use. Her bowel
regimen on admission was increased include PR bisacodyl. Patient
then received tap water enema ___ resulting in two bowel
movements, followed by ___ on ___. She was discharged with
bowel regimen.
# Chronic anemia:
Previously received Procrit injections. History of MGUS and
hemorrhoids. Her hematocrit was trended during her admission
without evidence of bleeding and remained stable.
# CAD/ HLD: Continued her home home statin, toprol
# HTN: Continued home spironolactone, Toprol.
# GERD: Continued home pantoprazole
# TRANSITIONAL ISSUES:
======================
- Torsemide increased to 10 mg daily this hospitalization from
every other day dosing
- Please wean daytime O2 as able
- continue bowel regimen upon discharge to ensure adequate bowel
movements. Please call your PCP's office if patient does not
have BMs.
-please check chem-7 on ___ to monitor electrolytes and
renal function ___ and fax to: Dr. ___:
___.
-please check chem-7 at time of PCP follow up
- F/U with primary care physician for management of pain
medication doses
- F/U with orthopedic surgery regarding ongoing management of
joint disease and coordination of pain management
- F/U with primary care physician or hematology regarding
further workup or management of anemia. Consider iron studies,
folate, B12 levels. Consider iron supplementation as outpatient
- F/U with cardiology or PCP regarding management of home
torsemide dosing, with potential uptitrating as necessary for
heart failure; f/u with PCP/cardiology regarding use of
atorvastatin 80 mg vs 40 mg.
- F/U with PCP or neurology regarding further workup and
management of cognitive impairment/dementia
# CODE STATUS: FULL (confirmed)
# CONTACT: daughter ___ (HCP with dad) ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Torsemide 10 mg PO EVERY OTHER DAY
2. Spironolactone 12.5 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Multivitamins 1 TAB PO DAILY
5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Fluticasone Propionate NASAL 2 SPRY NU DAILY
10. Pantoprazole 40 mg PO Q24H
11. Senna 8.6 mg PO BID:PRN constipation
12. Cranberry Concentrate (cranberry conc-ascorbic
acid;<br>cranberry extract) 800 mg oral Q12H
13. Magnesium Oxide 250 mg PO DAILY
14. Lidocaine 5% Patch 1 PTCH TD QAM
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. Cranberry Concentrate (cranberry conc-ascorbic
acid;<br>cranberry extract) 800 mg oral Q12H
3. Docusate Sodium 100 mg PO BID
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % (700 mg/patch) Please place on left hip daily
Disp #*30 Patch Refills:*0
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
9. Pantoprazole 40 mg PO Q24H
10. Senna 8.6 mg PO BID:PRN constipation
11. Spironolactone 12.5 mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. Acetaminophen 1000 mg PO Q8H
Do not take more than 3 g acetaminophen per day.
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times daily
Disp #*180 Tablet Refills:*0
14. Magnesium Oxide 250 mg PO DAILY
15. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 17 grams by
mouth daily Refills:*0
16. Reclining shower chair
Hip Osteoarthritis
ICD-9: 715.15
17. Bisacodyl 10 mg PO DAILY:PRN constipation
RX *bisacodyl [Alophen] 5 mg 2 tablet(s) by mouth daily Disp
#*60 Tablet Refills:*0
18. OxycoDONE (Immediate Release) 5 mg PO Q6H pain
RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth every 6 hours
Disp #*60 Tablet Refills:*0
19. Torsemide 10 mg PO DAILY
RX *torsemide 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
20. Oxygen
Hypoxia
ICD-9 799.02
21. Humalog ___ 30 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Left hip pain
Secondary: Pulmonary edema, urinary tract infection, diabetes
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 Ms. ___,
It was a pleasure caring for you at the ___
___. You were seen for your worsening hip pain at
home. You were evaluated by Orthopedic surgery who did not think
you needed a surgery. You received an x-ray of your hip which
did not show an infection or fracture of your hip. We continued
to take care of you on the medicine floor. You received
medications for your hip pain (Tylenol, oxycodone) which you
tolerated well.
You were found to have a urinary tract infection which we
treated with 7 days of antibiotics (ceftriaxone). You do not
need to continue antibiotics after discharge. You also had
shortness of breath during your admission. A chest x-ray showed
a small amount of fluid in your lungs. We treated you with
medicines (Lasix) to remove this fluid and we believe you
improved. We transitioned you back to Torsemide, the medication
you were on before coming into the hospital upon discharge. We
also increased this medication to a daily dose from every other
day. You had constipation during your admission which we treated
with oral laxatives and water enemas. You had several bowel
movements prior to discharge.
We wish you the best,
Your ___ care team
Followup Instructions:
___
|
10670085-DS-30
| 10,670,085 | 27,051,460 |
DS
| 30 |
2197-07-18 00:00:00
|
2197-07-23 10:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ceftin / Bactrim / Zocor / Lopressor / Rezulin / Ultram / Flagyl
/ Keppra / Compazine / darbepoetin alfa
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ with PMH of CAD s/p CABG (LIMA-LAD, TSVG-RI, TSVG-OM, and
PLA of RCA), CHF (EF > 55% ___, Aortic Stenosis s/p AVR, T2DM,
OSA presents with dyspnea. The pt and daughter report
progressive dyspnea over the past month associated with diffuse
edema with enlargement of abdomen, face, and b/l lower
extremities. Her family has been increasing her torsemide dose
from 40 mg daily to 60 mg daily intermittently in discussion
with her PCP/cardiology. Despite this intermittent adjustments,
the patient's dyspnea has progressed to limit her ability to
walk and move. The patient normally wears O2 at night, however,
has started using O2 during the day. She additionally reports
approximately 6 days of abdominal pain as well as intermittent
chest pain for the past day. Her most recent weight is from
___ and it was 174.8 pounds.
Of note, patient's daughter reports episode of
"unresponsiveness" for ?5 minutes on ___. This was only
witnessed by the patient's husband and son, who said the patient
had her tongue sticking out and was not responding to their
voice. The patient reportedly had an episode of incontinence
with this event. The patient is not normally incontinent per
daughter's report. The pt denies tongue biting during this
episode. Her son and husband denied any shaking movements and
did not notice any slurred speech or focal neurologic deficit
either before or after.
In the ED, initial vitals were T 97.6, HR 80, BP 132/70, 20, 96%
on RA
Exam notable for significant bibasilar crackles and diffuse
pitting edema
Labs showed:
- Na 125, K 4.8, Cl 84, BUN 4.5, Cr 1.5, Glucose 215
- Trop 0.02, ___ 11919
- WBC 7.0, Hgb 7.4, HCT 24.4, Plt 208, N86.8%
Imaging:
Patient was given 80mg IV furosemide
Decision was made to admit to ___ for CHF exacerbation
On arrival to the floor, the patient reports persistent SOB,
orthopnea and lightheadedness with walking. She reports some
abdominal pain located diffusely over the mid-epigastric area.
Denies chest pain, palpitations, NVD, constipation, dysuria,
hematuria, fevers, chills. She denies left hip pain currently
Review of systems: (+) Per HPI, all other ROS otherwise negative
Past Medical History:
- Coronary artery disease
* CABG (___): LIMA-LAD, TSVG-RI, TSVG-OM, and PLA of RCA.
* Unstable angina ___, stress MIBI with fixed defect
- Chronic systolic heart failure (LVEF 40% in ___. Estimated
Dry Weight 150lbs.
- History of critical aortic stenosis. s/p bovine AVR (___)
- Hypertension
- Dyslipidemia
- CKD
- Diabetes mellitus, type II
- Carcinoid tumor of the lung (right middle lobe, s/p resection)
- Obstructive sleep apnea (oxygen-dependent since lung
resection; utilizes 2L nasal cannula O2 only at nighttime; no
BiPAP)
- Restrictive lung disease
- History of deep venous thrombosis (in ___ twice, s/p IVC
filter placement; no chronic anticoagulation since ___
- Carpel tunnel syndrome (bilateral decompressions, ___
- Anemia of chronic disease (baseline HCT ___
- Seizure disorder with first convulsive seizure ___ (noted
to have multiple episodes of non-convulsive status epilepticus
durng continuous EEG monitoring during that admission; on keppra
now) Thought to be due to some antibiotic ? and tramadol
PAST SURGICAL HISTORY:
- s/p right middle lobe resection, VATS for carcinoid tumor
(___)
- s/p intramedullary rod fixation of left subtrochanteric femur
fracture (___)
- s/p irrigation debridement left hip joint, arthrotomy,
exchange bipolar component left hip hemiarthroplasty (___)
- s/p debridement and irrigation of hip abscess, removal of
arthroplasty hardware components, antibiotic spacer placement,
VAC application for wound closure (___)
- s/p debridement irrigation hip hematoma, removal of antibiotic
spacer and placement of functional antibiotic spacer and
application of surface VAC sponge (___) for left septic hip
joint
Social History:
___
Family History:
Denies significant family history of cardiovascular disease,
early MI, arrhythmia or sudden cardiac death. Father with a
history of lung cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 97.9, 121/59, 72, 22, 100% on RA
Weight at admission: 78.8kg w/shoes
General: well appearing, no acute distress
HEENT: JVP not visualized ___ body habitus
CV: RRR, nl S1 S2, no murmurs/rubs/gallops
Lungs: crackles at right base, no wheeze/rhonchi
Abdomen: soft, nontender, +distended, NABS
Ext: WWP, 2+ pitting edema to hip; sacral edema
Neuro: CN2-12 grossly intact, normal strength and sensation
Skin: area of erythema around scar of saphenous vein graft
removal on left lower extremity, no warmth, no purulent drainage
DISCHARGE PHYSICAL EXAM:
Vitals: 98.5, 108/50, 88, 18, 98RA
General: well appearing
HEENT: JVP not visualized ___ body habitus
Lungs: clear to auscultation b/l
CV: RRR, nl S1 S2, systolic murmurs RUSB to LUSB
Abdomen: soft, nontender, distended, NABS
Ext: WWP, no edema
Neuro: AAOx2 (not oriented to year, but oriented to month and
day)
Pertinent Results:
ADMISSION LABS:
___ 01:38PM BLOOD WBC-7.0 RBC-3.10* Hgb-7.4* Hct-24.4*
MCV-79* MCH-23.9* MCHC-30.3* RDW-15.3 RDWSD-43.5 Plt ___
___ 01:38PM BLOOD Neuts-86.7* Lymphs-5.5* Monos-7.0
Eos-0.3* Baso-0.1 Im ___ AbsNeut-6.04 AbsLymp-0.38*
AbsMono-0.49 AbsEos-0.02* AbsBaso-0.01
___ 01:38PM BLOOD Glucose-214* UreaN-43* Creat-1.5* Na-125*
K-4.8 Cl-84* HCO3-28 AnGap-18
___ 05:35AM BLOOD ALT-13 AST-19 AlkPhos-88 TotBili-0.4
___ 01:38PM BLOOD cTropnT-0.02* ___
___ 05:35AM BLOOD Calcium-8.7 Phos-4.9* Mg-2.0
___ 01:49PM BLOOD Lactate-1.4
PERTINENT INTERVAL LABS:
___ 05:05AM BLOOD CK-MB-3 cTropnT-0.03*
___ 06:40AM BLOOD CK-MB-2 cTropnT-0.04*
___ 03:05PM BLOOD CK-MB-2 cTropnT-0.04*
DISCHARGE LABS:
___ 06:00AM BLOOD WBC-6.2 RBC-3.68* Hgb-8.2* Hct-27.9*
MCV-76* MCH-22.3* MCHC-29.4* RDW-15.5 RDWSD-42.8 Plt ___
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD Glucose-190* UreaN-66* Creat-1.8* Na-138
K-4.0 Cl-91* HCO3-33* AnGap-18
___ 05:10AM BLOOD ALT-10 AST-14 AlkPhos-79 TotBili-0.7
___ 06:00AM BLOOD Calcium-9.2 Phos-3.1 Mg-2.3
IMAGING/STUDIES:
CXR ___
Exam is limited secondary to portable technique and patient body
habitus.
There is some evidence of interstitial edema as on prior. No
definite new
confluent consolidation identified. Pleural effusions are
difficult to
exclude. Cardial silhouette is enlarged but similar compared to
prior.
Prosthetic aortic valve is noted as well as anterior chest wall
hardware.
IMPRESSION:
Limited exam with probable interstitial edema.
CT HEAD ___
1. No acute intracranial abnormalities on the noncontrast head
CT.
CXR ___
Moderate pulmonary edema and moderate bilateral pleural
effusions have
increased since ___. Severe cardiomegaly is also
worsened. No
pneumothorax.
MICROBIOLOGY:
___ BLOOD CULTURE NGTD
Brief Hospital Course:
___ with PMH of CAD s/p CABG (LIMA-LAD, TSVG-RI, TSVG-OM, and
PLA of RCA), CHF (EF > 55% ___, Aortic Stenosis s/p AVR, T2DM,
OSA presents with dyspnea found to have acute CHF exacerbation,
treated with diuresis, hospital course complicated by altered
mental status and acute kidney injury.
# Acute on chronic diastolic heart failure: Patient presented
with dyspnea found to have BNP > 11,000 (previous admissions
1000-2000s) and CXR suggestive of pulmonary edema. Previous TTE
in ___ showed EF > 55% suggestive of diastolic CHF. The patient
was treated with IV diuresis, initially furosemide folus, then
lasix gtt with improvement in symptoms and weight loss. The
patient was transitioned back to a PO diuretic regimen. This was
stopped when the patient was found to have rising Cr (see below)
likely secondary to overdiuresis. The patient was discharged
with instructions to hold PO diuretics for one more day and then
start torsemide 40mg PO daily. The patient was continued on her
home metoprolol succ 25mg PO daily and spirinolactone 12.5mg PO
daily. The patient's weight at discharge 65.4kg.
# Episode of unresponsiveness: On presentation, the patient's
family reported that the patient had had an episode of
"unresponsiveness" within the past week, in which she appeared
to be asleep with her mouth open and tongue out, but would not
respond to commands. According to the patient's son, this
episode lasted 5 minutes, according to the patient's husband
this episode lasted 15 minutes. During this time the patient
reportedly had no jerking movements, tongue biting and was not
post-ictal afterwards, however she did have an episode of
urinary incontinence. The patient was evaluated with CT head,
which showed no acute changes. Neurology was consulted, given
the patient's history of status epilepticus on previous ICU
admission. Neurology could not identify the etiology of this
episode based on the patient's story. Neurology recommended
treatment with lacosamide for seizure prophylaxis given her
history of status epilepticus and given the unknown etiology of
this episode. The pt had previously been treated with keppra
after her first presentation with status epilepticus. This
medication had been discontinued for unknown reasons by the
patient's family. The patient's family and healthcare proxy
refused seizure prophylaxis with lacosamide (medical decisions
were deferred to the patient's healthcare proxy, her daughter,
given the patient's persistently altered mental status). The
patient's daughter was explained the risks of discontinuation of
this medication and verbalized understanding, but nonetheless
did not wish to continue this therapy. The patient was
maintained on seizure precautions and did not have any further
episodes while in house. The patient will f/u with neurology as
outpatient for further evaluation and further consideration of
anti-epileptic medications.
# Type II DM: The patient was maintained on ISS while in house.
She was restarted on her home insulin regimen at discharge.
# Toxic Metabolic Encephalopathy: the patient was found to have
altered mental status during her admission, intermittently
oriented x1 to x2. This was thought to be near the patient's
baseline at home, likely secondary to her underlying medical
comorbidities. The patient was managed with delirium precautions
and was maintained on bowel regimen.
# h/o CAD s/p CABG: The patient was continued on her home
Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain and statin as
below. Pt had previously been treated with ASA 81mg PO daily,
which was discontinued in ___. The patient's daughter (HCP)
refused treatment with aspirin given the patient's history of GI
bleeding and hip hematoma.
# ___ on CKD: The patient was found to have Cr elevated to 2.0,
likely secondary to overdiuresis, greater than her baseline
1.2-1.3. The patient's home diuretic was held, and will be
restarted after discharge. The patient will have repeat Chem 7
for further evaluation of renal function.
# Hyperlipidemia: continued home Atorvastatin 40 mg PO QPM
# h/o carcinoid tumor of lung, restrictive lung disease per
previous PFTs: continued O2 supplementation PRN
# OSA: continued home regimen of 2L NC at night, given
intolerance of CPAP.
# Anemia: the patient has a history of anemia, previously
evaluated by hematology who diagnosed pt with anemia of chronic
disease. H/H was found to be at baseline. Pt should f/u with
hematology for further evalaution and for consideration of iron
supplementation PRN.
# h/o hip pain: continued home acetaminophen and lidocaine patch
Transitional Issues:
- Discharge Weight 65.4kg
- f/u with neurology for further evaluation of episode of
unresponsiveness, and further consideration of anti-epileptic
prophylaxis
- f/u with cardiology for further evaluation of heart failure
regimen and for titration of torsemide
- Please repeat Chem 7 at next appointment on ___ to
monitor improvement in BUN and Cr.
- Please consider f/u with hematology for anemia, thought on
previous evaluation to be anemia of chronic disease, may
consider iron supplementation as needed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Cranberry Concentrate (cranberry conc-ascorbic
acid;<br>cranberry extract) 800 mg oral Q12H
3. Docusate Sodium 100 mg PO BID
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Lidocaine 5% Patch 1 PTCH TD QAM:PRN pain
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
9. Pantoprazole 40 mg PO Q24H
10. Senna 8.6 mg PO BID:PRN constipation
11. Spironolactone 12.5 mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. Acetaminophen 1000 mg PO Q8H:PRN pain
14. Magnesium Oxide 250 mg PO DAILY
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Bisacodyl 10 mg PO DAILY:PRN constipation
17. Torsemide 10 mg PO DAILY
Discharge Medications:
1. Commode
Diagnosis: Congestive Heart Failure
Prognosis: Good
Length of need: 13 months
2. Acetaminophen 1000 mg PO Q8H:PRN pain
3. Atorvastatin 40 mg PO QPM
4. Bisacodyl 10 mg PO DAILY:PRN constipation
5. Docusate Sodium 100 mg PO BID
6. Lidocaine 5% Patch 1 PTCH TD QAM:PRN pain
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
10. Pantoprazole 40 mg PO Q24H
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Senna 8.6 mg PO BID:PRN constipation
13. Spironolactone 12.5 mg PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
15. Cranberry Concentrate (cranberry conc-ascorbic
acid;<br>cranberry extract) 800 mg oral Q12H
16. Fluticasone Propionate NASAL 2 SPRY NU DAILY
17. Magnesium Oxide 250 mg PO DAILY
18. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: acute on chronic diastolic heart failure, history of
status epilepticus, toxic metabolic encephalopathy, acute kidney
injury
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 Ms. ___,
Thank you for allowing us to participate in your care at ___.
You were admitted to the hospital because of your shortness of
breath and swelling. This was due to an exacerbation of your
heart failure. We treated you with water pills to help remove
fluid from your body.
You told us that prior to coming to the hospital you had an
episode where you were unresponsive. You were evaluated by our
neurology team who recommended treatment with an anti-seizure
medicine. You refused to take this medication. Please follow up
with your neurology for further evaluation and management.
After discharge please weigh yourself every morning, and call
your doctor if your weight goes up more than 3 pounds.
Followup Instructions:
___
|
10670236-DS-14
| 10,670,236 | 20,938,672 |
DS
| 14 |
2185-08-28 00:00:00
|
2185-08-28 14:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Pedestrian struck
Major Surgical or Invasive Procedure:
___ Bold placement for ICP monitoring
___ Bifrontal decompressive hemicraniectomy
___ PEG
History of Present Illness:
Mr. ___ is a ___ year old gentleman who was brought to ___
via ambulance after being struck by a vehicle. The incident was
not witnessed and the patient was found lying on the side of the
road unresponsive. Upon arrival that patient was intubated with
a GCS of 8. Injuries notable for left supraorbital laceration,
SAH, subdural hemorrhage, bilateral temporal lobe contusions,
LUL lung contusion, L inferior pubic ramus fracture, L
clavicular fracture. Once hemodynamically stabilized, the
patient was transferred to the Trauma ICU for further evaluation
and management.
Past Medical History:
anxiety, depression, schizoaffective disorder
Social History:
___
Family History:
non-contributory
Physical Exam:
On Admission:
Gen: WD/WN, comfortable, NAD.
HEENT: Head laceration PERRL 2--> 1.5 sluggish. Has bilateral
corneal reflexes
Extrem: warm and well perfused
Mental Status: intubated
If Intubated:
[x]Cough [x]Gag
Motor:
Localizes to noxious stimuli bilateral UE
BLE withdraw briskly to noxious stimuli
On Discharge:
Opens eye spontaneous. Tracks examiner intermittently.
Follows simple commands intermittently, wiggles toes, lifts left
arm.
Mouths words, but nonverbal.
Pupils ___, bilat.
Incision clean, dry, and intact.
LS clear
RRR.
abdomen soft NTND. PEG site clean
Moves extremities spontaneously and to noxious.
Pertinent Results:
CT HEAD W/O CONTRAST Study Date of ___ 9:23 ___
IMPRESSION:
1. Multifocal intracranial hemorrhage, with significant
parenchymal contusion raising concern for axonal shear injury.
Close followup advised. No herniation.
2. Soft tissue injury at the left frontal scalp with possible
tiny foreign
bodies in the lateral margin of the soft tissue injury.
3. No acute fracture.
CT CHEST W/CONTRAST Study Date of ___ 9:24 ___
IMPRESSION:
1. High riding endotracheal tube requires advancement by at
least 3 to 4 cm.
2. Distended stomach, consider NG tube decompression.
3. Left lung apex contusion.
4. No solid organ injury.
5. Left distal clavicular fracture.
6. Cortical disruption resulting in partial-thickness fracture
of the left
inferior pubic ramus.
CT C-SPINE W/O CONTRAST Study Date of ___ 9:24 ___
IMPRESSION:
1. No acute fracture, malalignment, or prevertebral soft tissue
abnormality.
2. Ground-glass opacity in the left lung apex concerning for
pulmonary
hemorrhage, better evaluated on CT torso from the same day.
3. High riding endotracheal tube requires advancement.
CHEST (PORTABLE AP) Study Date of ___ 11:23 ___
IMPRESSION:
1. Interval advancement of the endotracheal tube, which now
terminates in
appropriate position in the mid thoracic trachea. The enteric
tube extends below the diaphragm and off the inferior edge of
the image.
2. Known left apical contusions better appreciated on CT.
3. Distal left clavicular fracture.
CT HEAD W/O CONTRAST Study Date of ___ 2:22 ___
IMPRESSION:
1. Interval significant progression of multifocal intracranial
acute
parenchymal hemorrhages. Small volume subarachnoid hemorrhage,
mildly more prominent. Progression of cerebral edema with more
effaced bilateral lateral ventricles. Stable minimal uncal
herniation bilaterally. Minimal midline shift.
2. Right frontal approach catheter terminates in the right
frontal lobe
parenchyma, with adjacent hematoma, which is likely from
previously seen
hematoma expansion.
PORTABLE HEAD CT W/O CONTRAST Study Date of ___ 8:15 AM
IMPRESSION:
1. Similar appearance of diffuse hemorrhagic contusions and
subdural,
subarachnoid, and intraventricular blood.
2. Similar diffuse cerebral swelling in addition to edema
surrounding the
hemorrhagic contusion.
3. No new hemorrhage.
CT HEAD WITHOUT CONTRAST: ___
IMPRESSION:
1. Status post bifrontal craniectomy with expected
pneumocephalus, subdural blood, soft tissue air and swelling.
2. Multiple hemorrhagic contusions with increasing brain
swelling and mass
effect as described above.
3. Similar subarachnoid and subdural blood.
4. No new intraparenchymal hemorrhage.
CT HEAD WITHOUT CONTRAST: ___
IMPRESSION:
1. Status post bifrontal craniectomy with expected postsurgical
findings
including pneumocephalus in adjacent soft tissue swelling and
air.
2. Multiple hemorrhagic contusions with surrounding edema and
diffuse brain swelling, unchanged. No new focus of hemorrhage
identified.
3. Redistribution of subarachnoid blood more posteriorly.
4. Interval resolution of shift of normally midline structures.
Venous Doppler Study Bilateral Lower Extremities: ___
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins. Incidental note is made of slow flow within the right
posterior tibial vein.
CHEST (PORTABLE AP) Study Date of ___ 5:12 AM
IMPRESSION:
Compared to chest radiographs ___ through ___.
Large scale bilateral lower lobe pneumonia developed on ___, worsened, subsequently unchanged since ___. Pleural
effusions are small if any.
No pneumothorax. Heart size normal.
CT ABD & PELVIS W/O CONTRAST Study Date of ___ 2:01 ___
IMPRESSION:
1. No evidence of retroperitoneal hematoma.
2. Trace nonhemorrhagic pelvic free fluid is new from prior.
3. Again noted is fracture of the left inferior pubic ramus,
along with
nondisplaced fracture at the junction of the left superior pubic
ramus
/acetabulum as well as a subtle fracture line in the left sacral
ala better appreciated on prior CT.
4. Consolidations in the bilateral lower lobes in keeping with
known
pneumonia.
CHEST (PORTABLE AP) Study Date of ___ 5:14 AM
IMPRESSION:
In comparison with the study of ___, the monitoring and
support
devices are stable. Again there are substantial areas of
consolidation
involving the lower lungs, consistent with bilateral basilar
pneumonia. Poor definition of the left hemidiaphragm may
reflect small pleural effusion.
CHEST (PORTABLE AP) Study Date of ___ 3:51 AM
IMPRESSION:
Bilateral lower lobe consolidations minimally improved. Cardiac
size is
normal. ET tube is in standard position. NG tube tip is out of
view below the diaphragm. There is no pneumothorax or enlarging
effusions
CHEST (PORTABLE AP) Study Date of ___ 9:22 AM
IMPRESSION:
1. Compared to ___, endotracheal tube has been
removed.
2. Decrease in bilateral lower lung parenchymal opacities,
consistent with
resolving bilateral pneumonia.
CTA CHEST Study Date of ___ 4:09 ___
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Bibasilar consolidations, while improved, persist. In the
setting of
secretions within the right main stem bronchus and right lower
lobe bronchi,
suggest sequela of aspiration.
3. Nondisplaced distal left clavicular fracture.
CHEST (PORTABLE AP) Study Date of ___ 3:57 AM
IMPRESSION:
Comparison to ___. Minimal decrease in extent and
severity of the pre-existing bilateral parenchymal opacities
reflecting pneumonia. No new parenchymal opacities. No pleural
effusions. No pulmonary edema. Normal size of the heart.
Stable correct position of the feeding tube.
___ CHEST (PORTABLE AP)
Right subclavian PICC line tip now overlies the distal SVC and
may have been
retracted slightly compared with the prior study.Orogastric type
tube extends beneath the diaphragm off the film.
Compared 1 day earlier and allowing for technical differences,
doubt other
significant interval change. Faint patchy hazy opacities at
both lung bases are similar to the prior study. No new focal
opacity identified. No CHF or gross effusion.
Nondisplaced left distal clavicular fracture again noted.
___ PEG Placement
The gastrostomy tube was attached to the loop of the
guidewire, and the entire unit was pulled back into the
stomach until the 3 cm mark of the gastrostomy tube was noted
at the skin level. The gastroscope was reintroduced and
adequate placement of the gastrostomy tube was identified.
The gastrostomy tube end was cut, the cramping appendage was
placed as well as a bump. It was secured to a drainage bag.
It was secured to the skin with a suture. The patient
tolerated this procedure well. He was taken to the ICU in
good condition. The sponge, needle, and instrument count
were correct at the end of the case.
___ CHEST (PORTABLE AP)
1. Compared to ___, there is new pneumoperitoneum, most
likely
secondary to recent PEG placement. Attention on follow-up is
recommended.
2. Bibasilar opacifications are not significantly changed in
appearance. No new focal consolidations are identified.
3. Right PICC line terminating in the mid SVC
___ PORTABLE ABDOMEN
Significantly increased pneumoperitoneum, better appreciated on
the same day chest radiograph comparing upright views. Given
recent percutaneous
gastrostomy tube placement, percutaneous gastrostomy tube
leak/malpositioning is the main consideration. Nonobstructive
bowel gas pattern.
___ CHEST (PORTABLE AP)
1. Compared to ___, increase in size of
pneumoperitoneum. This may be partly due to patient
positioning, and/or related to patient's recent PEG placement,
however is concerning for possible additional abdominal
pathology. Correlation with clinical exam and attention on
follow-up is recommended.
2. Stable appearance of bilateral basilar lung parenchymal
opacifications. No new focal areas of consolidation identified.
___ G/GJ/GI TUBE CHECK
No leak.
Improved pneumoperitoneum.
___ LENIS
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
___ Abdomen
IMPRESSION:
No evidence of ileus or obstruction.
___ 1:20 ___ CHEST (PA & LAT)
Pneumoperitoneum persists. Consolidation at the both lung bases
has improved since ___ but not resolved. Upper lungs are
clear, partially obscured by external devices. Heart size
normal. No pleural effusion.
___ 4:47 ___ BILAT LOWER EXT VEINS Study Date of
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
___ CXR
Comparison to ___. The free intra-abdominal air has
completely
resolved. Right PICC line is in stable position. On the
current image there is no endotracheal tube. No pneumonia, no
pleural effusions, no pulmonary edema.
___
Postsurgical changes from bifrontal craniectomy.
Encephalomalacia involving regions of multifocal hemorrhagic
contusions. No acute hemorrhage.
Brief Hospital Course:
ED COURSE:
___ pedestrian struck by MVC was found on the side of the road
and brought into trauma by on ___. Reported in field GCS was
8. He was intubated in the ED for GCS of 4. GCS of 8, but in the
trauma bay was intubated for a reported GCS of 4. He was HDS at
the time. Pan scan revealed the following injuries: SAH, SDH,
ICH with suspected ___, left clavicular fracture, left pulmonary
contusion, left inferior ramus pubic fracture. Appropriate
consultants were notified. He was thereafter brought to the
___ for management.
--___ COURSE:
Neurovent was placed and ICP were difficult to manage initially
- ___ were following closely. ICP's were eventually stabilized
(though elevated) with titration of sedation, hypertonic saline,
and several 23% boluses. Exam worsened from HD#1 to HD#2 with
initial withdrawal to pain to no response to any stimuli.
Decision was made for frontal craniectomy with NSurg on HD#2 for
persistently elevated ICP. Post procedure, patient was
transferred to ___ as primary team and patient was moved to
NICU.
--___ HOSPITAL COURSE:
NEURO
-elevated ICP
Patient was taken to the OR on ___ with Dr. ___
bifrontal craniectomy for persistently elevated ICP. Procedure
was uncomplicated. Neurovent was removed in the OR and new bolt
was placed. JP drain was left in place. He remained intubated
postop and was transferred to the neuro ICU where he remained
until ___. The bolt was removed on ___ and staples placed at
the exit site. He was given helmet to be worn when out of bed.
He was started on Amantidine ___ decreased mental status
with slight improvement. This can be increased weekly, and he
can follow up in ___ clinic with Dr. ___ as an
outpatient.
-Seizure:
cvEEG showed frontal seizures on ___. He was started on
Dilantin and increased keppra. Dilantin was discontinued due to
subtherapeutic levels and stable neurologic status without
recurrent seizures. Continued on Keppra 2g bid.
#RESPIRATORY
He initially failed extubation on ___ and was reintubated. He
was subsequently successfully extubated ___ and remained stable
on room air. He completed treatment for VAP (see ID).
#GI
He was unable to pass for PO diet due to mental status, and the
patient's mother and father agreed to PEG placement. He
underwent PEG placement on ___. Bleeding was noted around PEG
site and CXR and KUB were obtained, which were concerning for
increasing pneumoperitoneum; ACS was re-consulted. Tube study
did not show leak. Tube feedings advanced as tolerated and he
was started on reglan for gut mobility.
#CV
He had intermittent tachycardic and tachypnea. CTA was negative
for PE. Tachycardia was thought to be related to pain and
adrenergic storming given prior elevated ICP in setting of TBI.
He was also started on Metoprolol and it was uptitrated to 75mg
TID, standing valium 2.5q6, and also standing Tylenol for pain.
#ID
-VAP: He was intermittently febrile. CXR showed pneumonia and he
was treated with vancomycin (___) and zosyn (___).
-C.Diff: He began having diarrhea which was positive for Cdiff.
He was started on oral vancomycin and continued to 2 weeks after
completing zosyn for VAP (___). C.diff precautions were
discontinued after completion of treatment and resolution of
symptoms.
-UTI: Started on Cipro ___ for GNR urine culture and completed
his course on ___
-___ was consulted for evaluation, B-glucan positive and ID
consult placed. Per ID, further workup not indicated as patient
clinically improving, continued with antibiotics as above.
#GU
Foley was removed on ___ and he was maintained on condom
catheter.
#MSK/ORTHO
Imaging revealed left inferior pubic ramus pelvic fracture and L
nondisplaced clavicluar fracture. He was seen by ortho trauma
and deemed non-operable at this time. LUE is non-weight bearig,
but range of motion as tolerated. LLE is weight bearing as
tolerated. He should follow up with orthopedics 2 weeks after
discharge
#PLASTICS
Plastics service repaired facial laceration and he received
antibiotic ointment.
#DISPO
He had a prolonged hospital course while awaiting guardianship.
Hearing was held ___ he was appointed a guardian. He was
screened for rehab and was discharged on ___
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 1000 mg NG Q8H
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN bronchspasm,
wheezing
3. Amantadine 100 mg PO BID
4. Artificial Tear Ointment 1 Appl BOTH EYES QID:PRN unable to
close eyes completely
5. Artificial Tears ___ DROP BOTH EYES Q4H
6. Diazepam 2.5 mg PO Q8H
7. Docusate Sodium 100 mg PO BID:PRN constipation
8. Heparin 5000 UNIT SC BID
9. LevETIRAcetam ___ mg PO BID
10. Metoprolol Tartrate 75 mg PO TID
11. Polyethylene Glycol 17 g PO DAILY
12. Senna 8.6 mg PO BID:PRN no bowel movement in 24 hours
13. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
14. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Traumatic brain injury - ___, IPH, ___
Cerebral Edema
Pelvis fracture
Left clavicle fracture
Lung contusion
Facial laceration
c-diff
VAP
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Discharge Instructions
Brain Hemorrhage with Surgery
· You underwent a surgery called a craniectomy. A portion of
your skull was removed to allow your brain to swell. You must
wear a helmet when out of bed at all times.
· It is best to keep your incision open to air but it is ok to
cover it when outside.
· Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
· We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
· You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
· No driving while taking any narcotic or sedating medication.
· If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
· No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
· ***Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
· ***You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
· You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
· You may have difficulty paying attention, concentrating, and
remembering new information.
· Emotional and/or behavioral difficulties are common.
· Feeling more tired, restlessness, irritability, and mood
swings are also common.
· You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
· You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
· Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
· Headache is one of the most common symptoms after a brain
bleed.
· Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
· Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
· There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
· Severe pain, swelling, redness or drainage from the incision
site.
· Fever greater than 101.5 degrees Fahrenheit
· Nausea and/or vomiting
· Extreme sleepiness and not being able to stay awake
· Severe headaches not relieved by pain relievers
· Seizures
· Any new problems with your vision or ability to speak
· Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
· Sudden numbness or weakness in the face, arm, or leg
· Sudden confusion or trouble speaking or understanding
· Sudden trouble walking, dizziness, or loss of balance or
coordination
· Sudden severe headaches with no known reason
Followup Instructions:
___
|
10670236-DS-16
| 10,670,236 | 21,721,028 |
DS
| 16 |
2185-11-08 00:00:00
|
2185-11-08 11:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Ritalin
Attending: ___
Chief Complaint:
left eye swelling
Major Surgical or Invasive Procedure:
___ - removal of autologous bone graft, drainage and
washout of epidural abscess
___ - Placement of right double lumen powerPICC under ___
History of Present Illness:
Mr. ___ is a ___ year old gentleman known to the
Neurosurgery Service s/p severe TBI earlier this year s/p
bifrontal craniectomy with cranioplasty on ___ presents from
___ concerning for eye cellulitis. Pt had suture
removal on ___ and was noted by rehab to develop erythema under
the left eyebrow on ___. He developed swelling and erythema
that progressed over the week and per documentation
from rehab, patient was started on Keflex, Ancef then switched
over to Vancomycin. Pt sent to ED for evaluation with worsening
periorbital cellulititis. Pt unable to participate ___ history or
exam.
Past Medical History:
anxiety, depression, schizoaffective disorder
Pedestrian struck s/p bifrontal craniectomy with return for
cranioplasty on ___, PEG placement
Social History:
___
Family History:
Non-contributory.
Physical Exam:
Upon admission:
O: T: BP: 119/77 HR: 88 R 16 O2Sats 98% RA
Gen: WD/WN, comfortable, NAD. Pt becomes combative when any one
approaches the bed and does not tolerate physical examination.
Verbal outbursts "This is too much" and expletives.
HEENT: eryethema and edema of the left eyelid and forehead.
there is a well healed laceration above the left eyelid with
developing pustules. There is erythema that follows this linear
laceration. NO active drainage. Cranioplasty incision is well
healed without erythema, edema or drainage.
Unable to examine patient due to agitation. verbal outbursts
He does follow some simple commands and EOMs appear intact.
Motor: decreased bulk and normal tone bilaterally. No abnormal
movements, tremors.
Sensation: unable to test
Upon discharge:
___: Eyes open spontaneously, L pupil ___, R pupil 4.5-4. Did
not follow EOM testing. Follows some simple commands
intermittently (wiggles toes, squeezes fingers, thumbs up
bilaterally), MAE with good strength/purposeful. Frontal crani
incision c/d/i closed with sutures and staples, expressive
aphasia- no verbal output on this exam, no agitation.
Pertinent Results:
___ 05:51AM BLOOD WBC-7.2 RBC-3.00* Hgb-9.2* Hct-26.7*
MCV-89 MCH-30.7 MCHC-34.5 RDW-12.4 RDWSD-40.4 Plt ___
___ 05:51AM BLOOD Plt ___
___ 05:51AM BLOOD ___ PTT-30.3 ___
___ 05:51AM BLOOD Glucose-100 UreaN-7 Creat-0.5 Na-144
K-3.8 Cl-107 HCO3-27 AnGap-14
___ 05:51AM BLOOD Calcium-8.5 Phos-3.6 Mg-1.8
___ 01:05AM BLOOD Vanco-20.4*
___ 08:45AM BLOOD Vanco-17.1
___ 06:00AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 06:00AM URINE RBC-5* WBC-7* Bacteri-FEW Yeast-NONE
Epi-<1
___ 06:00AM URINE Color-Yellow Appear-Clear Sp ___
ABSCESS SUBGALEAL ABSCESS.
SOURCE: TISSUE CHANGED TO ABSCESS. S/W ___. ___
@ 13:25,
___. **FINAL REPORT ___
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. MODERATE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___ ___.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ PICC Placement under ___:
IMPRESSION:
Successful placement of a 40 cm right arm approach double lumen
PowerPICC with tip ___ the distal SVC. The line is ready to use.
___ Non-contrast Head CT
IMPRESSION:
1. Expected postsurgical changes after bifrontal craniectomy,
with a drain
extending across the superior frontal lobes. Decreased mass
effect upon the brain parenchyma.
2. Bifrontal hypodensity compatible with known traumatic brain
injury, likely similar compared to CT from ___. No
evidence of hemorrhage.
3. Left temporal/periorbital soft tissue swelling with locules
of air
compatible with recent drainage of a left periorbital fluid
collection.
Brief Hospital Course:
#Cranial infection
___ year old male known to the Neurosurgery service s/p severe
TBI earlier this year with bifrontal craniectomy and
cranioplasty last month, presents to ___ with
left periorbital cellulitis. CT with contrast concerning for
possible intracranial abscess communicating with L periorbit.
Intubated ___ ED, fluid collection was tapped, unable to drain.
Expressed frank pus, cultures sent. MRI was done which revealed
large bifrontal epidural empyema and thick irregular bifrontal
dural enhancement, Extensive left periorbital and left frontal
scalp cellulitis. Patient was taken to the OR for removal of
autologous bone graft and washout on ___. Procedure was well
tolerated, cultures sent from OR. Patient was extubated and
transferred back to the ICU. ID was consulted and he was started
on empiric Vancomycin, Cefepime and Flagyl. OR cultures grew
coag positive staph. The patient was subsequently narrowed to
vancomycin to be continued for 6 weeks under the outpatient
direction of ID. Per ID, likely L eye cellulitis was the initial
focus, then dissected into scalp and cranium. Now with removal
of frontal autologous cranioplasty + operative debridement,
source control established. Extended duration of antibiotics
recommended per ID given high stakes of failure and residual
infection. His R PICC was malpositioned and positioned correctly
under ___ on ___. Prior to discharge, the patient did not
require restraints for 24 hours; he was placed ___ mitts to
prevent disruption of the wound which he did not require wearing
continuously, and this was acceptable to the rehab. On ___ his
vanco trough was 17.1 and he was discharged on IV Vanco with
instructions to monitor serum trough levels further. He has
scheduled follow-up with ID.
Medications on Admission:
Mylanta 30ml daily prn indigestion,Bisacodyl 10mg PR daily prn
constipation, Sorbitol 30ml daily qpm, citalopram 40mg qpm,
albuterol neb q6h prn dyspnea, heparin subq bid, Levetiracetam
2000mg BID, Miconazole 2% topical powder QID prn rash,
Multivitamin daily, Ocular lubricant 1 drop 6x day prn dry eyes,
Maalox 10ml bid, Claritin 10ml bid, acetaminophen 625mg q6h prn
pain, trazadone 25mg q6h prn, zyprexa 5mg BID, zyprexa 2.5mg q8h
prn agitation, erythromycin 0.5% ophthalmic ointment 1 app QID,
amantadine 50mg daily
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Senna 17.2 mg PO QHS
3. Vancomycin 1500 mg IV Q 8H
4. Amantadine 50 mg PO BID
5. TraZODone 25 mg PO QHS:PRN agitation/sleep
6. Acetaminophen 650 mg PO Q6H
7. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB/wheeze
8. Artificial Tear Ointment 1 Appl BOTH EYES Q6H
9. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
10. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
11. Citalopram 40 mg PO DAILY
12. Heparin 5000 UNIT SC BID
13. LevETIRAcetam ___ mg PO BID
14. Loratadine 10 mg PO DAILY
15. Miconazole Powder 2% 1 Appl TP QHS:PRN groin
16. Multivitamins W/minerals Liquid 15 mL PO DAILY
17. OLANZapine 2.5 mg PO TID:PRN agitation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Periorbital Cellulitis
Cranial infection
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:
Discharge Instructions
Removal bone graft and intracranial abscess washout
Surgery
You underwent surgery to have your artificial bone removed.
You must wear a helmet OOB at all times.
Please keep your sutures and staples along your incision dry
until they are removed.
It is best to keep your incision open to air but it is ok to
cover it temporarily and loosely when the patient is outside or
begins picking at it.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
You should continue on IV Vancomycin until your
follow-up with ID. You will need your trough levels monitored.
What You ___ Experience:
Headache or pain along your incision.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse ___ the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes ___ sensation ___ your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness ___ the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
10670364-DS-18
| 10,670,364 | 28,907,790 |
DS
| 18 |
2136-12-29 00:00:00
|
2136-12-31 21:09:00
|
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:
Bone marrow biopsies, ___ line placement
History of Present Illness:
___ with no significant past medical history is transferred from
___ with suspected Leukemia. The patient states that 3
days prior to adission, he felt unwell and had a fever as well
as a slightly sore throat. There was no associated shortness of
breath, easy bleeding or bruising, sick contacts, or focal
symptoms. This persisted until the morning of transfer when he
went to ___. There, he was found to be pancytopenic
with 27% peripheral blasts on smear; CXR was also done which was
negative. He was sent to the ___ by taxi where Cr
was 1.5; he was give Cefepime by report, IVF, and transferred to
the ___ ER for further management. Vitals in the ___ ER:
98.5 92 132/69 16 100% RA. He was given Allopurinol ___ PO
and IVF. He received 1 unit of platelets for count of 15.
Past Medical History:
Hx of Malaria as a child
Hx of Measles
s/p tonsilectomy ___
s/p laser repair of partial retinal detachment in left eye ___
s/p tooth extraction ___
Social History:
___
Family History:
Grandmother had kidney disease and cancer but type is unknown.
No other blood disorders or malignancies.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: T 100.0 bp 148/80 HR 106 RR 18 SaO2 100RA
GEN: NAD, awake, alert
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and
without lesion + LAD
NECK: Supple
CV: Reg tachycardia, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Soft, NT, ND, spleen palpable, bowel sounds present
MSK: normal muscle tone and bulk
EXT: No c/c, normal perfusion
SKIN: No rash, warm skin
NEURO: oriented x 3, normal attention, no focal deficits, intact
sensation to light touch
PSYCH: appropriate
.
DISCHARGE PHYSICAL EXAM:
AVSS, afebrile
GEN: NAD, awake, alert
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and
without lesions
NECK: Supple
CV: RRR, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Soft, NT, ND, spleen palpable, bowel sounds present
MSK: normal muscle tone and bulk
EXT: No c/c, normal perfusion
SKIN: No rash, warm skin
NEURO: CNs intact, no focal deficits
PSYCH: appropriate
Pertinent Results:
ADMISSION LABS:
___ 11:16PM PLT COUNT-17*
___ 09:30PM GLUCOSE-130* UREA N-17 CREAT-1.2 SODIUM-138
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-23 ANION GAP-15
___ 09:30PM ALT(SGPT)-14 AST(SGOT)-24 LD(LDH)-370* ALK
PHOS-49 TOT BILI-0.4
___ 09:30PM ALBUMIN-4.0 CALCIUM-8.4 PHOSPHATE-3.2
MAGNESIUM-2.3 URIC ACID-4.0
___ 09:30PM D-DIMER-192
___ 09:30PM WBC-2.6* RBC-3.21* HGB-9.5* HCT-27.4* MCV-86
MCH-29.5 MCHC-34.5 RDW-14.4
___ 09:30PM NEUTS-5* BANDS-4 LYMPHS-49* MONOS-5 EOS-0
BASOS-0 ___ MYELOS-0 OTHER-37*
___ 09:30PM PLT SMR-RARE PLT COUNT-19*
___ 09:30PM ___ PTT-32.0 ___
___ 09:30PM ___
BM Biopsy ___:
DIAGNOSIS:
HYPERCELLULAR BONE MARROW WITH EXTENSIVE INVOLVEMENT BY ACUTE
MYELOGENOUS LEUKEMIA.
Note: The immunophenotype is consistent with myeloid leukemia
with co-expression of CD19. Cytogenetic analysis shows trisomy
8. FISH analysis for t(8;21) was negative.
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
The smear is adequate for evaluation. Erythrocytes are
hypochromic and microcytic with slight anisopoikilocytosis
including rare ovalocytes, acanthocytes, dacrocytes, and
echinocytes. One nucleated RBC seen on scan. The white blood
cell count is decreased. Hypolobated neutrophils are seen,
including pseudo Pelger ___ cells. Occasional slender Auer
rods are seen in blasts in peripheral blood. The platelet count
appears decreased. Rare large platelets are seen. A 200 cell
differential shows: 15% neutrophils, 1% bands, 43% lymphocytes,
1% monocytes, 1% eosinophils, 0% basophils, 39% blasts.
Aspirate Smear:
The aspirate material is adequate for evaluation and consists of
multiple cellular spicules. Erythroid precursors are relatively
decreased in number and exhibit normoblastic maturation.
Myeloid precursors are decreased in number and show dyspoietic
maturation. Megakaryocytes are decreased in number. Abnormal
forms are seen including rare micromegakaryocytes. The aspirate
is involved primarily by large cells with fine chromatin,
nucleoli, and few granules, consistent with blasts. Many blasts
with Auer rods are seen. Cells differentiated beyond
promyelocytes are rare. A 500 cell differential shows: 75%
blasts, 1% promyelocytes, 1% myelocytes, 1% metamyelocytes, 1%
bands/neutrophils, 0% eosinophils, 14% erythroids, 5%
lymphocytes, 2% plasma cells.
Clot Section and Biopsy Slides:
The core biopsy material is adequate for evaluation. It
consists of a 1.0 cm core biopsy of trabecular marrow and
cortical bone with a cellularity of 80%. There is wall to wall
infiltrate of immature mononuclear cells, consistent with
blasts. Rare megakaryocytes are seen. Erythroid precursors are
markedly decreased in number. Maturing myeloid precursors are
decreased in number. Megakaryocytes are decreased in number.
The clot shows rare clusters of blasts.
SPECIAL STAINS:
Iron stain is inadequate for evaluation due to lack of spicules.
Repeat marrow:
ECHO ___:
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). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
CT CHEST ___:
No lung parenchymal changes likely to explain the clinical
presentation of the patient. All visible changes are minimal
and non-characteristic. Signs of mild chronic airways disease.
Borderline sized lymph nodes in the mediastinum and the axillary
regions.
CT ABDOMEN PELVIS ___:
1. Limited examination due to lack of intravenous contrast and
thin body habitus. No intra-abdominal source of infection
identified.
2. Small amount of simple pelvic fluid can be seen in males
although unusually.
CT sinuses ___:
IMPRESSION: Minimal mucosal thickening of the paranasal
sinuses.
CT ABDOMEN/PELVIS:
1. Mild susceptibility seen within both the liver and spleen,
consistent with
changes related to iron overload (hemosiderosis).
2. Otherwise, no explanation for the patient's transaminitis.
3. Specifically, no biliary or gallbladder abnormalities.
Slight narrowing at
the superior most aspect of the common hepatic duct is
consistent with a
commonly seen variant resulting from the crossing of the right
hepatic artery.
DISCHARGE LABS:
___ 12:00AM BLOOD WBC-3.7* RBC-3.05* Hgb-9.3* Hct-27.2*
MCV-89 MCH-30.6 MCHC-34.3 RDW-15.1 Plt ___
___ 12:00AM BLOOD Neuts-59 Bands-0 ___ Monos-20*
Eos-0 Baso-0 Atyps-2* ___ Myelos-0
___ 12:00AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-1+ Spheroc-1+ Ovalocy-1+
Schisto-1+ Tear Dr-OCCASIONAL
___ 12:00AM BLOOD ___ PTT-30.0 ___
___ 12:00AM BLOOD ___ 03:56AM BLOOD ___ ___
___ 12:00AM BLOOD Glucose-104* UreaN-12 Creat-1.0 Na-139
K-4.0 Cl-103 HCO3-26 AnGap-14
___ 12:00AM BLOOD ALT-87* AST-84* LD(LDH)-325* AlkPhos-102
TotBili-0.2
___ 12:00AM BLOOD Calcium-8.9 Phos-4.5 Mg-2.1
___ 4:20 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ ___
12:10PM.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
Brief Hospital Course:
___ yo male transferred from OSH for with fevers, pancytopenia,
37% peripheral blasts suspicious for leukemia.
# Leukemia. Pt presented w/ anemia, thrombocytopenia,
neutropenia with 37% peripheral blasts. Febrile on admission w/
stable vital signs. Bone marrow biopsy performed, results
consistent w/ AML; FISH shows no 8:20 translocation, normal
cytogenetics. Pre-chemo echo normal. Started on 7+3 on ___.
Tolerated chemo well. Tumor lysis monitoring QD; no evidence of
TLS. Developed mild mucositis upon nadiring, treated w/ nystatin
and magic mouthwash. Experienced one episode of "floaters" in
vision in the setting of platelets <20; ophthalmology examined,
thought possible retinal hemorrhage, goal thereafter to keep
plts> 30. Repeat BM biopsy at day 14 (___) showed 15% blasts
in marrow. Started on HiDAC ___, again tolerated well with
few complaints except bilateral eye irritation, for which he has
follow up in several months with opthmololgy. In several weeks,
the patient's ANC did not appear to be coming up appropriately,
with a monocytic predominance to his white count. He had an
additional bone marrow biopsy revealing early monocytes rather
than blasts. This was reassuring, and the patient was discharged
with possibility of transplant at some point in the future.
Prior to discharge, his counts began to rise out of the
neutropenic range.
#Neutropenic fever. Pt arrived febrile, given empiric cefepime
and vancomycin. UA normal; urine culture, blood cultures, flu
cultures all negative. Fevers subsided, pt was afebrile ~ 6
days. On ___ pt spiked again in setting of vanc/cef,
continued to spike as high as 102.9. Infectious work up negative
including Ct chest abd/pelvis. Thick and thin smear neg for
malaria negative. Cefipime/vanc for broad coverage, imipenem
initiated briefly in place of cef but d/c'd due to rash. Fevers
again resolved in setting of HiDAC, supporting disease, not
infection, as source. Vancomycin d/c'd as active gram positive
infection thought unlikely source of fevers.
#Neutropenic fever #2: the patient again spiked a fever in early
___, accompanied by abdominal pain. A CT scan revealed
typhlitis, and he was started on imipenem. He began to have
loose stools which came back c diff positive. He was started on
oral vancomycin and defervesced. His abdominal pain resolved
within 2 days. Imipenem was taken off and he was monitored
cautiously, and was discharged on a fourteen day course of oral
vancomycin. He was not neutropenic on discharge.
# Transaminitis w/ RUQ tenderness. Most likely drug effect,
normal CT and US imaging. Several medications is possible
hepatotoxic effects were held and LFTs improved.
#Cough. Very mild, nonproductive initially, now resolved. Flu
swab and cxs negative. Had mild hemoptysis in setting of
mucositis, likely related to oropharyngeal lesion (pt felt "pop"
followed by incr mucus in throat, coughed up blood-tinged
sputum), did not recur. Chest CT read as chronic airways
disease, but in consultation w/ radiology fellow, low concern
for infection. Tamiflu 75 mg QD for ppx as several pts on floor
w/ flu, this was eventually discontinued as rare reports of
oseltamivir being associated with conjuntivitis and
transaminitis.
#Hyperglycemia. A1c mildly elevated; pt can f/u as outpt if
persists. Temporarily placed on ISS.
Transitional issues:
#Continue oral vancomycin for fourteen day course
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
RX *acyclovir 400 mg 400 tablet(s) by mouth every eight hours
Disp #*90 Tablet Refills:*0
2. Artificial Tears Preserv. Free ___ DROP BOTH EYES Q4H:PRN eye
irritation
RX *artificial tear ointment [Artificial Tears] ___ drops in
each eye every four hours Disp #*1 Bottle Refills:*0
3. Fluconazole 200 mg PO Q24H
RX *fluconazole 200 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin 125 mg 1 capsule(s) by mouth every six hours Disp
#*56 Capsule Refills:*0
5. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every eight hours Disp
#*15 Tablet Refills:*0
6. Prochlorperazine ___ mg PO Q6H:PRN nausea
RX *prochlorperazine maleate 5 mg ___ tablet(s) by mouth every
six hours Disp #*180 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Myelogenous Leukemia
Secondary diagnoses:
neutropenic fever
typhlitis
severe clostridium dificile colitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted for fevers
and a blood smear suspicious for cancer. You received a bone
marrow biopsy that showed acute myelogenous leukemia. You were
treated with chemotherapy, which you tolerated very well. We now
feel it is safe for you to leave the hospital. Please follow up
with your oncologist next week.
Your chemotherapy course was complicated by an infection of the
intestines. You will need to complete a course of oral
antibiotics.
During your treatment you developed eye irritation, likely a
side effect of one of the chemotherapy drugs. Please follow up
with the eye doctors at the ___ listed below.
Lastly, you begain to develop a bothersome sound in the ears
called pulsatile tinnitus. If this continues after you leave the
hospital, please call the Ear Nose and Throat clinic at
___ to make an appointment.
We made the following changes to your medications:
START vancomycin through ___
START oxycodone as needed for pain
START zofran as needed for nausea
START acyclovir
START fluconazole
Followup Instructions:
___
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2137-03-20 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:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ with h/o AML with good cytogenetics (CEBP
alpha mutation) s/p 7+3 (D1: ___, requiring ___
with HiDAC (___) with remission on marrow ___,
currently C3D18, coming in with fevers, cough, sore throat. Pt
reports he was feeling well until 5d ago when he developed sore
throat. He reports cough and runny nose since yesterday; cough
productive of brownish sputum. Developed fever to 101.5 this AM
at 2am and then 100.5 at 8am. Fevers associated with chills and
rigors. No sinus pain or sick contacts. Reports intermitent HAs,
currently ___. No photophobia, n/v. Taking PO ok. Had nausea 6d
ago with episode of emesis. Decreased UOP today. No dysuria,
rashes, joint pains, myalgias, diarrhea. Had myalgias 2wks ago
and ___. Wbc on routine labs ___ yesterday. Pt
prescribed Cipro 500 BID on ___ for neutropenic ppx.
In the ED, initial vitals were: 100.2 110 147/86 16 100%. Labs
notable for: WBC of 0.2, Hct 26.9, 18, lactate 1.1. Pt got Vanc
1g + Cefepime 2g. CXR done, bl cx sent. Got 1L NS bolus then
started on IVF at 100cc/hr. Vitals prior to transfer: 101.9 100
133/70 14 99%
Review of Systems:
(+) Per HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- ___: developed bad taste in his mouth chills,
nightsweats and fevers with decreased appetite and mild cough
and went to ___. In retrospect, had 3 weeks of
gum bleeding.
- ___: CBC with pancytopenia and blsts so sent to ___
where WBC 3, Hgb 9, platelets 15, Cr 1.5, PTT 29, ___ 14, fib
560. Given Cefepime and transfered to ___. On exam, shotty ant
sup cervical LN, and minimal R>L axillary LAD. WBC 2.6, Hgb 9.5,
Plt 19, N5, B4, L49, M5, Other37, UA 40, LDH 370. PBS with many
different age early leukocytes: many with open chromatin, many
with obvious multiple large nucleoli with primative features,
many with fine granules, others with coarse granules, infrequent
with cleaved nuclear morphology.
-___: Bone marrow bx with AML FISH without 8:20
translocation, cytogenetics NL. Also consented for dendritic
cell vaccine ___.
- ___: Started 7+ 3 (Daunorubicin 90mg/m2 D1,2,3,
Cytarabine 100mg/m2 ___. Course complicated by continued
neutropenic fever requiring Cefepime, Vancoycin, Voriconazole,
peripheral retinal degernation, thrush.
- ___: D14 bone marrow with 15% blasts
- ___: HiDAC (Cytarabine 3000mg/m2 Q12H D1,3,5) reinduction
after whih developed repeat fevers, thickened cecum on ___ CT
c/w typhlitis and Vancomycin/Flagyl added back to Cefepime,
Micafungin and then changed to Imipenem from Cefepime/Flagyl.
Tested positive for cdiff ___ and started on oral vancomycin.
- ___: bone marrow as was not recovering counts with early
monocytes, not blasts. Shows remission.
- ___ C2D1 HiDAC
- ___ C3D1 HiDAC
PAST MEDICAL/SURGICAL HISTORY:
Hx of malaria as a child
Hx of Measles
s/p tonsilectomy ___
s/p laser repair of partial retinal detachment in left eye ___
s/p tooth extraction ___
Social History:
___
Family History:
Grandmother had kidney disease and cancer but type is unknown.
No other blood disorders or malignancies.
Physical Exam:
Admission PE:
VITALS: 102.8, 94, 146/82, 16, 100% RA
GENERAL - ___ young ___ male, warm to
touch, in NAD
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, dry MM, OP clear,
no frontal or maxillary sinus tenderness
NECK - supple, no cervical LAD
CV - tachycardiac, regular, no murmurs
LUNGS - CTAB, breathing comfortably, no accessory muscle use
CHEST - R sided hickman nontender and without erythema
ABDOMEN - soft, NT, ND, +BS
EXTREMITIES - WWP, no ___ edema
NEURO - awake, A&Ox3, CNs ___ grossly intact, muscle strength
___ throughout, no meningismus, no photophobia
.
Discharge PE:
Pertinent Results:
Admission Labs:
___ 12:42PM UREA ___
___ TOTAL ___ ANION ___
___ 12:42PM ALT(SGPT)-65* AST(SGOT)-35 LD(LDH)-184 ALK
___ TOT ___
___ 12:42PM ___
___ 11:20AM URINE ___ SP ___
___ 11:20AM URINE ___
___
___
___ 09:12AM ___
___ 09:10AM ___ UREA ___
___ TOTAL ___ ANION ___
___ 09:10AM ___
___
___ 09:10AM ___
___
___ 09:10AM ___
___
___
.
>> MICRO:
- bl cx ___: no growth
- ucx ___: no growth
- NP swab ___: parainfluenza 3
.
>> IMAGING:
- CXR ___: No radiographic evidence of pneumonia
- Renal U/S ___: Normal.
- CXR ___: No radiographic evidence of pneumonia.
.
Brief Hospital Course:
___ with h/o AML with good cytogenetics (CEBP alpha mutation)
s/p 7+3 (D1: ___, requiring ___ with HiDAC
(___) with remission on marrow ___, currently
C3D18, coming in with fevers, cough, sore throat.
.
# Febrile neutropenia ___ Parainfluenza 3 infection: Symptoms
most c/w viral upper respiratory infection with h/o sore throat,
nasal congestion. NP swab returned positive for parainfluenza 3.
Pt also with indwelling hickman but looked good. No other
localizing symptoms. No diarrhea or GI symptoms. No urinary
symptoms, UA/ucx neg. CXR clear and without evidence of PNA. Pt
put on Vanc + Cefepime. Pt persistently febrile to ___,
continued MIVF to account for insensible losses. Fluc ppx
changed to micafungin on ___ and then changed back to
fluconazole ___. Pt defervesced by ___. Pt with residual
cough and sore throat during course, especially as counts
recovered, but no evidence of mucositis on exam and pulm exam
remained normal. Final blood cultures were negative for growth
and respiratory panel was positive for parainfluenza 3. He was
treated with supportive measures and discharged home to
___ in clinic on ___ for lab work. His ANC was 339 on
day of discharge, but patient had been afebrile off abx x 24
hours, with no complaints and negative blood cultures.
.
# ___: Cr to 1.5 on admission, not significantly improved with
IVF resuscitation. BUN also not significantly elevated
suggesting intrinsic renal origin and urine lytes also
suggestive of intrinsic renal pathology. Renal U/S normal. Urine
eos neg and no blood or protein on UA. DDx included AIN (though
no new meds prior to admission to explain), ATN (though no clear
periods of hypotension), HUS/TTP (though no clear evidence based
on diff), GN (though no blood or protein on UA). Cr downtrended
and normalized during admission.
.
# Anemia, thrombocytopenia: related to recent chemo, pt should
be soon to get past nadir. Pt had episode of epistaxis ___ NP
swab so transfused plts. He remained stable thereafter.
.
# AML: admitted C3D18 of HiDAC consolidation. Continued
fluconazole and acyclovir ppx.
.
# H/o C diff: no current diarrhea, continued PO vanc
.
>> Transitional issues:
- Please consider tapering off PO vanc in the OP setting per ID
recs
- pt will f/u with Dr. ___ in ___ clinic
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. Fluconazole 200 mg PO Q24H
3. Vancomycin *NF* 125 mg ORAL Q6H
4. Ciprofloxacin HCl 500 mg PO Q12H
5. ___ ___ *NF* (___)
___ mg/30 mL Mucous Membrane PRN
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
RX *acyclovir 400 mg 1 tablet(s) by mouth every 8 hours Disp
#*90 Tablet Refills:*3
2. Fluconazole 200 mg PO Q24H
RX *fluconazole [Diflucan] 200 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*3
3. Vancomycin *NF* 125 mg ORAL Q6H
RX *vancomycin 125 mg 1 capsule(s) by mouth every 6 hours Disp
#*120 Capsule Refills:*3
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Febrile neutropenia ___ parainfluenza infection
AML
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 a neutropenic fever from a viral illness. The
virus isolated from a swab of your nose was parainfluenza. You
were put on antibiotics to cover you for a possible concurrent
bacterial infection because your white blood cell counts were so
low. Your counts improved and you were feeling better.
Your kidney function was also abnormal when you were admitted
but this normalized during your stay.
Please ___ at the appointments listed below. Please see
the attached list for updates to your home medications. Your
home meds have not been changed with the exception of stopping
the Cipro.
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:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with AML s/p Dose #3 of high-dose cyterabine presents to the
ERI with febrile neutropenia. The patient has been compliant
with his Acyclovir and Fluconazole and has also been taking
Cipro 500mg PO BID since he became neutropenic. He has never
received G-CSF. He states that he developed a non-productive
cough approximately 6 days ago without any rinorrhea, sore
throat, chest pain, or sinus pain. He has been compliant with
wearing his mask and gloves in class and around other people and
cannot identify any sick contacts. On ___ he developed a mild,
global headache ___ in intensity without any visual changes or
nausea/vomiting. He took his T which was 101. He reports his
central line dressing is itchy to his skin but has remained
intact, non-tender and no problems changing once/week.
Vitals in the ER: 99.6 105 141/61 16 100% ra
Pt received Acetaminophen 1000mg PO ONCE, CEFEPIME 2g IV ONCE,
Vancomycin 1000mg IV ONCE.
.
REVIEW OF SYSTEMS:
(+) Per HPI; dry skin
(-) Denies chills, night sweats, rhinorrhea or congestion.
Denies shortness of breath, or wheezing. Denies chest pain,
chest pressure. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain. Denies dysuria, arthralgias or myalgias. All
other ROS negative
.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- ___: developed bad taste in his mouth chills,
nightsweats and fevers with decreased appetite and mild cough
and went to ___. In retrospect, had 3 weeks of
gum bleeding.
- ___: CBC with pancytopenia and blsts so sent to ___
where WBC 3, Hgb 9, platelets 15, Cr 1.5, PTT 29, ___ 14, fib
560. Given Cefepime and transfered to ___. On exam, shotty ant
sup cervical LN, and minimal R>L axillary LAD. WBC 2.6, Hgb 9.5,
Plt 19, N5, B4, L49, M5, Other37, UA 40, LDH 370. PBS with many
different age early leukocytes: many with open chromatin, many
with obvious multiple large nucleoli with primative features,
many with fine granules, others with coarse granules, infrequent
with cleaved nuclear morphology.
-___: Bone marrow bx with AML FISH without 8:20
translocation, cytogenetics NL. Also consented for dendritic
cell vaccine ___.
- ___: Started 7+ 3 (Daunorubicin 90mg/m2 D1,2,3,
Cytarabine 100mg/m2 D1-7). Course complicated by continued
neutropenic fever requiring Cefepime, Vancoycin, Voriconazole,
peripheral retinal degernation, thrush.
- ___: D14 bone marrow with 15% blasts
- ___: HiDAC (Cytarabine 3000mg/m2 Q12H D1,3,5) reinduction
after whih developed repeat fevers, thickened cecum on ___ CT
c/w typhlitis and Vancomycin/Flagyl added back to Cefepime,
Micafungin and then changed to Imipenem from Cefepime/Flagyl.
Tested positive for cdiff ___ and started on oral vancomycin.
- ___: bone marrow as was not recovering counts with early
monocytes, not blasts. Shows remission.
- ___ C1 HiDAC for consolidation.
- ___ C2 HiDAC for consolidation.
- ___ C3 HiDAC for consolidation.
PAST MEDICAL/SURGICAL HISTORY:
Malaria as a child
Measles
Tonsilectomy ___
Laser repair of partial retinal detachment in left eye ___
Tooth extraction ___
Social History:
___
Family History:
Grandmother had kidney disease and cancer but type is unknown.
No other blood disorders or malignancies.
Physical Exam:
Vitals: T 98.4 bp 140/80 HR 90 SaO2 100 RA RR 18
GEN: NAD, awake, alert
HEENT: supple neck, dry mucous membranes, no oropharyngeal
lesions
PULM: normal effort, CTAB
CHEST: Port dressing clean, dry, nontender, intact
CV: RRR, no r/m/g/heaves
ABD: soft, NT, ND, bowel sounds present
EXT: normal perfusion
SKIN: warm, dry
NEURO: AOx3, no focal sensory or motor deficits
PSYCH: calm, cooperative
Pertinent Results:
Admission:
___ 09:34PM LACTATE-1.0
___ 09:24PM GLUCOSE-86 UREA N-14 CREAT-1.3* SODIUM-142
POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-29 ANION GAP-12
___ 09:24PM ALT(SGPT)-33 AST(SGOT)-26 ALK PHOS-119 TOT
BILI-0.4
___ 09:24PM LIPASE-20
___ 09:24PM ALBUMIN-4.7 CALCIUM-9.1 PHOSPHATE-3.7
MAGNESIUM-1.9
___ 09:24PM WBC-0.7*# RBC-3.29* HGB-9.8* HCT-28.9* MCV-88
MCH-29.9 MCHC-34.0 RDW-16.0*
___ 09:24PM NEUTS-0 BANDS-0 LYMPHS-47* MONOS-50* EOS-0
BASOS-0 ATYPS-2* ___ MYELOS-0 BLASTS-1*
___ 09:24PM PLT SMR-VERY LOW PLT COUNT-30*
___ 09:24PM ___ PTT-28.6 ___
___ 11:30AM PLT COUNT-32*#
___ 08:30AM WBC-0.4*# RBC-3.31*# HGB-10.2*# HCT-28.8*#
MCV-87 MCH-30.8 MCHC-35.4* RDW-16.2*
___ 08:30AM NEUTS-0 BANDS-1 LYMPHS-77* MONOS-17* EOS-1
BASOS-0 ATYPS-4* ___ MYELOS-0
___ 08:30AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
TEARDROP-OCCASIONAL
___ 08:30AM PLT SMR-RARE PLT COUNT-13*#
.
CXR ___ IMPRESSION: Wide caliber double-lumen catheter
terminating in upper portion of right atrium. Otherwise, chest
findings within normal limits.
Discharge:
___ 06:22AM BLOOD WBC-1.8* RBC-2.76* Hgb-8.2* Hct-23.9*
MCV-87 MCH-29.6 MCHC-34.3 RDW-16.1* Plt ___
___ 06:22AM BLOOD Neuts-29* Bands-1 ___ Monos-29*
Eos-1 Baso-0 Atyps-1* ___ Myelos-0 Plasma-1*
Brief Hospital Course:
#Neutropenic fever: Pt presented with fever to 101 degrees,
cough, and generalized fatigue in setting of neutropenia from
previous dose of HiDAC. He was started empirically on cefepime
and vancomycin. He has a low grade fever to 100.4 within 24hrs
of admission but remained afebrile for remaineder of admission.
Infectious work up including viral screen was unrevealing.
___ site was clear and without erythema. His symptoms
resolved and he felt well at time of discharge with improvement
of ANC over 500 at time of discharge. He was continued on
fluconazole and acyclovir prophalaxis as an outpatient in
addition to PO vancomycin given hx of Cdiff. He had no GI
symptoms this admission.
.
# AML: completed cycle #3 HiDAC, day 21 at time of discharge
with improvement in ANC. Treatment otherwise well tolerated. No
signs of leukemia on peripheral smear this admission. He was
continued on Acyclovir and fluconazole prophylaxis.
.
# Anemia: Due to myelosuppression from chemotherapy. Was stable
this admission and did not require transfusion.
..
# Hx of C. diff colitis: Continued outpatient vancomycin during
admission. He had normal bowel movements with no recent
diarrhea.
.
Transitions of Care:
#Pt will continue oral vancomycin for ppx Cdiff coverage
#He will follow up with Dr. ___ further management of AML
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. Fluconazole 200 mg PO Q24H
3. Lorazepam 0.5-1 mg PO Q4H:PRN Nausea
4. Ondansetron ___ mg PO Q8H:PRN Nausea
5. Vancomycin *NF* 125 mg ORAL Q6H
6. Ciprofloxacin HCl 500 mg PO Q12H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Neutropenic fever
Secondary diagnosis:
Acute Myelogenous Leukemia
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 ___ at ___.
___ came in with fevers and a cough in the setting of recent
chemotherapy which had lowered your immune system. We started
___ on antibiotics and your fevers improved. We continued ___ on
antibiotics until your blood counts improved. We never located
the source of your fever, but we believe it was most likely due
to a viral infection.
Followup Instructions:
___
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|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
lethargy, gait imbalance
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs ___ is a ___ female who has decompensated liver
cirrhosis secondary to NASH with hepatic encephalopathy,
ascites, portal hypertension with esophageal varices and a
portal vein thrombosis, MELD of 13 on liver transplant list who
presents with lethargy and gait imbalance. Patient states 4 days
ago she had some episodes of epigastric pain with no nausea or
vomiting she also had a short episode where she felt confused
but this resolved. 2 days ago she did have some epigastric pain
that is resolved. During a clinic visit yesterday morning she
was in good health, although she mentioned these brief episodes.
.
Yesterday (___) around 1600 she said she started feeling
unbalanced and dizzy on walking. She states she did not fall.
She also felt very weak and tired in general. Overnight she
felt cold but denies fever or chills. She tried to watch TV but
found that it was difficult to follow the plot and that she was
easily confused and distracted. She called her brother to come
take her to the hospital. When he arrived, she had a difficult
time speaking as she knew what she wanted to say but it was not
coming out properly. Her brother said that her speech was
slurred. She also noted that her right leg had a "pins and
needles" sensation and that it was hard to move. On walking she
had a tendency to be weak on the right. Again she did not fall.
She denies vision changes, headache, facial droop, weakness in
arms or legs.
.
In the ED, initial vitals were 96.8 71 137/59 16 100%. Neuro
exam was normal. Labs were notable for pancytopenia (stable
from prior), LFTs were stable. CXR and ___ CT were
unremarkable. EKG was NSR with no acute changes.
.
On arrival to the floor, she denies any confusion or weakness.
She continues to feel cold and slightly lightheaded. She notes
some residual right leg tingling.
Past Medical History:
# type 2 diabetes, diagnosed ___ years ago.
# NASH:
-- c/b cirrhosis
-- esophageal varices (two cords of grade one varices) with
prior banding procedures.
-- portal vein and splenic vein thrombosis, on warfarin started
___.
-- ascites
-- reactivated on transplant list ___
# iron deficiency anemia
# migraine headaches
# hypercholesterolemia
# psoriatic arthritis
# chest pain: positive stress test in ___ with a reversible
inferior defect, later followup by catheterization showed
basically clean coronary arteries.
# History of positive PPD s/p INH therapy.
# Psoriasis
Social History:
___
Family History:
Mother still alive at ___ s/p stroke ___ yr ago. Father still alive
at ___, has DM2 and prostate cancer. Denies Fam Hx of neuro
disease. Uncle with probable history of TB.
Physical Exam:
PHYSICAL EXAMINATION:
VS: 96.8 125/70 66 18 100% RA weight 89.9 FSBS 124
Orthostatic: lying down 96/49 73; sitting 115/60 68;
standing 123/65 71
GENERAL: comfortable, appropriate, NAD
HEENT: Sclera anicteric. PERRL, EOMI. MMM, OP clear.
NECK: Supple with no JVD, LAD. No thyromegaly.
CARDIAC: RRR, nl S1 S2, no MRG.
LUNGS: CTAB, no rales, wheezes or rhonchi.
ABDOMEN: Soft, ___, mild distension.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 1+
edema.
NEURO: CN ___ tested and intact. Strength ___ throughout.
PSYCH: oriented x3, recall of 3 objects intact at 2 minutes,
serial 7s normal (within limits of language barrier), speech
fluid and appropriate
Pertinent Results:
Admission Labs:
___ 01:43AM BLOOD ___
___ Plt ___
___ 01:43AM BLOOD ___
___
___ 01:49AM BLOOD ___ ___
___ 01:43AM BLOOD ___
___
___ 01:43AM BLOOD ___
___ 01:43AM BLOOD ___
___ 01:43AM BLOOD ___
___ 01:43AM BLOOD ___
___
___ 04:45AM URINE ___ Sp ___
___ 04:45AM URINE ___
___ Urobiln->12 ___
___ 04:45AM URINE ___
___
Discharge Labs:
___ 05:35AM BLOOD ___
___ Plt ___
___ 05:35AM BLOOD ___
___
___ 05:35AM BLOOD ___
Microbiology:
___ CULTURE - YEAST
___ CULTURE - PENDING
___ CULTURE - NO GROWTH
Imaging:
CT ___ (___):
FINDINGS: There is no evidence for acute intracranial
hemorrhage, large mass, mass effect, edema, or hydrocephalus.
There is preservation of ___ differentiation. The basal
cisterns appear patent. Visualized bones and soft tissues are
unremarkable. The visualized portions of the paranasal sinuses
and mastoid air cells are well aerated.
IMPRESSION: No CT evidence for acute intracranial process.
.
CXR (___):
FINDINGS: No focal consolidation, pleural effusion, or
pneumothorax is seen. Heart size is top normal. There is no
evidence for pulmonary edema.
IMPRESSION: No radiographic evidence for acute cardiopulmonary
process.
.
MR ___ (___):
FINDINGS: There is no evidence of acute infarct seen. There is
no mass effect, midline shift, or hydrocephalus. The
___ T1 images demonstrate increased signal within the
region of both basal ganglia which is a nonspecific finding and
is most likely secondary to hepatic encephalopathy. There are
multiple foci of T2 hyperintensity in the subcortical and deep
white matter of both cerebral hemispheres which have increased
since the prior study and indicate progression of small vessel
disease. Following gadolinium, no evidence of abnormal
parenchymal, vascular, or meningeal enhancement seen. Slightly
asymmetric enhancement of the right tentorium appears to be
within normal limits.
IMPRESSION:
1. No evidence of acute infarct, mass effect, or hydrocephalus.
No other acute abnormalities.
2. Moderate changes of small vessel disease which appear to have
increased since the previous MRI of ___.
3. Increased signal in basal ganglia on ___ which is a
nonspecific finding and most likely is due to hepatic
encephalopathy.
4. No evidence of enhancing brain lesion.
Brief Hospital Course:
___ with decompensated liver cirrhosis secondary to NASH with
hepatic encephalopathy, ascites, portal hypertension with
esophageal varices and a portal vein thrombosis, MELD of 13 on
liver transplant list who presented with lethargy and gait
imbalance.
.
# Confusion, expressive aphasia: The patient's symptoms led to
a broad differential including neurological (migraine, TIA,
CVA), cardiac (arrhythmia, orthostasis), endocrine (hypothyroid,
hypoglycemia), and liver (encephalopathy). Encephalopathy was
less likely given the short ___ and rapid resolution of
her symptoms. The patient was orthostatic on presentation, but
her symptoms were not present only on standing or position
change. As a diabetic, she was at risk for hypoglycemia, but
her symptoms did not seem timed for periods at risk for
hypoglycemia. Her TSH was normal. She had a history of
migraine, but they do not present with these symptoms as aura
and she denied headache on this occasion. Telemetry revealed no
arrhythmias. The short time frame and acute nature of her
symptoms was very concerning for TIA. CVA was unlikely given
normal ___ CT in the ED. MR showed white matter disease that
may be related to her symptoms. She was started on aspirin for
stroke prevention. It was recommended that she ___ to
ensure her orthostatic hypotension resolved, and to check a
lipid panel to better understand her risk factors.
.
# Liver disease: The patient has cirrhosis, with history of
encephalopathy, ascites, portal HTN, varices, and portal vein
thrombosis. She was continued on her home regimen of lactulose,
rifaximin, furosemide, and spironolactone. Her nadolol, used
for varices, was reduced to lower her risk for orthostatic
hypotension.
.
# Psoriasis: She had relatively few lesions, not pruritic.
Minimal arthritis pain. Her home medications were continued.
.
# Anemia: Hct dropped to 24.9 from 27.1 on admission, but then
rebounded to 26.0. No new anemia workup was performed.
.
# Diabetes: ___ with home insulin regimen. Her
home regimen was slightly reduced and a sliding scale used. She
has not hypoglycemic on presentation or during her admission.
.
# Health maintenance: Continued calcium, iron, vitamin D.
.
# CODE: Full
.
Transitional:
- Suggest lipid panel at PCP appt
- ___ for orthostatic hypotension
Medications on Admission:
- betamethasone dipropionate 0.05 % Lotion apply bid to
psoriasis on weekends avoid ___
- calcipotriene [Dovonex] 0.005 % Cream apply to psoriasis twice
a day to psoriasis ___ through ___ ___
- desonide 0.05 % Cream apply once a day to folds/genitals for
psoriasis as needed for ___ days then stop ___
- etanercept [Enbrel] 50 mg/mL (0.98 mL) Syringe 50 mg subcut q
week
- furosemide 40 mg Tablet 1 Tablet(s) by mouth in the am
- insulin lispro protam & lispro [Humalog Mix ___ 100 unit/mL
(___) Suspension 55U twice a day ___
- ketoconazole [Nizoral] 2 % Shampoo wash hair as directed daily
- lactulose 10 gram/15 mL Solution 15 ml(s) by mouth three times
a day
- nr lumbar or abdominal corset use as directed back pain, abd
pain; abdominal hernia
- nadolol 40 mg Tablet 1 Tablet(s) by mouth once a day
___
- rifaximin [Xifaxan] 550 mg Tablet one Tablet(s) by mouth twice
a day
- spironolactone 100 mg Tablet 1 Tablet(s) by mouth once a day
- nr triamcinolone acetonide 0.1 % Ointment apply twice a day to
psoriasis on arms/legs/back/chest for ___ days per month as
needed avoid face,folds,genitals---medium potency topical
steroid ___
Discharge Medications:
1. betamethasone dipropionate 0.05 % Lotion Sig: One (1) Appl
Topical 2X/WEEK (___).
2. calcipotriene 0.005 % Cream Sig: One (1) Appl Topical 5X/WEEK
(___).
3. Enbrel 50 mg/mL (0.98 mL) Syringe Sig: One (1) ML
Subcutaneous QSUN (every ___.
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. insulin lispro protam & lispro 100 unit/mL (___) Suspension
Sig: ___ (55) units Subcutaneous twice a day.
6. ketoconazole 2 % Shampoo Sig: One (1) Appl Topical ASDIR (AS
DIRECTED).
7. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO TID (3
times a day).
8. nadolol 40 mg Tablet Sig: 0.5 Tablet PO once a day.
9. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. triamcinolone acetonide 0.1 % Ointment Sig: One (1) Topical
once a day: ___ days per month as needed avoid
face,folds,genitals.
12. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: Two (2) Tablet, Chewable PO BID (2 times a day).
15. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Transient ischemic attack, orthostatic hypotension
Secondary: NASH cirrhosis, type 2 DM
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 at ___
___. You were admitted for dizziness and difficulty
speaking which was concerning for a transient ischemic attack,
when blood flow to the brain is blocked temporarily. Your
symptoms also could have been caused by orthostatic hypotension,
a type of low blood pressure that occurs when standing up. We
have adjusted your medications and expect your symptoms to
improve with these adjustments.
.
The following changes have been made to your medications:
- DECREASE nadolol to 20 mg daily to reduce the risk of
orthostatic hypotension
- START Aspirin 325 daily
.
You should have your cholesterol checked before your next PCP
appointment because you may need to be started on a cholesterol
medication.
.
Please take your medications and follow up with your doctors as
___ below.
Followup Instructions:
___
|
10670705-DS-31
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| 31 |
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|
2124-04-07 20:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Diagnostic paracentesis
History of Present Illness:
Mrs ___ is a ___ female who has decompensated liver
cirrhosis secondary to NASH with hepatic encephalopathy,
ascites, portal hypertension with esophageal varices and a
portal vein thrombosis, on liver transplant list who presents
with abdominal pain. She c/o intermittent epigastric pain x 1
day. +nausea, no emesis. +chills, subjective fever and feels
weak. Of note, she was recently discharged from on ___ after
eval for lethargy/gait imbalance, which was felt to be secondary
to orthostatic hypotension vs neurological origin, but had
resolved on discharge. No diarrhea/recent sick contacts/rash/RUQ
pain/CP/SOB/neuro sxs. Says last BM was well formed last ___ with
no blood or melena.
.
In the ED, initial vitals were 99.4 99 150/90 18 100% RA. Labs
showed CBC/coags stable from ___, LFTs/lipase nl, Tbili stable.
Diagnostic paracentesis was attempted and failed. CT a/p showed
Increased right colonic wall thickening due to portal colopathy
vs infectious or ischemic colitis.Right portal vein not
visualized, may represent extension of portal vein thombosis.
She was given 4mg IV morphine prior to the paracentesis.
Percocet was also given for abdominal pain, as well as IV
Zofran. BC x2 drawn and IV Flagyl and IV Cipro given. Most
Recent Vitals prior to transfer: 98.8, 88, 143/77, 98 RA, 18
Past Medical History:
# type 2 diabetes.
# NASH Cirrhosis complicated by:
-- esophageal varices (two cords of grade one varices) with
prior banding procedures.
-- portal vein and splenic vein thrombosis, chronic,
nonocclusive
-- ascites
--SBP early ___
-- reactivated on transplant list ___
# iron deficiency anemia
# migraine headaches
# hypercholesterolemia
# psoriatic arthritis
# History of positive PPD s/p INH therapy.
# Psoriasis
Social History:
___
Family History:
Mother with previous CVA. Father has DM2 and prostate cancer.
Physical Exam:
Adm PE:
VS: 99.8, 149/63, 84, 20, 100RA
GENERAL: comfortable, appropriate, NAD
HEENT: PERRL, EOMI. MM dry, OP clear.
NECK: Supple with no JVD, LAD. No thyromegaly.
CARDIAC: RRR, nl S1 S2, no MRG.
LUNGS: CTAB, no rales, wheezes or rhonchi.
ABDOMEN: Soft, non-tender, mild distension. + prominent ventral
hernia
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 1+
edema.
NEURO: oriented x3, no asterixis
.
Discharge PE:
VS: 97.7 (98.9) 115/60 76 100%RA
GENERAL: comfortable, appropriate, NAD
HEENT: MMM, OP clear.
CARDIAC: RRR, no MRG.
LUNGS: CTAB, no rales, wheezes or rhonchi.
ABDOMEN: Soft, mildly tender, mild distension. + prominent
umbilical hernia
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 1+
edema b/l ___.
NEURO: oriented x3, no asterixis
SKIN: Diffuse dyspigmented patches scattered throughout entire
body
Pertinent Results:
Adm labs:
___ 08:15AM BLOOD WBC-3.7*# RBC-3.08* Hgb-8.5* Hct-26.9*
MCV-88 MCH-27.6 MCHC-31.6 RDW-20.3* Plt Ct-50*
___ 08:15AM BLOOD Neuts-78.3* Lymphs-14.1* Monos-3.7
Eos-3.7 Baso-0.2
___ 08:37AM BLOOD ___ PTT-32.2 ___
___ 08:15AM BLOOD Glucose-113* UreaN-12 Creat-0.8 Na-137
K-3.7 Cl-106 HCO3-23 AnGap-12
___ 08:15AM BLOOD ALT-24 AST-38 AlkPhos-87 TotBili-2.4*
___ 06:32AM BLOOD Albumin-3.5 Calcium-8.4 Phos-2.3* Mg-1.7
___ 04:45PM ASCITES TotPro-1.3 Glucose-240 LD(LDH)-73
___ 04:45PM ASCITES WBC-3475* ___ Polys-79*
Lymphs-4* Monos-3* Macroph-14*
.
Micro:
___ 12:40 pm BLOOD CULTURE SET#2.
ESCHERICHIA COLI. FINAL SENSITIVITIES.
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
___ UCx: Yeast
___ 12:23 pm STOOL CONSISTENCY: FORMED Source:
Stool.
FECAL CULTURE (Pending):
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ___:
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
___ 3:38 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
.
___ - ___ BCx: No growth at discharge x 6 total sets.
.
Imaging:
___. Increased right colonic wall thickening, maybe
due to portal colopathy but infectious or ischemic colitis
cannot be excluded. No obvious thromboembolus in mesenteric
vessels.
2. Chronic thrombosis of the main portal vein extending to the
left portal vein, with non-visualization of the right portal
vein. This may be due to the timing of image acquisition or
progression of portal vein thrombosis. If clinically indicated,
consider Doppler ultrasound study of the liver.
3. Hepatic cirrhosis with sequelae of portal hypertension
including ascites, splenomegaly, and extensive mesenteric
varicosity.
4. Large but stable umbilical hernia containing multiple loops
of non-obstructed small bowel, free fluid, and
omentum/mesentery.
.
___ ___ guided paracentesis: IMPRESSION: Successful
ultrasound-guided diagnostic paracentesis
.
Discharge labs:
___ 05:55AM BLOOD WBC-1.2* RBC-2.60* Hgb-7.2* Hct-23.6*
MCV-91 MCH-27.7 MCHC-30.6* RDW-21.7* Plt Ct-43*
___ 05:40AM BLOOD Neuts-51 Bands-7* ___ Monos-3
Eos-7* Baso-1 Atyps-4* ___ Myelos-0
___ 05:55AM BLOOD ___ PTT-34.0 ___
___ 05:55AM BLOOD ___ ___
___ 05:55AM BLOOD Glucose-96 UreaN-14 Creat-0.8 Na-136
K-3.7 Cl-105 HCO3-24 AnGap-11
___ 05:55AM BLOOD ALT-10 AST-29 LD(LDH)-183 AlkPhos-52
TotBili-1.3
___ 05:55AM BLOOD Calcium-8.8 Phos-2.6* Mg-1.9
Brief Hospital Course:
Summary: ___ woman with NASH cirrhosis complicated by hepatic
encephalopathy, ascites, portal hypertension with esophageal
varices and a portal vein thrombosis, admitted for SBP.
.
# SBP and associated e coli bacteremia: Not suspected to be
secondary peritonitis after a work-up for this was unrevealing.
Treated with Ceftriaxone for 4 days, which was halted secondary
to pancytopenia, with an ANC at discharge of 610. ID was
consulted and recommended switching to Ciprofloxacin 500 mg po
q12 hours for total 14 day antibiotic course from ___ (first day
of clear cultures). Surveillance blood cultures, peritoneal
cultures, and stool cultures had been sent, which were not
growing anything at the time of discharge will need follow-up as
an outpatient.
.
# Pancytopenia: Time-course correlates with ceftriaxone, which
was subsequently changed to ciprofloxacin. However, other
etiologies are possible, including marrow suppression from
e-coli bacteremia. Now stabilized, and some lines trending up.
___ 610. Enbrel was held given neutropenia. Patient was
carefully counseled to watch for fever at home, and to
immediately call her outpatient physicians or go to the
emergency room for a temperature >100.4. She was scheduled for
follow-up 3d post discharge for PCP appointment and repeat count
check. ID did not recommend listing pancytopenia as an adverse
reaction of ceftriaxone in the patient's record, as they did not
feel confident this medication was to blame.
.
# NASH Cirrhosis: Decompensated. continued lactulose and
rifaximin for encephalopathy. Initially held and later
restarted lasix and spironolactone. continued nadolol for
varices
.
# Psoriasis with psoriatic arthritis: Currently relatively few
lesions, and she feels her current regimen controls her symptoms
well. Minimal arthritis pain. continued topical regimen, but
held Enbrel in setting of neutropenia and infection.
.
# Diabetes: continued home regimen (per pt's report of her home
doses which was different than listed in OMR).
.
# History of possible TIA: On 325mg daily ASA; Deferred to
primary outpatient providers.
.
# Health maintenance: continued calcium, iron, vitamin D
.
==========
TRANSITIONAL ISSUES:
-Needs very close follow-up of surveillance blood cultures,
stool cultures, and peritoneal fluid cultures
-Needs close monitoring of her CBC for pancytopenia, including
neutropenia
-Restart enbrel for psoriasis when indicated - currently held in
setting of neutropenia and SBP
-14d total course for SBP and e coli bacteremia; starting from
___.
Medications on Admission:
BETAMETHASONE DIPROPIONATE - 0.05 % Lotion - apply bid to
psoriasis on weekends avoid face-folds-genitals
CALCIPOTRIENE [DOVONEX] - 0.005 % Cream - apply to psoriasis
twice a day to psoriasis ___ through ___
DESONIDE - 0.05 % Cream - apply once a day to folds/genitals for
psoriasis as needed for ___ days then stop
ETANERCEPT [ENBREL] - 50 mg/mL (0.98 mL) Syringe - 50 mg subcut
q
week DX ___
FUROSEMIDE - 40 mg Tablet - 1 Tablet(s) by mouth in the am
INSULIN LISPRO PROTAM & LISPRO [HUMALOG MIX 75-25] - 100 unit/mL
(75-25) Suspension - 55U twice a day
KETOCONAZOLE [NIZORAL] - 2 % Shampoo - wash hair as directed
daily
LACTULOSE - 10 gram/15 mL Solution - 15 ml(s) by mouth three
times a day with orange flavoring
LUMBAR OR ABDOMINAL CORSET - - use as directed back pain, abd
pain; abdominal hernia icd9:789.00
NADOLOL - 20 mg Tablet - 1 Tablet(s) by mouth once a day
PRAVASTATIN 10mg daily
RIFAXIMIN [XIFAXAN] - 550 mg Tablet - one Tablet(s) by mouth
twice a day
SPIRONOLACTONE - 100 mg Tablet - 1 Tablet(s) by mouth once a day
TRIAMCINOLONE ACETONIDE - 0.1 % Ointment - apply twice a day to
psoriasis on arms/legs/back/chest for ___ days per month as
needed avoid face,folds,genitals
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - 1
Tablet(s) by mouth DAILY (Daily)
CALCIUM CARBONATE-VITAMIN D3 - 600 mg (1,500 mg)-400 unit Tablet
- 1 Tablet(s) by mouth once daily
FERROUS SULFATE - 325 mg (65 mg iron) Tablet - 1 Tablet(s) by
mouth once a day
GUAIFENESIN - 100 mg/5 mL Liquid - 5 mL(s) by mouth every ___
hours as needed for cough
Discharge Medications:
1. betamethasone dipropionate 0.05 % Lotion Sig: One (1) Appl
Topical BID (2 times a day): apply bid to psoriasis on weekends
avoid face-folds genitals .
2. calcipotriene 0.005 % Cream Sig: One (1) Appl Topical BID (2
times a day): ___ through ___.
3. ketoconazole 2 % Shampoo Sig: One (1) Topical once a day.
4. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO TID (3
times a day).
5. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. triamcinolone acetonide 0.1 % Ointment Sig: One (1) Topical
twice a day: apply twice a day to
psoriasis on arms/legs/back/chest for ___ days per month as
needed avoid face,folds,genitals.
9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit
Tablet Sig: One (1) Tablet PO once a day.
11. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. Insulin
Continue your home insulin dosing; which you reported to be NPH
55u with breakfast, and 25u with dinner; and humalog sliding
scale
13. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
14. spironolactone 100 mg Tablet Sig: One (1) Tablet PO once a
day.
15. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): For 14 day total course, started on ___.
Disp:*qs Tablet(s)* Refills:*0*
16. Outpatient Lab Work
Please obtain a CBC with differential on ___ or ___
___ and have the results sent to Dr. ___
___ ___
Discharge Disposition:
Home
Discharge Diagnosis:
Spontaneous bacterial peritonitis
E. coli bacteremia
Pancytopenia
Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted and found to have an infection in your
abdomen. We treated you with antibiotics to kill the infection.
The bacteria responsible for your symptoms also made it into
your blood, so you should take 2 weeks of antibiotics total.
.
It is very important for you to follow-up with your doctors as
___ below.
.
Please also note the following medication changes:
-Start ciprofloxacin 500mg twice a day through ___
-Stop Enbrel until your doctor tells you to restart it
You will also need blood counts
Followup Instructions:
___
|
10670705-DS-33
| 10,670,705 | 21,860,176 |
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| 33 |
2125-04-12 00:00:00
|
2125-04-15 08:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Weakness and abdominal pain
Major Surgical or Invasive Procedure:
EGD
Colonoscopy
History of Present Illness:
___ with history of NASH cirhosis with associated hepatic
encephalopthay, SBP, portal hypertension, esophageal varices on
liver transplant list here with abdominal pain since this
morning and increase in abdominal girth. She reports waking up
with abominal pain and weakness and felt "unable to get up from
bed". She also felt feverish with chills, though no documented
fever. She denied N/V/D or constipation. She denies blood in
the stool or melena.
In the ED, triage vitals were 98.8 109 116/56 20 99%. She was
AAOx3. Bedside ultrasound did not view significant ascites to
perform paracentesis. Formal US showed moderate ascites. CT
scan showed Edematous bowel wall involving the stomach, duodenum
and proximal jejunum may reflect third-spacing or,
alternatively, infectious or inflammatory gastroduodenitis, as
well as increased ascites from prior. ED did not feel
comfortable performing tap in ED.
On the floor, VS are 99.6 119/57 110 18 99% ra. She
endorses abdominal pain and headache currently.
ROS: per HPI, denies vision changes, rhinorrhea, congestion,
sore throat, cough, shortness of breath, chest pain, diarrhea
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
# type 2 diabetes.
# NASH Cirrhosis complicated by:
-- esophageal varices (two cords of grade one varices) with
prior banding procedures.
-- portal vein and splenic vein thrombosis, chronic,
nonocclusive
-- ascites
--SBP early ___
-- reactivated on transplant list ___
# iron deficiency anemia
# migraine headaches
# hypercholesterolemia
# psoriatic arthritis
# History of positive PPD s/p INH therapy.
# Psoriasis
Social History:
___
Family History:
Mother with previous CVA. Father has DM2 and prostate cancer.
Physical Exam:
Admission:
VS: 99.6 119/57 110 18 99% ra
GENERAL: Pleasant female, mild distress from abdominal pain,
mildly jaundiced
HEENT: Sclera icteric. MMM.
CARDIAC: RRR with no excess sounds appreciated
LUNGS: CTA b/l with no wheezing, rales, or rhonchi.
ABDOMEN: Distended but Soft, large ventral hernia. Abomden is
mildly tender to palpation throughout. +Caput medusae
EXTREMITIES: No edema. Warm and well perfused, no clubbing or
cyanosis.
NEUROLOGY: No asterixis
SKIN: + Spiders, evidence of psoriasis over abdomen, elbows, and
lower extremities.
NEURO: A/O x3, no asterixis
Pertinent Results:
Admission:
___ 02:00PM BLOOD WBC-4.7# RBC-3.20* Hgb-8.9* Hct-28.8*
MCV-90 MCH-27.7 MCHC-30.7* RDW-18.6* Plt Ct-60*
___ 02:00PM BLOOD Neuts-86.4* Lymphs-7.8* Monos-4.4 Eos-1.2
Baso-0.3
___ 02:00PM BLOOD ___ PTT-34.0 ___
___ 02:00PM BLOOD Glucose-230* UreaN-15 Creat-1.1 Na-130*
K-3.9 Cl-100 HCO3-21* AnGap-13
___ 02:00PM BLOOD ALT-28 AST-51* AlkPhos-86 TotBili-2.7*
___ 02:00PM BLOOD Albumin-3.1* Calcium-8.4 Phos-2.7 Mg-1.8
Discharge:
Brief Hospital Course:
___ female w/hx of Class C NASH cirrhosis c/b SBP, ascites,
esophageal varices, and hepatic encephalopathy presenting with 3
days of increasing weakness, fatigue, and abdominal pain being
treated emperically for SBP.
# SBP: Patient presented with worsening abdominal pain and
malaise for several days. She was afebrile on admission but was
tachycardic with WBC of 2. In the ED and on admission, a safe
pocket for paracentesis could not be identified on ultrasound.
Given clinical picture and history of SBP in past, decision was
made to empirically treat for SBP and she received ceftriaxone
2gm and albumin at SBP dosing (first and third days). She did
have 1 set of ED blood cultures that grew strep viridans but
this was felt to be a contaminate by ID consult. Within 24
hours of admission, patient was feeling well and had no active
complaints or complications. LFTs were at baseline during
admission. A PICC line was placed and Ms. ___ complete a
10 day course of ceftriaxone at ID recommendation in setting of
neutopenia. She had been on cipro prophylaxis but will be
transitioned to Bactrim prophylaxis at discharge in setting of
possible treatment failure.
#Bacteremia: Pt found to have strep viridans in ___ bottles on
admission (unfortuantely only 1 set drawn). Symptoms and
rapidity of improvement along with organism make this most
likely a contaminant (roughly 80% of all strep viridans
bacteremias are due to transient bacteremia or skin
contaminant). ID consult felt comfortable not treating
infection. She did not show any septic physiology. A TTE was
negative for vegetations. Surveillance cultures have been
negative. There was no signs of dental infection on gross exam.
She completed a course of ceftriaxone as above.
# Pancytopenia:Patient has a known history of pancytopenia and
has been followed by hematology in past but has not followed up
in several years. Hematocrit was 28.8 on admission but found to
drop following admission to 19. There was no clear source of
bleeding on endoscopy, colonscopy and on CT imaging. She
received 1 uint of PRBC. It is believed she was hemoconcentrated
on admission and drop is in setting of receiving albumin. While
pancytopenia can be attributed to liver disease, it is more
severe than is normally seen. We recommend outpatient heme/onc
follow up with consideration of bone marrow biopsy.
# NASH cirrhosis: Class C, complicated by polymicrobial SBP,
hepatic encephalopathy, portal hypertension and esophageal
varices. Has history of grade I esophageal varices with banding
in the past, but no evidence of esophageal varices on recent EGD
in ___. Liver function at baseline this admission without signs
of further decompensation. MELD 16 on admission. Currently on
transplant list but on hold due to surgical anatomy being
difficult. She was continued on lactulose, rifaxamin, and
nadalol. Spironolactone and lasix were held in setting of
infection and restarted at discharge. Her SBP prophylaxis was
changed to Bactrim from cipro.
# Psoriasis: Evidence of plaques on exam. Held enbrel in setting
of possible infection (gets on ___. Continued
betamethasone dipropionate 0.05% BID
and Dovonex 0.005% cream to affected areas twice daily ___
through ___
Transitions of Care:
1. Pt currently on hold on transplant due to surgical anatomy.
___ has been consulted to see if they can recanulize portal vein.
2. Pt need heme/onc follow up
3. She will complete a 10 day course of ceftriaxone as an
outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Betamethasone Dipro 0.05% Lot. 1 Appl TP BID
to psoriasis on weekends avoid face-folds-genitals
2. Calcipotriene 0.005% Cream 1 Appl TP BID
___ through ___
3. Desonide 0.05% Cream 1 Appl TP ONCE DAILY
apply to folds/genitals as needed for ___ days then stop
4. Enbrel *NF* (etanercept) 50 mg/mL (0.98 mL) Subcutaneous once
weekly
50mg sc once per week
5. Humalog ___ 55 Units Breakfast
Humalog ___ 30 Units Dinner
6. Furosemide 60 mg PO DAILY
hold for sbp< 90
7. Ketoconazole Shampoo 1 Appl TP ASDIR
8. Lactulose 15 mL PO TID
titrate to ___ BM/day
9. Nadolol 20 mg PO DAILY
hold for sbp<90, HR<55
10. Omeprazole 20 mg PO DAILY
11. Pravastatin 10 mg PO DAILY
12. Rifaximin 550 mg PO BID
13. Spironolactone 150 mg PO DAILY
hold for sbp <90
14. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN
psoriasis
BID to psoriasis on arms/legs/back/abdomen on weekends avoid
face,folds,genitals---medium potency topical steroid
15. Aspirin 325 mg PO DAILY
16. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin
D3) 600 mg(1,500mg) -400 unit Oral daily
17. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Betamethasone Dipro 0.05% Lot. 1 Appl TP BID
to psoriasis on weekends avoid face-folds-genitals
3. Ferrous Sulfate 325 mg PO DAILY
4. Humalog ___ 55 Units Breakfast
Humalog ___ 30 Units Dinner
5. Lactulose 15 mL PO TID
titrate to ___ BM/day
6. Nadolol 20 mg PO DAILY
hold for sbp<90, HR<55
7. Omeprazole 20 mg PO DAILY
8. Pravastatin 10 mg PO DAILY
9. Rifaximin 550 mg PO BID
10. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin
D3) 600 mg(1,500mg) -400 unit Oral daily
11. Desonide 0.05% Cream 1 Appl TP ONCE DAILY
apply to folds/genitals as needed for ___ days then stop
12. Enbrel *NF* (etanercept) 50 mg/mL (0.98 mL) Subcutaneous
once weekly
50mg sc once per week
13. Furosemide 60 mg PO DAILY
hold for sbp< 90
14. Ketoconazole Shampoo 1 Appl TP ASDIR
15. Spironolactone 150 mg PO DAILY
hold for sbp <90
16. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN
psoriasis
BID to psoriasis on arms/legs/back/abdomen on weekends avoid
face,folds,genitals---medium potency topical steroid
17. CeftriaXONE 2 gm IV Q24H Duration: 3 Days
Last dose ___
RX *ceftriaxone 2 gram 1 bag daily Disp #*3 Bag Refills:*0
18. Calcipotriene 0.005% Cream 1 Appl TP BID
___ through ___
19. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
Start taking this medication on ___
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth daily Disp #*30 Tablet Refills:*2
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Spontaneous Bacterial Peritonitis
NASH Cirrhosis
Pancytopenia
Secondary Diagnosis:
Psoriasis
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 ___ at ___.
___ came in with increasing fatigue, weakness, and abdominal
pain. We believe these symptoms were secondary to a bacterial
infection in ___ abdomen. We treated ___ with antibiotics with
improvement in your symptoms. ___ will finish a 10 day course of
antibiotics as an outpatient - last day is ___.
We also noted that your blood cell counts are very low and
recommend follow up with hematology as an outpatient as ___
probably need a bone marrow biopsy to evaluate this. Endoscopy
and colonscopy showed no signs of bleeding.
Followup Instructions:
___
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