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10670705-DS-37
| 10,670,705 | 26,600,738 |
DS
| 37 |
2126-10-04 00:00:00
|
2126-10-07 14:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ertapenem
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ yo lady with h/o NASH cirrhosis, complicated by
portal, splenic vein and SMV thromboses, esophageal varices
status post banding, recurrent ascites and hepatic
encephalopathy, diabetes type 2 and psoriatic arthritis on
Enbrel p/w fevers and abdominal pain.
Patient was in usual state of health until today at around 3 pm
when she had acute onset of chills and rigors. She then had
epigastric abdominal pain around 5 pm. Took ibuprofen prior to
arrival. Daughter took temp at home and it was 102 orally.
Patient endorses nausea but no vomiting. Has baseline diarrhea
about ___ from lactulose which she says is watery but
unchagned in nature. No melanotic stool or BRBPR. She has a dry
chronic cough for the past 4 months. She has had a headache
today as well and feels like her mouth is very dry.
In the ED initial vitals were: 100.6 97 146/58 18 100% RA
- Labs were significant for WBC 3.1 with 79% neutrophils, h/h
10.2/31.3, plt 52, ALP 472, tbili 3.7, AST 67, lipase 68, alb
3.1, INR 1.6
- urinalysis 6wbc, 4 epi, few bacteria
- diagnostic paracentesis showed 12 WBC, 2100 RBC,
- RUQ u/s with patent main portal vein and cirrhotic liver with
large volume ascites and splenomegaly.
- CXR without acute intrathoracic process.
- Patient was given 2g ceftriaxone, tylenol, 1L NS and admitted
to medicine for further care.
Vitals prior to transfer were: 99.1 90 115/59 18 97%
On the floor, initial VS were 98.6 89 108/51 16 100% RA. Patient
states her abdominal pain and nausea have both resolved and she
is feeling well.
Past Medical History:
- ___ Cirrhosis: complicated by hx of esophageal varices (two
cords of grade one varices) with prior banding procedures, hx
chronic nonocclusive portal vein and splenic vein thromboses,
ascites, hx SBP early ___. Patient reactivated on transplant
list ___.
- Diabetes mellitus, type II
- Anemia, iron deficiency
- Hypercholesterolemia
- Migraine headaches
- Psoriatic arthritis
- Psoriasis
- Hx positive PPD s/p INH therapy.
Social History:
___
Family History:
Mother with previous CVA. Father has DM2 and prostate cancer.
Physical Exam:
ADMIT PHYSICAL EXAM:
Vitals - 98.6 89 108/51 16 100% RA.
GENERAL: elderly woman in NAD, lying comfortably in bed
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, dry mucous membranes, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: distended, large ventral hernia nontender to palpation,
+BS, nontender to palpation throughout, no rebound/guarding
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema, PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, no asterixis
SKIN: warm and well perfused, psoriatic plaques distributed
primarily along lower extremities, but visible on abdomen as
well
DISCHARGE PHYSICAL EXAM
VS: 98 95 138/78 20 100%
GENERAL: elderly woman in NAD, lying comfortably in bed
HEENT: AT/NC, anicteric sclera, pink conjunctiva
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: distended, large ventral hernia nontender to palpation,
+BS, nontender to palpation throughout, no rebound/guarding
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema, PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, no asterixis
SKIN: warm and well perfused, psoriatic plaques distributed
primarily along lower extremities, but visible on abdomen as
well, L forearm notable for erythema/bruising with border marked
from IV incertion on ___
Pertinent Results:
ADMIT LABS
___ 07:39PM BLOOD WBC-3.1*# RBC-2.90* Hgb-10.2* Hct-31.3*
MCV-108* MCH-35.3* MCHC-32.8 RDW-16.3* Plt Ct-52*#
___ 07:39PM BLOOD Plt Ct-52*#
___ 07:39PM BLOOD Glucose-119* UreaN-13 Creat-1.0 Na-133
K-3.7 Cl-98 HCO3-25 AnGap-14
___ 07:39PM BLOOD ALT-29 AST-67* AlkPhos-472* TotBili-3.7*
___ 03:06AM BLOOD Calcium-7.4* Phos-2.8 Mg-1.5*
CT ABDOMEN
1. Cirrhotic liver with sequela of portal hypertension including
splenomegaly
and varices.
2. Chronic portal vein, proximal splenic, and proximal superior
mesenteric
vein thrombosis, as described above, not significantly changed
from prior.
3. Moderate abdominal ascites, mildly increased from ___.
4. Stable small bowel and ascites containing large ventral
hernia, without
evidence of obstruction, unchanged from ___.
LIVER US
1. Patent main portal vein.
2. Cirrhotic liver with large volume ascites and splenomegaly.
3. Status post cholecystectomy.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ (___) ON ___
@ 19:51.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
DISCHARGE LABS
___ 03:20PM BLOOD WBC-1.7* RBC-2.45* Hgb-8.8* Hct-26.6*
MCV-109* MCH-35.9* MCHC-33.0 RDW-16.3* Plt Ct-33*
___ 06:05AM BLOOD ___ PTT-36.3 ___
___ 06:05AM BLOOD Glucose-111* UreaN-12 Creat-0.8 Na-133
K-3.8 Cl-102 HCO3-24 AnGap-11
___ 06:05AM BLOOD ALT-21 AST-49* AlkPhos-261* TotBili-2.6*
___ 06:05AM BLOOD Calcium-8.0* Phos-1.7* Mg-1.9
Brief Hospital Course:
Ms. ___ is a ___ yo woman with h/o NASH cirrhosis c/b portal,
splenic vein and SMV thromboses, esophageal varices status post
banding, recurrent ascites and hepatic encephalopathy, diabetes
type 2 and psoriatic arthritis who was admitted for fevers and
abdominal pain.
# UTI - patient had a boderline UA. Based on her symptoms and
history of cirrhosis she was treated presumptively for SBP until
the peritoneal fluid analysis came back negative. With her
constellation of symptoms concerning for UTI she was
transitioned to PO cefpodaox for a ___t time of
discharge she was aymptomatic and tolerating PO. Her Bcx came
back with coag neg staph and this was thought to be a
contaminate.
CHRONIC ISSUES:
# ___ cirrhosis c/b encephalopathy and ascites: current MELD
17, was compensated at time of admission and discharge with
tbili and INR at baseline. Home lasix/spironolactone, rifaximin
and lactulose were continued.
# varices s/p banding: home nadolol was initially held given
suspicion for SBP but restarted on discharge.
# T2DM: continued home insulin + sliding scale
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Betamethasone Dipro 0.05% Lot. 1 Appl TP BID
3. Calcipotriene 0.005% Cream 1 Appl TP BID
4. Ciprofloxacin HCl 250 mg PO Q8H
5. Ferrous Sulfate 325 mg PO DAILY
6. Gabapentin 100 mg PO Q8H
7. Ketoconazole Shampoo 1 Appl TP ASDIR
8. Lactulose 30 mL PO TID
9. Lidocaine 5% Patch 1 PTCH TD DAILY
10. Omeprazole 20 mg PO DAILY
11. Pravastatin 10 mg PO DAILY
12. Rifaximin 550 mg PO BID
13. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID
14. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral daily
15. Desonide 0.05% Cream 1 Appl TP DAILY
16. etanercept 50 mg/mL (0.98 mL) subcutaneous qweek
17. NovoLOG Mix 70-30 (insulin asp prt-insulin aspart) 100
unit/mL (70-30) SUBCUTANEOUS 55 UNITS SC QAM AND 25 UNITS SC QPM
18. Furosemide 40 mg PO DAILY
19. Nadolol 20 mg PO DAILY
20. Spironolactone 100 mg PO DAILY
Discharge Medications:
1. Ferrous Sulfate 325 mg PO DAILY
2. Furosemide 40 mg PO DAILY
3. Lactulose 30 mL PO TID
4. Omeprazole 20 mg PO DAILY
5. Pravastatin 10 mg PO DAILY
6. Rifaximin 550 mg PO BID
7. Spironolactone 100 mg PO DAILY
8. Cefpodoxime Proxetil 400 mg PO Q12H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice per day Disp
#*16 Tablet Refills:*0
9. Aspirin 81 mg PO DAILY
10. Betamethasone Dipro 0.05% Lot. 1 Appl TP BID
11. Calcipotriene 0.005% Cream 1 Appl TP BID
12. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral daily
13. Desonide 0.05% Cream 1 Appl TP DAILY
14. etanercept 50 mg/mL (0.98 mL) subcutaneous qweek
15. Ketoconazole Shampoo 1 Appl TP ASDIR
16. Lidocaine 5% Patch 1 PTCH TD DAILY
17. Nadolol 20 mg PO DAILY
18. NovoLOG Mix 70-30 (insulin asp prt-insulin aspart) 100
unit/mL (70-30) SUBCUTANEOUS 55 UNITS SC QAM AND 25 UNITS SC QPM
19. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID
20. Ciprofloxacin HCl 250 mg PO Q24H
21. Gabapentin 100 mg PO Q8H
Discharge Disposition:
Home
Discharge Diagnosis:
urinary tract infection
cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___, you were admitted because you had an infection in
your bladder. We treated you with antibiotics and you will
continue taking the antibiotic for 4 more days (last day
___. Please follow up with all the appointements we have set
up for you.
Followup Instructions:
___
|
10670705-DS-38
| 10,670,705 | 29,329,010 |
DS
| 38 |
2126-12-11 00:00:00
|
2126-12-11 16:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ertapenem
Attending: ___.
Chief Complaint:
___, hyponatremia
Major Surgical or Invasive Procedure:
1 U PRBC
History of Present Illness:
Ms. ___ is a ___ w/ NASH cirrhosis complicated by portal and
splenic vein thromboses not on anticoagulation, esophageal
varices s/p banding, ascites, hx of SBP, and hepatic
encephalopathy, DM type II, and psoriatic arthritis who is being
admitted from clinic with ___ (cr 0.9 to 1.3) and hyponatremia
with Na 133 to 126.
Patient reports being at ___ from ___ for vacation
purpose. She reports having episode of belly pain while at
___ and was diagnosed with "pancreatitis". She also
reports episodes of coughing one week ago when she was in
___. Two days ago she had onset of left thigh pain. She was
seen in the ___ ED last night and discharged with ibuprofen.
Labs notable for hyponatremia and ___ as above. Per patient she
has also been feeling tired and fatigued for the past couple of
day. She is more sleepy than usual. She has been taking her
lactulose. She reports cough x 4 days, chills and night sweats
but no fevers. No dysuria, hematuria or abdominal pain. No
n/v/d. She reprorts decreased po intake in the past few days.
Past Medical History:
- ___ Cirrhosis: complicated by hx of esophageal varices (two
cords of grade one varices) with prior banding procedures, hx
chronic nonocclusive portal vein and splenic vein thromboses,
ascites, hx SBP early ___ hx of hepatic encephalopathy
- Diabetes mellitus, type II
- Anemia, iron deficiency
- Hypercholesterolemia
- Migraine headaches
- Psoriatic arthritis
- Psoriasis
- Hx positive PPD s/p INH therapy.
Social History:
___
Family History:
Mother with previous CVA. Father has DM2 and prostate cancer.
Physical Exam:
PHYSICAL EXAM ON ADMISSION
VS: 98.8 128/78 82 100%RA ___ 135
Gen: chronically ill appearing, answering questions
appropriately though in a slow manner
HEENT: anicteric sclera, MMM
CV: distant heart sounds, RRR, no murmurs, rubs or gallops
Pulm: CTAB
Abd: +BS, obese, distended, large ventral hernias, nontender to
palpation
Ext: trace peripheral edema
Skin: several scattered well-defined pink erythematous scaly
plaques on lower extremities, torso consistent with psoriasis
Neuro: A+Ox3, no asterixsis, slow in answering questions
PHYSICAL EXAM ON DISCHARGE
O: 97.8 171/90 79 18 98%RA
GEN: Alert and orientedx3, mentating appropriately, able to
ambulate, seen coughing
HEENT: NCAT, MMM
CV: RRR, S1+S2, NMRG
RESP: rhoncherous bilaterally, moist cough, no crackles or
wheezes
ABD: +BS, firm ascites, mild TTP throughout
GU: Deferred
EXT: WWP, trace edema
NEURO: CN II-XII grossly intact
Pertinent Results:
LABS ON ADMISSION
-------------------
___ 04:15AM WBC-2.2* RBC-3.29* HGB-10.9* HCT-32.8*
MCV-100* MCH-33.0* MCHC-33.1 RDW-19.2*
___ 04:15AM NEUTS-47* BANDS-0 ___ MONOS-10 EOS-4
BASOS-0 ATYPS-1* ___ MYELOS-0
___ 04:15AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-1+
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
SCHISTOCY-OCCASIONAL TEARDROP-1+
___ 04:15AM PLT SMR-VERY LOW PLT COUNT-53*
___ 04:15AM ___ PTT-34.5 ___
___ 04:15AM GLUCOSE-113* UREA N-21* CREAT-1.3*
SODIUM-126* POTASSIUM-7.7* CHLORIDE-100 TOTAL CO2-23 ANION
GAP-11
___ 04:15AM ALT(SGPT)-57* AST(SGOT)-229* ALK PHOS-433*
AMYLASE-78 TOT BILI-3.3*
___ 04:15AM LIPASE-104*
___ 04:15AM ALBUMIN-3.1*
___ 04:26AM LACTATE-2.1* K+-4.0
PERTINENT LABS
-------------
___ 04:45AM URINE Color-Yellow Appear-Hazy Sp ___
___ 04:45AM URINE Blood-MOD Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
___ 04:45AM URINE RBC-25* WBC-7* Bacteri-MANY Yeast-NONE
Epi-3
___ 04:45AM URINE CastHy-7*
___ 04:45AM URINE Hours-RANDOM UreaN-529 Creat-93 Na-29
K-37 Cl-46
___ 04:45AM URINE Osmolal-396
___ 11:26AM ASCITES WBC-67* ___ Polys-4* Lymphs-32*
Monos-2* Macroph-62*
___ 11:26AM ASCITES TotPro-1.6 Albumin-LESS THAN
LABS ON DISCHARGE
-------------------
___ 01:45PM BLOOD WBC-2.3*# RBC-2.58* Hgb-8.5* Hct-25.5*
MCV-99* MCH-32.9* MCHC-33.2 RDW-20.6* Plt Ct-40*
___ 01:45PM BLOOD Plt Ct-40*
___ 07:07AM BLOOD ___ PTT-37.9* ___
___ 07:07AM BLOOD Glucose-102* UreaN-12 Creat-1.0 Na-136
K-4.1 Cl-101 HCO3-24 AnGap-15
___ 07:07AM BLOOD ALT-32 AST-60* AlkPhos-234* TotBili-3.3*
___ 07:07AM BLOOD Calcium-8.0* Phos-2.9 Mg-2.4
___ 09:18AM BLOOD Hapto-5*
IMAGING
---------
___ Imaging HIP UNILAT MIN 2 VIEWS ___
Unread
___ Imaging CHEST (PA & LAT) ___. Unread
___ Imaging PARACENTESIS DIAG/THERA ___.
Approved
IMPRESSION:
Successful ultrasound-guided diagnostic paracentesis of 20 mL of
serosanguineous fluid from the right lower quadrant. Specimens
were sent for labs requested by the ordering team.
NOTIFICATION: The findings were discussed by Dr. ___
with Dr.
___ on the telephone on ___ at 12:30 ___.
The study and the report were reviewed by the staff radiologist.
___ Imaging CHEST (PA & LAT) ___. Approved
IMPRESSION:
Lungs are fully expanded and clear. Heart size previously
enlarged, is now normal. Pulmonary vasculature and pleural
surfaces are unremarkable. There may be granulomatous lymph node
calcifications in both hila, but there is no evidence of active
infection.
___ Imaging FEMUR (AP & LAT) LEFT ___
Approved
FINDINGS:
Five views of the left femur show no acute fracture or
dislocation. There are no radiopaque foreign bodies or soft
tissue calcifications. There are no suspicious lytic or
sclerotic osseous lesions.
___ Imaging UNILAT LOWER EXT VEINS ___
Approved
FINDINGS:
There is normal compressibility, flow and augmentation of the
left common
femoral, superficial femoral, and popliteal veins. Normal color
flow this is demonstrated in the posterior tibial, and the
peroneal veins were not seen. There is normal respiratory
variation in the common femoral veins bilaterally. No evidence
of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower
extremity veins,
though the peroneal veins were not seen.
The study and the report were reviewed by the staff radiologist.
MICROBIOLOGY
-------------
___ SPUTUM GRAM STAIN-PENDING; RESPIRATORY
CULTURE-PENDING INPATIENT
___ 2:19 pm SPUTUM Source: Expectorated.
GRAM STAIN (Pending):
RESPIRATORY CULTURE (Pending):
___ PERITONEAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-PRELIMINARY; ANAEROBIC CULTURE-PRELIMINARY INPATIENT
___ 11:26 am PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH
___ BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE-PENDING; BLOOD/AFB CULTURE-PENDING
INPATIENT
___ 6:45 am BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE (Pending):
BLOOD/AFB CULTURE (Pending):
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ 6:45 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ URINE URINE CULTURE-FINAL INPATIENT
___ 4:45 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
___ BLOOD CULTURE Blood Culture, Routine-FINAL
{CANCELLED}
___ 4:15 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
CANCELLED. Culture negative as of: ___ @ 08:35AM.
Test canceled/culture discontinued per: ___ ON
___ @
07:02AM. TEST CANCELLED, PATIENT CREDITED.
Brief Hospital Course:
___ with NASH cirrhosis admitted with ___ (cr 0.9 to 1.3) and
hyponatremia (126) with course complicated by fever and likely
GI bleed.
BRIEF HOSPITAL COURSE
======================
ACTIVE ISSUES
--------------
# ACUTE KIDNEY INJURY: Cr on admission up to 1.3 from recent
baseline of 0.9. Patient recently seen in ED with increased Cr,
discharged with ibuprofen for leg pain. Most likely ___ resulted
from volume depletion in setting of poor PO intake while being
on diuretics. given high FEN Urea and Sodium-avid urine lytes.
Urinalysis also concerning for UTI. Diuretics and naldolol held
on admission due to concerns for intravascular volume depletion
v. hepatorenal syndrome. SBP unlikely given negative diagnostic
tap, and patient appropriately resolved with albumin challenge.
Patient counseled to avoid NSAIDS. Home dose diuretics were held
at the time of discharge. Please consider restart.
# HYPONATREMIA: Hyponatremia most likely a result of volume
depletion and diuretic effect. Diuretics held on admission.
Hyponatremia resolved from 126 to baseline 136 at time of
discharge. Consider restart of diuretics.
# ACUTE BLOOD LOSS ___ EPISTAXIS: Patient with 10 point drop in
hematocrit on ___ with melenous stool. Pt hemodynamically
stable EGD ___ without varices but with angioectasias.
Patient also with significant epistaxis. She was placed on
octreotide drip, and IV PPI BID. Patient as hemodynamically
stable with stable Hct for 48 hours at time of discharge.
Suspicion for GI Bleed low. She is scheduled for a repeat EGD
___, consider earlier workup if bleed/melena recur.
# URINARY TRACT INFECTION: Patient with rise in creatinine and
urinalysis with postive nitrites, leukocs, WBCs, many bacteria,
although with 3 epis. Patient treated with ciprofloxacin and
ceftriaxone since admission ___. Urine culture no growth
to date, no CVA tenderness on exam. Patient was treated with 4
day course.
# VIRAL UPPER RESPIRATORY INFECTION: Pt with cough and sore
throat on admission. History of positve PPD. CXR on admission
and repeat on ___ without any foci of pneumonia. Most likely
viral URI.
# ___ CIRRHOSIS: complicated by portal and splenic vein
thromboses not on anticoagulation, esophageal varices s/p
banding, ascites, hx of SBP, and hepatic encephalopathy. MELD on
admission 17. No further workup of etiology during
hospitalization. MELD on discharge: 16.
--h/o Hepatic Encephalopathy: No e/o asterixis on admission,
although mental status concerning for somnolence and fatigue on
admission. This resolved by time of discharge. Patient's
lactulose and rifaximin was continued. Most likely triggered by
___ and UTI.
--Varices: Last EGD ___. Naldol held in setting ___ due
to concern for hepatorenal syndrome. Patient restarted after
appropriate response to albumin challenge. Will need repeat EGD
in ___ per records.
--Ascites/SBP: Patient with ascites, no history of TIPs. Patient
empirically started on ceftriaxone for concern for SBP given
mild fever and mental status, which was discontinued upon
negative SBP results. She was restarted on prophylactic cipro on
discharge.
--Renal: Most likely prerenal azotemia (see above).
--Coagulopathy: INR 1.4 on admission. Given Vitamin K 5 mg x 3
days with no effect.
STABLE CHRONIC ISSUES
# Diabetes mellitus, type II: Patient maintained on lower dose
of 70/30 and humalog insulin sliding scale
# Anemia, iron deficiency: Patient continued on ferrous sulfate
-continue ferrous sulfate
# Hypercholesterolemia: Home dose statin continued
# Psoriasis c/b psoriatic arthritis: Patient was continued on
triamcinolone, calcipotriene, betamethasone, ketoconazole. Home
dose Enbrel held due to concern for infection. Patient not due
for next dose until ___
TRANSITIONAL ISSUES
[] Hepatology: She was home dose diuretics and nadolol were held
at the time of discharge. Please consider restart
[] Patient with ?GIBleed in house with h/o angioectasias on
previous EGD, most likely due to significant epistaxis. Due for
repeat EGD ___.
[] Please ensure patient follows up with PCP and hepatologist.
These could not be arranged prior to discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 325 mg PO BID
2. Furosemide 40 mg PO DAILY
3. Lactulose 30 mL PO TID
4. Omeprazole 20 mg PO DAILY
5. Pravastatin 10 mg PO DAILY
6. Rifaximin 550 mg PO BID
7. Spironolactone 100 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Betamethasone Dipro 0.05% Lot. 1 Appl TP BID
10. Calcipotriene 0.005% Cream 1 Appl TP BID
11. Desonide 0.05% Cream 1 Appl TP DAILY
12. etanercept 50 mg/mL (0.98 mL) subcutaneous qweek
13. Ketoconazole Shampoo 1 Appl TP ASDIR
14. Lidocaine 5% Patch 1 PTCH TD DAILY
15. Nadolol 20 mg PO DAILY
16. NovoLOG Mix 70-30 (insulin asp prt-insulin aspart) 100
unit/mL (70-30) SUBCUTANEOUS 5 UNITS SC QAM AND 2 UNITS SC QPM
17. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID
18. Ciprofloxacin HCl 250 mg PO Q24H
19. Gabapentin 100 mg PO QAM
20. Gabapentin 300 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Betamethasone Dipro 0.05% Lot. 1 Appl TP BID
3. Calcipotriene 0.005% Cream 1 Appl TP BID
4. Ciprofloxacin HCl 250 mg PO Q24H
5. Desonide 0.05% Cream 1 Appl TP DAILY
6. Gabapentin 100 mg PO QAM
7. Gabapentin 300 mg PO BID
8. Lactulose 30 mL PO TID
9. Lidocaine 5% Patch 1 PTCH TD DAILY
10. Nadolol 20 mg PO DAILY
11. Pravastatin 10 mg PO DAILY
12. Rifaximin 550 mg PO BID
13. etanercept 50 mg/mL (0.98 mL) subcutaneous qweek
14. Ferrous Sulfate 325 mg PO BID
15. Ketoconazole Shampoo 1 Appl TP ASDIR
16. NovoLOG Mix 70-30 (insulin asp prt-insulin aspart) 100
unit/mL (70-30) SUBCUTANEOUS 5 UNITS SC QAM AND 2 UNITS SC QPM
17. Omeprazole 20 mg PO DAILY
18. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
-------------------
ACUTE KIDNEY INJURY
HYPONATREMIA
ACUTE ON CHRONIC ANEMIA
SECONDARY DIAGNOSIS
NASH CIRRHOSIS
VIRAL URI
URINARY TRACT INFECTION
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitting due to worsening kidney function and an
abnormally low sodium level. Both of these were most likely due
to not drinking enough water, and by taking ibuprofen. In the
future, please remember to drink plenty of water and to AVOID
ibuprofen, Midol, Aleve/naproxen or any other "NSAID" as these
can damage your kidneys.
While admitted, we were also concerned that you were bleeding.
You received 1 U transfusion and monitored. You received
medications to help prevent bleeding.
Please follow up with your primary care provider, Dr. ___
___, and your hepatologist Dr. ___ to restart your Lasix
and spironolactone.
It was a pleasure taking care of you at ___. We wish you well.
-Sincerely,
Your Team at ___
Followup Instructions:
___
|
10670818-DS-18
| 10,670,818 | 25,852,395 |
DS
| 18 |
2150-06-06 00:00:00
|
2150-06-06 14:59:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Demerol
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female with abdominal pain for the past few days.
Associated with distension. Nausea, no vomiting, has been
taking zofran at home. Denies fevers, dysuria, CP, SOB. Does
endorse drinking alcohol about 5 days prior to admission.
Recently hospitalized (at ___ to ___) in ___, intubated for
2 weeks, diagnosed with PNA, pancreatitis. States she feels
like this is her pancreatitis presentation.
In ___ ED:
VS: 98.6 88 116/78 20 99%
Received morphine 5 mg x 1
KUB without evidence of obstruction
Upon transfer to floor:
Mental Status: a&ox3
Lines & Drains: 20g Lac
Fluids: NS
Drips: morphine for pain, last dose at ___
Precautions: universal
Belongings: clothes with pt
Most Recent Vitals: 97.7, 131/89, 89, 18, 100%
Comments: ambulates with steady gait
Upon arrival to floor, patient endorses above story, with
central, dull, non-radiating abd pain, improved after pain
control.
ROS as noted above, remainder of 12 point ROS negative
Past Medical History:
chronic hepatits c
HTN
osteopenia
depressions
h/o wilms tumor
s/p ex-lap for SBO
Social History:
___
Family History:
no history of pancreatic cancer
Physical Exam:
VS: 97.7 151/94 HR 63 RR 16 100% RA
General: pleasant, no distress
HEENT: anicteric sclerae
CV: RRR, normal S1, S2, no m,r,g
Pulm: lungs CTA bilaterally
Abd: tender in ___ area, no rebound or
guarding
Ext: no c/c/e
Neuro: A and O x 3, ambulatory without assistance
Pertinent Results:
___:35PM PLT COUNT-252
___ 04:35PM NEUTS-60.0 ___ MONOS-5.1 EOS-2.5
BASOS-1.1
___ 04:35PM WBC-8.4 RBC-3.59* HGB-10.9* HCT-34.6* MCV-96
MCH-30.3 MCHC-31.4 RDW-13.8
___ 04:35PM TRIGLYCER-117
___ 04:35PM ALBUMIN-4.2 CALCIUM-9.7 PHOSPHATE-4.0
MAGNESIUM-1.8
___ 04:35PM LIPASE-200*
___ 04:35PM ALT(SGPT)-35 AST(SGOT)-52* ALK PHOS-99 TOT
BILI-0.2
___ 04:35PM estGFR-Using this
___ 04:35PM GLUCOSE-118* UREA N-22* CREAT-0.8 SODIUM-139
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-28 ANION GAP-13
___ 04:43PM LACTATE-1.2
___ 05:20PM URINE MUCOUS-OCC
___ 05:20PM URINE HYALINE-11*
___ 05:20PM URINE RBC-<1 WBC-8* BACTERIA-FEW YEAST-NONE
EPI-2
___ 05:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-TR
___ 05:20PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 05:20PM URINE UCG-NEGATIVE
___ 05:20PM URINE HOURS-RANDOM
KUB:
Nonobstructive bowel gas pattern
RUQ U/S:
FINDINGS: The liver is normal without focal or textural
abnormality. The main portal vein is patent with hepatopetal
flow. The gallbladder is
non-distended and has a normal wall thickness. A small amount
of mobile
debris is present within the gallbladder. A 2-mm polyp is seen
within the fundus. No shadowing gallstone is identified. The
common duct measures 6 mm and there is no intra- or
extra-hepatic bile duct dilatation. The pancreas is
unremarkable without peripancreatic fluid or ductal dilatation.
The spleen is normal and measures 9.4 cm. Several periportal
lymph nodes are not pathologically enlarged.
IMPRESSION: 2-mm gallbladder fundus polyp. No evidence of
cholelithiasis.
Brief Hospital Course:
___ year old female with history of HTN, hepatitis C, s/p ex lap
for SBO, and recent OSH admission for pneumonia and pancreatitis
presents from rehab with nausea, abdominal pain, and elevated
lipase, consistent with recurrent acute pancreatitis.
# Acute pancreatitis: Epigastric abdominal pain with radiation
to the side and back, with nausea, and lipase of 200,
consistent with mild acute pancreatitis. She had recently been
admitted at ___ with severe acute pancreatitis complicated by
ARDS. The cause of her pancreatitis was felt to be EtOH
related, after discussion with PCP. She has a history of heavy
EtOH abuse, and minimizes her history with providers. She did
admit to a "Few" drinks the weekend before symptoms started.
RUQ US was negative for gallstones. She improved over 72 hrs
with NPO, IVF, and pain control. She was discharged to follow
up with her PCP and was given analgesics/antiemetics. EtOH
cessation counseling was provided.
# ETOH abuse/dependence: Has a significant history according to
her PCP. Recently claims to have cut down, since her recent
hospitalization. She did not have signs of EtOH withdrawal in
house. Cessation counseling was provided.
# HTN- continued Diovan
# Depression/Anxiety- continued Celexa
Medications on Admission:
Diovan 80 mg daily
Celexa 40 mg daily
albuterol sulfate HFA 90 mcg/actuation PRN
Discharge Medications:
1. valsartan 80 mg tablet Sig: One (1) tablet PO DAILY (Daily).
2. citalopram 20 mg tablet Sig: Two (2) tablet PO DAILY (Daily).
3. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
___ Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
4. ZOFRAN ODT 4 mg tablet,disintegrating Sig: One (1)
tablet,disintegrating PO every eight (8) hours as needed for
nausea.
Disp:*15 tablet,disintegrating(s)* Refills:*0*
5. Tylenol ___ mg tablet Sig: ___ tablets PO every ___ hours as
needed for pain: limit 4 grams per day.
6. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation: take with oxycodone to prevent constipation.
Disp:*30 Powder in Packet(s)* Refills:*0*
7. oxycodone 5 mg tablet Sig: One (1) tablet PO every ___ hours
as needed for pain: do not take with alcohol or driving/with
machinery due to sedation.
Disp:*30 tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute pancreatitis
Hypertension
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with acute abdominal pain and elevated lipase,
consistent with recurrent pancreatitis. No clear cause was
found, but we highly suspect that recent alcohol use may have
triggered this. For this reason, it is very important that you
abstain from further alcohol use.
Please resume all medications as prescribed. Please note that
opiate medications (oxycodone) may cause excessive sedation, so
do not take with alcohol, while driving, or using machinery
Followup Instructions:
___
|
10671052-DS-14
| 10,671,052 | 22,036,908 |
DS
| 14 |
2141-07-23 00:00:00
|
2141-07-23 09:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R ankle fracture
Major Surgical or Invasive Procedure:
Open reduction internal fixation of right ankle ___,
___
History of Present Illness:
___ w/ no PMH who was intoxicated restrained driver in ___
resulting in right ankle fracture transferred from OSH for
further management. Per report, self-extricated from rollover
MVC, windshield spidered and airbag deployment. Car went over
guardrail into woods. CT torso, head CT negative at OSH. She is
s/p procedural sedation for closed reduction or right ankle at
the OSH. Concern for open fracture, received ancef, tdap.
Past Medical History:
None
Social History:
___
Family History:
NC
Physical Exam:
On admission:
Vitals - 98.1 108 104/60 20 100% RA
General - Comfortable appearing, in C-collar.
MSK - RLE in splint from OSH. With splint removed, area covered
with band aid with some prior bleeding, which has resolved.
There is a pin sized hole on medial aspect of the ankle with
surrounding ecchymoses. Fires ___, SILT DP/SP/S/S, 2+
___ pulses.
On discharge:
___
Gen: NAD, A+Ox3
RLE:
Splint in place, c/d/i
WWP toes
SILT over toes
Wiggling toes
No pain with passive motion of toes
Pertinent Results:
___ 05:00AM BLOOD WBC-7.6 RBC-4.04* Hgb-11.8* Hct-35.7*
MCV-88 MCH-29.1 MCHC-33.0 RDW-16.8* Plt ___
___ 05:00AM BLOOD Neuts-74.6* ___ Monos-4.8 Eos-0.6
Baso-0.2
___ 05:00AM BLOOD Plt ___
___ 05:00AM BLOOD ___ PTT-24.2* ___
___ 05:00AM BLOOD Glucose-124* UreaN-5* Creat-0.5 Na-138
K-3.8 Cl-102 HCO___ AnG___
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right ankle fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction and internal
fixation, which the patient tolerated well (for full details
please see the separately dictated operative report). The
patient was taken from the OR to the PACU in stable condition
and after recovery from anesthesia was transferred to the floor.
The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is nonweight bearing in the right
lower extremity, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*50 Capsule Refills:*0
3. Enoxaparin Sodium 40 mg SC DAILY Duration: 2 Weeks
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg SC once a day Disp #*14
Syringe Refills:*0
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*80 Tablet Refills:*0
5. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*50 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Right 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:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
ACTIVITY AND WEIGHT BEARING:
- Nonweight bearing in the right lower extremity
Physical Therapy:
___ RLE
Treatments Frequency:
The patient will remain in her postoperative splint until her 2
week follow up appointment, at which time her dressings and
splint will be taken down and her staples will be removed.
Followup Instructions:
___
|
10671331-DS-8
| 10,671,331 | 27,683,623 |
DS
| 8 |
2160-06-02 00:00:00
|
2160-06-02 14:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Biaxin / Cephalexin / Tetracycline / morphine / Toradol /
clarithromycin / Penicillins / vancomycin / Suboxone
Attending: ___
Chief Complaint:
patient presented to the hospital with left eye pain swelling
and erythema
Major Surgical or Invasive Procedure:
none
History of Present Illness:
presented with left eye pain and swelling after she manually
lanced it and the pain/swelling has been getting and she came to
the ED where ophthalmo Fellow saw her and he stated that it is
not orbital cellulitis but it is pre-septal cellulitis. Patient
was hard to establish IV access and picc line was placed for
her. Patient is very eager to leave although her cellulitis was
not completely resolved. I discussed with her the risk of
leaving AMA including worsening of her infection to extend to
her neurological system or the risk of losing her eye but she
insisted on leaving and she does not want to stay in the
hospital. I informed her that her abscess around her eye need to
be drained and she refused any further treatment and she does
not want to stay, a prescription of Bactrim has been given and
she was informed that it is not full treatment for her eye
infection and she is aware and understands the risks
Past Medical History:
Chronic pancreatitis
Drug abuse
Social History:
IV drug user
smoker
Pertinent Results:
___ 05:20AM BLOOD WBC-11.2* RBC-4.26 Hgb-12.7 Hct-38.0
MCV-89 MCH-29.8 MCHC-33.4 RDW-12.7 RDWSD-41.3 Plt ___
___ 10:00AM BLOOD Neuts-65.2 ___ Monos-9.9 Eos-4.9
Baso-0.3 Im ___ AbsNeut-7.68* AbsLymp-2.27 AbsMono-1.17*
AbsEos-0.58* AbsBaso-0.04
___ 05:20AM BLOOD Plt ___
___ 11:18AM BLOOD ___ PTT-30.3 ___
___ 05:20AM BLOOD Glucose-109* UreaN-7 Creat-0.6 Na-139
K-3.8 Cl-97 HCO3-27 AnGap-15
___ 05:20AM BLOOD Calcium-8.8 Mg-1.9
___ 04:45PM BLOOD ___ pO2-41* pCO2-49* pH-7.38
calTCO2-30 Base XS-2
Brief Hospital Course:
presented with left eye pain and swelling after she manually
lanced it and the pain/swelling has been getting and she came to
the ED where ophthalmo Fellow saw her and he stated that it is
not orbital cellulitis but it is pre-septal cellulitis. Patient
was hard to establish IV access and picc line was placed for
her. Patient is very eager to leave although her cellulitis was
not completely resolved. I discussed with her the risk of
leaving AMA including worsening of her infection to extend to
her neurological system or the risk of losing her eye but she
insisted on leaving and she does not want to stay in the
hospital. I informed her that her abscess around her eye need to
be drained and she refused any further treatment and she does
not want to stay, a prescription of Bactrim has been given and
she was informed that it is not full treatment for her eye
infection and she is aware and understands the risks
Discharge Medications:
Bactrim DS 2 tabs daily for 10 days
Discharge Disposition:
Home
Discharge Diagnosis:
Pre-septal cellulitis
Discharge Condition:
AMA
Discharge Instructions:
you have facial skin infection
you are leaving against medical advice after the risks were
explained to you. you can lose your vision and cause severe
problems
please seek medical attention if you develop worsened symptoms
of redness, pain, headache, neck stiffness, visual changes
Followup Instructions:
___
|
10671739-DS-21
| 10,671,739 | 25,719,422 |
DS
| 21 |
2165-12-05 00:00:00
|
2165-12-06 22:16:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Atorvastatin / simvastatin
Attending: ___.
Chief Complaint:
slurred speech
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Dr. ___ is a ___ right-handed woman presenting with
the above on a background of prior right CEA, now completely
occluded right ICA, and left ICA stenosis (at bifurcation),
hypercholesterolemia,
One week ago she noted that her speech was slurred when talking
to a friend at 7 AM. Pronunciation was difficult, but not
finding words. Her mouth on the right was full of saliva at the
time, but she was not drooling. She did not look in the mirror,
given that she was walking on the street. It lasted at least
five minutes, as far as she noted, but her friends felt that
speech continued to sound slurred for several days. She did not
notice any other symptoms or difficulty with her right hand, and
has not had these symptoms before. She told her NP today and
was
referred to the ED, apparently with agreement of her primary and
vascular surgeon from prior CEA, Dr. ___. She attributes
this late presentation to her ___ upbringing, now
agnostic, and minimization of symptoms.
She has been taking aspirin and Plavix, with the latter resumed
a
"couple of months" ago, and taken only 75 mg once daily. This
seems to have been started by Dr. ___ at ___, perhaps her
cardiologist there. Of note, in a clinic note dated ___,
"She now relays that she was not taking it in recent months, but
restarted it about two weeks ago." In this setting her right
internal carotid became occluded, after right CEA had been
performed in ___. She takes all medications at night.
She has been seen in clinic by Dr. ___ and was due
for repeat carotid ultrasound in ___ this year.
Occasionally lightheaded on rising in AM, and can lilt to the
left on initial steps, then steady. Lost 10 lbs over last year,
inexplicably, but now regaining. Further 13 system review of
systems negative except as above.
Past Medical History:
- Left arm numbness, lasting for several hours in ___ or ___
speculation of cerebrovascular etiology, entering OMR as
"stroke". ___, imaging performed and referred to
Neurosurgery - perhaps radicular.
- Right amaurosis fugax, twice, two to ___ years ago. She
refers to these as "mini-strokes". Possible some visual loss in
this eye, but may be refractive.
- Hypercholesterolemia, on pravastatin
- Peripheral vascular, cerebrovascular and coronary artery
disease, including prior right CEA and now right ICA occlusion
- Hypothyroidism, on levothyroxine
- COPD with active smoking
- Vertigo, likely peripheral origin
- Leukoaraiosis
- Obsessive compulsive disorder
- Pacemaker - "slow heart beat", sees Cardiology, but cannot
recall where, says if not here, then ___
- Medication non-compliance
- Perianal rash, not compliant with treatment, one year duration
- Peripheral vascular disease
Social History:
___
Family History:
Father with strokes in ___, then major stroke at ___. Mother
cancer d. ___ (breast). All siblings deceased: sister, breast
ca., suicide, other.
Physical Exam:
ADMISSION EXAM:
PHYSICAL EXAM:
Vitals: 98.7 68 157/73 18 99% ra
General Appearance: Comfortable, no apparent distress.
HEENT: NC, OP clear, MMM.
Neck: Supple. Bruit at base of left neck, not higher up and not
on right.
Lungs: CTA bilaterally.
Cardiac: RRR. Normal S1/S2, but distant sounds (presumably given
COPD). No audible M/R/G.
Abdominal: Soft, NT, BS+
Extremities: Warm and well-perfused. Peripheral pulses 2+.
Neurologic:
Mental status:
Awake and alert, cooperative with exam, normal affect.
Orientation: Oriented to person, place, date and context.
Language: Normal fluency, comprehension, repetition, naming. No
paraphasic errors. Normal MOYBW. Registration of three words at
one trial, two guesses, but full immediate recall, then full
delayed recall of all at five minutes without hints. Fund of
knowledge for recent events within normal limits.
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 symmetric.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Tone normal throughout. Normal bulk.
Power
D B T WE WF FE FAb | IP Q H AT G/S EDB TF
R ___ ___ 5 | ___ ___ 5
L ___ ___ 5 | ___ ___ 5
Reflexes: B T Br Pa Ac
Right ___ 0 0
Left ___ 0 0
Toes downgoing bilaterally
Sensation intact to light touch, joint position, pinprick
bilaterally. Vibration mild to moderately reduced. Romberg
negative.
Normal finger nose, great toe finger, RAM's bilaterally.
Gait:
Normal initiation, cessation, turn, base. Reduced arm swing and
slightly stooped. Cannot tandem.
===========================
DISCHARGE EXAMINATION:
unchanged from admission
Pertinent Results:
ADMISSION LABS:
___ 04:00PM BLOOD WBC-8.4 RBC-4.67 Hgb-15.3 Hct-44.6 MCV-96
MCH-32.9* MCHC-34.4 RDW-12.1 Plt ___
___ 04:00PM BLOOD Neuts-72* Bands-0 Lymphs-16* Monos-6
Eos-6* Baso-0 ___ Myelos-0
___ 04:00PM BLOOD Glucose-94 UreaN-15 Creat-0.8 Na-141
K-3.9 Cl-106 HCO3-23 AnGap-16
___ 11:46PM BLOOD Calcium-9.1 Phos-3.3 Mg-2.0
STROKE LABS:
___ 05:35AM Cholest-169 Triglyc-284* HDL-50 CHOL/HD-3.4
LDLcalc-62
___ 11:46PM %HbA1c-5.3 eAG-105
___ 11:46PM TSH-6.0* T3-104 Free T4-1.4
===================================
IMAGING:
CTA HEAD/NECK ___: IMPRESSION:
1. Complete occlusion of the right internal carotid artery from
its origin through its intracranial segments with flow
reconstitiuted distally, unchanged from the prior examination.
2. No acute intracranial abnormality, no evidence of acute
infarction or hemorrhage. However, please note that sensitivity
for infarct is diminished in the setting of the patient's
extensive chronic small vessel disease and if infarct is
strongly suspected, further evaluation with MRI may be
beneficial.
3. Stable atherosclerotic disease of the left internal carotid
artery origin, with 60% stenosis, and of the proximal right
subclavian artery.
4. Unchanged 2 mm right MCA bifurcation aneurysm.
ECHOCARDIOGRAM ___:
The left atrium is normal in size. 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 low normal (LVEF 50%). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve is not well seen. There is
mild aortic valve stenosis. The mitral valve leaflets are mildly
thickened. There is severe mitral annular calcification. Trivial
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] There is no pericardial effusion. No obvious
cardiac source of embolus seen.
CAROTID ULTRASOUND ___:
There is complete occlusion of the right internal carotid
artery. This finding is concordant with the CTA performed on ___.
There is 60-69% stenosis within the left internal carotid
artery.
Brief Hospital Course:
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? () Yes, confirmed
done - (x) Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 62) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? (x) Yes - () No [reason
() non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >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
================================
Ms. ___ is a ___ yo RH woman with PMH of hypertension,
hyperlipidemia, R amaurosis fugax and significant vascular
disease, including s/p R CEA but currently completely occluded R
ICA and L ICA stenosis who presented with transient episode of
slurred speech +/- possible paraphasic error/"using wrong words"
concerning for symptomatic L ICA stenosis. CT head did not show
clear new infarcts, but it was difficult to interpret given her
significant small vessel disease. We were unable to obtain MRI
given her her pacemaker.
She was admitted to the hospital and was started on heparin gtt.
Vascular surgery was also consulted for possible procedure.
Given the complication with her completed occluded R ICA, L CEA
was deferred for now. After discussion with vascular surgery,
decision was made to discharge her on aspirin and plavix, and to
follow up her carotid stenosis with serial carotid ultrasound.
She was also instructed to please quit smoking as well to help
decrease the risk of worsening stenosis. Her other stroke labs
including lipids and A1C were at goal and her other medications
were continued.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of
breath/wheezing
2. Atenolol 25 mg PO DAILY
3. ClomiPRAMINE 100 mg PO DAILY
4. ClonazePAM 1 mg PO QHS
5. Clopidogrel 75 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Levothyroxine Sodium 88 mcg PO DAILY
8. Pravastatin 40 mg PO DAILY
9. Tiotropium Bromide 1 CAP IH DAILY
10. Aspirin 325 mg PO DAILY
11. Bisacodyl 10 mg PR HS:PRN constipation
12. DiphenhydrAMINE 25 mg PO HS:PRN itching
13. Docusate Sodium 100 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Fish Oil (Omega 3) 1000 mg PO Frequency is Unknown
16. Psyllium 1 PKT PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. ClomiPRAMINE 100 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. DiphenhydrAMINE 25 mg PO HS:PRN itching
6. Docusate Sodium 100 mg PO DAILY
7. Fish Oil (Omega 3) 1000 mg PO DAILY
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. Levothyroxine Sodium 88 mcg PO DAILY
10. Pravastatin 40 mg PO DAILY
11. Tiotropium Bromide 1 CAP IH DAILY
12. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of
breath/wheezing
13. Bisacodyl 10 mg PR HS:PRN constipation
14. ClonazePAM 1 mg PO QHS
15. Multivitamins 1 TAB PO DAILY
16. Psyllium 1 PKT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
R carotid artery occlusion. L carotid artery stenosis. Transient
Ischemic Attack.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of dysarthria resulting
from a TRANSIENT ISCHEMIC ATTACK (TIA), a condition where part
of your brain is temporarily deprived of blood flow. 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. This
is likely related to your carotid artery stenosis. Imaging of
your arteries was done and showed the R carotid was completely
occluded and your L carotid had significant stenosis (60-69%).
You were temporarily placed on heparin to thin your blood and to
prevent further clots. This was stopped prior to discharge. You
did not have any further symptoms during your hospitalization.
You were seen by vascular surgery who recommended repeat carotid
ultrasound and follow-up in 3 months.
You should continue to take aspirin and clopidogrel. Please take
your other medications as prescribed.
****You were advised to quit smoking and indicated your plan to
do so. This is one of the most important things you can do for
your health and to prevent future strokes.****
Please followup with Neurology, Vascular Surgery, 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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10671739-DS-22
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| 22 |
2165-12-11 00:00:00
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2165-12-11 14:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Atorvastatin / simvastatin
Attending: ___.
Chief Complaint:
TIA
Major Surgical or Invasive Procedure:
L Carotid Endarterectomy
History of Present Illness:
___ s/p R CEA in ___, who was hospitalized from ___ to
___ for TIAs, she was found to have complete occlusion of R
ICA, and 60-69% L ICA stenosis per imaging studies. She was
placed on heparin gtt and she was symptoms free during this
period. Pt was discharged on antiplatelet agents with plan to
follow her left carotid stenosis with serial ultrasound. Pt's PA
called her this morning and notice slurred of speech and she was
advised to come to ___ ED. and head CT was done that shows
no acute process. Pt was transferred to ___ for possible
carotid endarterectomy. By the time I see her, she denies any
slurred speech, weakness, numbness, change in vision. denies any
pain/N/V/F/C.
Past Medical History:
- Left arm numbness, lasting for several hours in ___ or ___
speculation of cerebrovascular etiology, entering OMR as
"stroke". ___, imaging performed and referred to
Neurosurgery - perhaps radicular.
- Right amaurosis fugax, twice, two to ___ years ago. She
refers to these as "mini-strokes". Possible some visual loss in
this eye, but may be refractive.
- Hypercholesterolemia, on pravastatin
- Peripheral vascular, cerebrovascular and coronary artery
disease, including prior right CEA and now right ICA occlusion
- Hypothyroidism, on levothyroxine
- COPD with active smoking
- Vertigo, likely peripheral origin
- Leukoaraiosis
- Obsessive compulsive disorder
- Pacemaker - "slow heart beat", sees Cardiology, but cannot
recall where, says if not here, then ___
- Medication non-compliance
- Perianal rash, not compliant with treatment, one year duration
- Peripheral vascular disease
Social History:
___
Family History:
Father with strokes in ___, then major stroke at ___. Mother
cancer d. ___ (breast). All siblings deceased: sister, breast
ca., suicide, other.
Physical Exam:
Vitals: 97 61 114/66 16 96%RA
GEN: NAD. Alert, oriented x3.
HEENT: No scleral icterus. Mucous membranes moist. EOMI, cranial
nerves 2 to 12 are intact.
CV: RRR
PULM: Unlabored breathing, CTAB
ABD: Soft, nondistended, nontender. No R/G. No masses.
EXT: Warm without ___ edema/c/c. Upper and lower extremities
sensory/strength are grossly intact.
Pulses:
Carotid Bruit- not appreciated Right:+1 Left:+1
Femoral Right:+2 Left:+2
DP Right: Dopplerable Left: Dopplerable
___ Right: Dopplerable Left: Dopplerable
Radial Right: Dopplerable Left: Dopplerable
Pertinent Results:
___ 09:07PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:07PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 04:40PM GLUCOSE-90 UREA N-16 CREAT-1.0 SODIUM-140
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-28 ANION GAP-12
___ 04:40PM ALT(SGPT)-33 AST(SGOT)-43* ALK PHOS-67 TOT
BILI-0.4
___ 04:40PM ALBUMIN-4.1 CALCIUM-9.4 PHOSPHATE-3.8
MAGNESIUM-2.1
___ 04:40PM WBC-8.3 RBC-4.24 HGB-14.3 HCT-40.6 MCV-96
MCH-33.7* MCHC-35.3* RDW-11.9
___ 04:40PM NEUTS-61.1 ___ MONOS-7.0 EOS-6.6*
BASOS-1.0
___ 04:40PM PLT COUNT-262
___ 04:40PM ___ PTT-20.9* ___
Brief Hospital Course:
Mrs. ___ was transferred to ___ Emergency Department from
___ ED for TIA. A CT of the head was performed
while she was in the ___ ED, which did not show evidence of an
acute stroke. She was admitted to ___ under the Vascular
Surgery Service on ___ with plans for a carotid
endarterectomy on ___. She was taken to the OR on ___ for a L
CEA, the procedure was uncomplicated, please see the dictated
operative note for details of the procedure.
The patient's pain was well controlled post-operatively and she
remained neurovascularly intact. She developed some bleeding
that required a suture to be placed at bedside on POD 0. She was
observed for signs of continued bleeding, of which there were
none. On POD 2 the patient was sitting in a chair when she
became hypotensive (systolic BP 74), unresponsive with
occasionaly myoclonic jerks. A code stroke was called, she was
started on IVF. Her mental status slowly improved, a CTA of the
head and neck did not show any evidence of an acute intracranial
process and her left carotid artery remained open s/p
endarterectomy. Her mental status returned to baseline withing
___ minutes. She was continued on IVF and remained
normotensive to mildly hypertensive for the duration of her
hospital course. She was evaluated by Physical Therapy and found
to have respiratory and balance deficits. She was recommended
for short term rehab.
On the day of discharge she was ambulatory with assistance,
voiding without difficulty, neurovascularly intact and
tolerating a regular diet. She agreed with the recommendation
for short term rehab and was discharged to an ___ rehab
facility.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tiotropium Bromide 1 CAP IH DAILY
2. Nicotine Patch 21 mg TD DAILY
3. econazole *NF* 1 % Topical BID rash
4. sertaconazole *NF* 2 % Topical BID rash
5. ClonazePAM 1 mg PO QHS
6. Aspirin 325 mg PO DAILY
7. Atenolol 25 mg PO DAILY
8. ClomiPRAMINE 100 mg PO DAILY
9. Clopidogrel 75 mg PO DAILY
10. DiphenhydrAMINE 25 mg PO HS:PRN itching
11. Docusate Sodium 100 mg PO DAILY
12. Fish Oil (Omega 3) 1000 mg PO DAILY
13. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
14. Levothyroxine Sodium 88 mcg PO DAILY
15. Pravastatin 40 mg PO DAILY
16. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of
breath/wheezing
17. Bisacodyl 10 mg PR HS:PRN constipation
18. Multivitamins 1 TAB PO DAILY
19. Psyllium 1 PKT PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. ClomiPRAMINE 100 mg PO DAILY
3. ClonazePAM 1 mg PO QHS
4. Docusate Sodium 100 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Levothyroxine Sodium 88 mcg PO DAILY
7. Tiotropium Bromide 1 CAP IH DAILY
8. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*25 Tablet Refills:*0
9. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of
breath/wheezing
10. Bisacodyl 10 mg PR HS:PRN constipation
11. Clopidogrel 75 mg PO DAILY
12. DiphenhydrAMINE 25 mg PO HS:PRN itching
13. econazole *NF* 1 % Topical BID rash
14. Fish Oil (Omega 3) 1000 mg PO DAILY
15. Multivitamins 1 TAB PO DAILY
16. Nicotine Patch 21 mg TD DAILY
17. Pravastatin 40 mg PO DAILY
18. Psyllium 1 PKT PO DAILY
19. sertaconazole *NF* 2 % Topical BID rash
20. Atenolol 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left Carotid Artery Stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
WHAT TO EXPECT:
1. Surgical Incision:
It is normal to have some swelling and feel a firm ridge along
the incision
Your incision may be slightly red and raised, it may feel
irritated from the staples
2. You may have a sore throat and/or mild hoarseness
Try warm tea, throat lozenges or cool/cold beverages
3. You may have a mild headache, especially on the side of your
surgery
Try ibuprofen, acetaminophen, or your discharge pain
medication
If headache worsens, is associated with visual changes or
lasts longer than 2 hours- call vascular surgeons office
4. It is normal to feel tired, this will last for ___ weeks
You should get up out of bed every day and gradually increase
your activity each day
You may walk and you may go up and down stairs
Increase your activities as you can tolerate- do not do too
much right away!
5. It is normal to have a decreased appetite, your appetite will
return with time
You will probably lose your taste for food and lose some
weight
Eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
MEDICATION:
Take all of your medications as prescribed in your discharge
ACTIVITIES:
No driving until post-op visit and you are no longer taking
pain medications
No excessive head turning, lifting, pushing or pulling
(greater than 5 lbs) until your post op visit
You may shower (no direct spray on incision, let the soapy
water run over incision, rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area
CALL THE OFFICE FOR: ___
Changes in vision (loss of vision, blurring, double vision,
half vision)
Slurring of speech or difficulty finding correct words to use
Severe headache or worsening headache not controlled by pain
medication
A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
Trouble swallowing, breathing, or talking
Temperature greater than 101.5F for 24 hours
Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
___
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2166-04-13 22:05:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Atorvastatin / simvastatin
Attending: ___
___ Complaint:
Falls
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old woman with a history of PVD with occlusion
left superficial femoral artery stent s/p left femoropopliteal
bypass with course complicated by right MCA stroke post
operatively (admission ___ to ___. She was
discharged to ___ Rehab and per her report had
multiple falls during that rehab stay such that she needed to be
infront of the nursing station for several hours a day where she
could be observed. Due to this she ultimately left the rehab
against medical advice on ___, however she has
already had two falls at home today with trauma to her left arm.
She denies any head trauma, loss of consciousness, neck or head
pain or light headedness. She called her PCPs office who she
reports instructed her to go to the ED.
In the ED initial VS were T: 98.1 HR: 82 BP: 123/55 RR; 18 98%
RA.
A head CT was performed showing no intracranial hemorrhage or
calvarium fracture, and progressive periventricular white matter
changes. The ED case manager was unable to get her placed back
at ___ as she would need to be rescreened, and
patient could not cover the alternative of 24 hour care at home,
and thus was admitted for placement
Past Medical History:
- Left arm numbness, lasting for several hours in ___ or ___
speculation of cerebrovascular etiology, entering OMR as
"stroke". ___, imaging performed and referred to
Neurosurgery - perhaps radicular.
- Right amaurosis fugax, twice, two to ___ years ago. She
refers to these as "mini-strokes". Possible some visual loss in
this eye, but may be refractive.
- Hypercholesterolemia, on pravastatin
- Peripheral vascular, cerebrovascular and coronary artery
disease, including prior right CEA and now right ICA occlusion
- Hypothyroidism, on levothyroxine
- COPD with active smoking
- Vertigo, likely peripheral origin
- Leukoaraiosis
- Obsessive compulsive disorder
- Pacemaker - "slow heart beat", sees Cardiology, but cannot
recall where, says if not here, then ___
- Medication non-compliance
- Perianal rash, not compliant with treatment, one year duration
- Peripheral vascular disease
Social History:
___
Family History:
Father with strokes in ___, then major stroke at ___. Mother
cancer d. ___ (breast). All siblings deceased: sister, breast
ca., suicide, other.
Physical Exam:
Admission Physical
==================
VS: 97.0 HR: 79 BP: 114/60 RR16 97% RA
General- Alert, oriented, no acute distress, slow speech, not
slurred currently
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi, decreased breath sounds
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- Alert and oriented to person, place and time. Notable for
___ strength in left upper arm, left lower leg. Bruising over
left lateral arm and forearm.
Gait: deferred.
DISCHARGE PHYSICAL
==================
Vitals- 97.9 104-141/46-56 141/54 ___ 18 94-99%RA
General- AAOx3, slow speech
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, normal JVP, no LAD
Lungs- Poor resp effort. CTAB/L no w/r/r
CV- RRR, normal S1 + S2, no m/g/r
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, no clubbing, cyanosis or edema R
upper arm dressing c/d/i. Distal pulse intact, warm and
well-perfused.
Neuro- AAOx3. ___ strength in left upper arm, left lower leg.
Gait: deferred.
Pertinent Results:
Admission Labs:
===============
___ 05:40AM BLOOD WBC-6.5 RBC-3.43* Hgb-10.5* Hct-32.7*
MCV-95 MCH-30.6 MCHC-32.2 RDW-13.2 Plt ___
___ 05:40AM BLOOD ___ PTT-41.1* ___
___ 05:40AM BLOOD Glucose-89 UreaN-15 Creat-0.7 Na-139
K-3.7 Cl-104 HCO3-26 AnGap-13
___ 05:40AM BLOOD Calcium-8.6 Phos-4.4 Mg-1.8
DISCHARGE LABS:
===============
___ 09:30AM BLOOD WBC-7.1 RBC-4.06* Hgb-12.5 Hct-39.2
MCV-97 MCH-30.7 MCHC-31.8 RDW-13.5 Plt ___
___ 09:30AM BLOOD ___ PTT-30.4 ___
CTH without CONTRAST ___
1. No intracranial hemorrhage or calvarial fracture.
2. Progressive evolution of chronic infarction and small vessel
ischemic
disease.
LEFT ELBOW PLAIN RADIOGRAPH ___
No acute fracture or dislocation.
FEMUR LEFT AP& LAT ___
1. No evidence of displaced fracture or malalignment of the
left femur.
Possible soft tissue contusion overlying the left hip.
___ ___
No evidence of DVT in the left leg.
Brief Hospital Course:
___ with a history of CVA's who left AMA from rehab. She
presents after multiple falls wanting rehab placement.
#. s/p MCA stroke: Patient with recent admission for ___
to ___ for peripheral vascular disease with
occlusion of left superficial femoral artery stent s/p left
femoropopliteal bypass with course complicated by right MCA
stroke post operatively. She was discharged to rehabiliation
and had difficulty with balance and falls there per report. She
then left against medical advice. Upon returning home, she had
two falls but denies striking her head. She then represented to
___ requesting placement for rehab as she realized she would
not be able to function independently at home. On exam, she has
profound weakness secondary to stroke. Head CT was unremarkable
as was x ray of elbow and leg. She was evaluated by physical
therapy who recommended rehabilitation. She was continued on all
her home medications.
#. Bleeding at R upper arm heparin injection site. Noted on
evening ___ with profuse bleeding following heparin
injection requiring multiple dressing changes. HCT was stable
and coags wnl. dressing with pressure applied with bleeding
cessation and site dressing c/d/i at discharge.
#. Left lower extremity swelling: Left lower extremity swelling
noted on exam with tenderness over calf and shin. Lower
extremity ultrasound was negative for DVT and x-ray negative for
fracture. Swelling subsequently improved.
#. Hypothyroidism: Continued levoxyl at home dose.
#. COPD: Stable, no wheezing on exam. Continued home spiriva,
albuterol, advair.
Transitional Issues:
- Patient with recent R MCA stroke with L-sided weakness.
Requires assistance with transfers and ambulation. Expected
duration of rehab is <30 days.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClomiPRAMINE 150 mg PO HS
2. ClonazePAM 2 mg PO QHS
3. Pravastatin 40 mg PO HS
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Aspirin 325 mg PO DAILY
6. Atenolol 25 mg PO DAILY
7. Clopidogrel 75 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
10. Levothyroxine Sodium 88 mcg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Psyllium 1 PKT PO DAILY:PRN CONSTIPATION
13. Tiotropium Bromide 1 CAP IH DAILY
14. Bisacodyl 10 mg PR HS:PRN constipation
15. ClonazePAM 0.5 mg PO DAILY prn anxiety
16. Fish Oil (Omega 3) ___ mg PO DAILY
17. DiphenhydrAMINE 25 mg PO DAILY:PRN pruritus
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
2. Aspirin 325 mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. Bisacodyl 10 mg PR HS:PRN constipation
5. ClomiPRAMINE 150 mg PO HS
6. ClonazePAM 2 mg PO QHS
7. Clopidogrel 75 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Fish Oil (Omega 3) ___ mg PO DAILY
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
11. Levothyroxine Sodium 88 mcg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Pravastatin 40 mg PO HS
14. Psyllium 1 PKT PO DAILY:PRN CONSTIPATION
15. Tiotropium Bromide 1 CAP IH DAILY
16. ClonazePAM 0.5 mg PO DAILY prn anxiety
17. DiphenhydrAMINE 25 mg PO DAILY:PRN pruritus
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Fall
Secondary Diagnosis:
Right middle cerebral artery stroke
Peripheral vascular disease
Discharge Condition:
Mental Status: Clear and coherent but with slurred and slow
speech
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You came to the hospital from your home due to falling after
leaving the rehab facility. Your falls are due to weakness from
your recent stroke and being deconditioned from your recent
hospitalization. You were seen by physical therapy with
recommendation to return to the rehab facility.
It was a pleasure caring for you at ___.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
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2167-03-25 00:00:00
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2167-03-25 17:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Atorvastatin / simvastatin
Attending: ___.
Chief Complaint:
Sore throat
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of COPD (GOLD
III)and peripheral vascular disease s/p femoral stenting and
bypass who presents with sore throat and dyspnea. Three weeks
ago she began experiencing a sore throat. She presented to
___ ED twice and she was sent home each time
without any treatments. Yesterday her dyspnea upon exertion
increased and her sore throat became so severe that it prevented
her from taking her medications and eating food. She went to
___ again last night where they advised her to
gargle her throat with salt water. She attempted this and had no
improvement in her symptoms. She decided to present to ___ ED
for further management.
She denies any prior COPD exacerbations, sick contacts, travel,
contact with children. She has had formed bowel movements and no
nausea, vomiting, or dysuria. She denies having a fever or cough
over the past few few weeks. She has been feeling weaker than
usual. She has an aide with her around the clock who also has
noticed that her voice has become raspier since yesterday.
In the ED she was afebrile (98.5F, HR90, 126/54, 130, 91%RA).
She had a normal CXR and EKG with unremarkable findings. She was
given Albuterol and Ipratropium nebs, salumedrol 125mgIV, and
azithromycin 500mg IV and then transferred to the floor for
further magangement. On the floor, she complained of sore
throat.
ROS:
+Raspy voice but not hot potato sounding. No fevers, chills,
night sweats. +50 lb weight loss unintentional in last year. No
changes in vision or hearing, no changes in balance. No cough,
No chest pain or palpitations. No nausea or vomiting. No
diarrhea or constipation. No dysuria or hematuria. No
hematochezia, no melena. No numbness or weakness, no focal
deficits.
Past Medical History:
PMH: L leg claudication, CAD, peripheral vascular disease, COPD
gold stage III, h/o CVA, incontinence, b/l carotid stenosis,
hyperlipidemia, hypothyroidism, OCD, vertigo
PSH: L fem-AK popliteal bypass graft with non-reversed saphenous
vein graft ___, LLE angiogram ___ (Patent b/l CIA
stents, stenosis of L femoral-above-knee bypass graft both at
the proximal and the distal anastomotic sites, stenosis of L
iliac artery beyond the stent, patent popliteal artery and
2-vessel runoff to the foot), R CEA (___), L CEA (___),
pacemaker
Social History:
___
Family History:
Father with strokes in ___, then major stroke at ___. Mother
cancer d. ___ (breast). All siblings deceased: sister, breast
ca., suicide, other.
Physical Exam:
ADMISSION EXAM:
Vitals- 98.1, 158/73, 85, 22, 95%RA
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, MMM, yellow-white exudates seen on
tonsils b/l with some pharyngeal stranding, uvula not deviated,
no tonsillar or peritonsillar abscess appreciated, voice raspy,
no drooling, no trismus
Neck- supple, JVP not elevated, no LAD or tender adenopathy
Lungs- CTAB no wheezes, rales, rhonchi, good air movement
CV- Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU- no Foley
Ext- warm, well perfused, 1+ pulse in Left ___, 2+ pulses
elsewhere, no clubbing, cyanosis or lower extremity edema
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE EXAM:
Vitals: T97.7 HR64-70 85 ___ RR20 97-100%RA ___
pain
GENERAL - Alert, chronically ill-appearing in NAD
HEENT - EOMI, sclerae anicteric, MMM, OP clear, no exudates
visualized
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, abdominal bruit
peresnt
EXTREMITIES - WWP, no c/c, no edema
NEURO - A&Ox3, CNs II-XII grossly intact
Pertinent Results:
ADMISSION LABS:
___ 02:10PM BLOOD WBC-17.3*# RBC-4.33 Hgb-13.3 Hct-40.3
MCV-93# MCH-30.7 MCHC-33.0 RDW-13.6 Plt ___
___ 02:10PM BLOOD Neuts-85.1* Lymphs-8.6* Monos-5.6 Eos-0.6
Baso-0.2
___ 02:10PM BLOOD Glucose-113* UreaN-15 Creat-0.8 Na-142
K-4.0 Cl-104 HCO3-23 AnGap-19
___ 07:10AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.1
___ 02:18PM BLOOD Lactate-2.8*
DISCHARGE LABS:
___ 08:00AM BLOOD WBC-10.8 RBC-3.50* Hgb-10.9* Hct-33.5*
MCV-96 MCH-31.2 MCHC-32.6 RDW-13.9 Plt ___
___ 08:00AM BLOOD Glucose-75 UreaN-19 Creat-0.7 Na-141
K-3.8 Cl-106 HCO3-24 AnGap-15
___ 08:00AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.0
___ 07:39AM BLOOD Lactate-2.1*
___ BLOOD CULTURE - NGTD
R/O Beta Strep Group A (Final ___:
NO BETA STREPTOCOCCUS GROUP A FOUND.
___ ECG
Ventricular paced rhythm. No significant change compared with
previous tracing of ___.
___ CXR
Dual lead left-sided pacemaker is again seen with leads
extending to the
expected positions of the right atrium and right ventricle. No
focal
consolidation, pleural effusion or pneumothorax is seen. The
cardiac and
mediastinal silhouettes are unremarkable. Bilateral anterior
costochondral calcifications are again noted. No overt pulmonary
edema is seen.
IMPRESSION:
No acute cardiopulmonary process.
Brief Hospital Course:
___ with COPD (GOLD stage III, not needing home oxygen), HTN,
and peripheral vascular disease s/p femoral stenting and bypass,
admitted for sore throat most consistent with acute
tonsillitis/pharyngitis which limited her ability to take home
PO medications.
# Acute tonsillitis/pharyngitis: ED was initially suspicious for
COPD exacerbation and gave patient IV steroids and IV
azithromycin. However, her O2 sat was at baseline on room air.
CXR and lungs clear, no cough or sputum, no evidence for COPD
exacerbation. She had a sore throat without cough and exam shows
tonsillar exudates. She met 2 Centor criteria (lack of cough,
tonsillar exudates) for Group A Strep. Patient did not have any
trismus or peritonsillar abscess seen. However, given
leukocytosis to 17, lactate 2.8, and severe sore throat with
exudates, she was treated with Unasyn overnight. She was
transitioned to Augmentin to complete 7-day total course. DDx
bacterial or viral pharyngitis or tonsillitis. Strep culture
returned negative. Symptoms managed with lozenges and liquid
acetaminophen. She tolerated regular diet on discharge and
symptoms resolved.
## CHRONIC ISSUES ##
#COPD. Gold stage III. Followed by Dr. ___. Cont home COPD
regimen.
#CAD. History of CVA. Stable. Continue home aspirin, atenolol,
pravastatin.
#Hypothyroidism. Continue home levothyroxine
#Peripheral Vascular Disease. Continue clopidogrel.
#Depression: Hx. of OCD and depression. Cont clompipramine and
clonazepam PRN.
# CODE STATUS: She was previously DNR/DNI during past
admissions, but now states she is full code.
# CONTACT: Neighbor/Friend: ___ ___
###TRANSITIONAL ISSUES###
- Augmentin 875mg PO Q12H for 5 more days, last day ___,
total 7-day course
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. ClomiPRAMINE 150 mg PO HS
4. Bisacodyl ___AILY:PRN constipation
5. ClonazePAM 0.5 mg PO QHS:PRN anxiety
6. Docusate Sodium 100 mg PO DAILY:PRN constipation
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. Pravastatin 40 mg PO HS
9. Tiotropium Bromide 1 CAP IH DAILY
10. Levothyroxine Sodium 88 mcg PO DAILY
11. Albuterol Sulfate (Extended Release) 90 mcg PO Q4H:PRN for
SOB
12. dimethicone 1.3 % topical qid PRN rash
13. DiphenhydrAMINE 25 mg PO DAILY:PRN pruritis
14. Multivitamins 1 TAB PO DAILY
15. Psyllium 1 PKT PO DAILY
16. Ensure (food supplement, lactose-free) one can oral four
times daily
17. Clopidogrel 75 mg PO DAILY
18. Lovaza (omega-3 acid ethyl esters) 2 gram oral BID
19. Milk of Magnesia 30 mL PO DAILY:PRN constipation
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 5 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*10 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. Bisacodyl ___AILY:PRN constipation
4. Clopidogrel 75 mg PO DAILY
5. Docusate Sodium 100 mg PO DAILY:PRN constipation
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. Levothyroxine Sodium 88 mcg PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
9. Albuterol Sulfate (Extended Release) 90 mcg PO Q4H:PRN for
SOB
10. Atenolol 25 mg PO DAILY
11. dimethicone 1.3 % topical qid PRN rash
12. DiphenhydrAMINE 25 mg PO DAILY:PRN pruritis
13. Ensure (food supplement, lactose-free) 1 can ORAL FOUR TIMES
DAILY
14. Multivitamins 1 TAB PO DAILY
15. Psyllium 1 PKT PO DAILY
16. ClomiPRAMINE 150 mg PO HS
17. ClonazePAM 0.5 mg PO QHS:PRN anxiety
18. Pravastatin 40 mg PO HS
19. Lovaza (omega-3 acid ethyl esters) 2 gram oral BID
20. Milk of Magnesia 30 mL PO DAILY:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
PRIMARY:
-Acute pharyngitis
SECONDARY:
-Chronic obstructive pulmonary disease
-Peripheral vascular disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you at ___
___. You were admitted to the hospital for a sore
throat infection, which kept you from taking your home
medications. You were started on antibiotics which you will
continue to take at home. You were discharged when you felt you
could take your oral medications and could tolerate a regular
diet.
Followup Instructions:
___
|
10671739-DS-27
| 10,671,739 | 24,744,881 |
DS
| 27 |
2167-11-10 00:00:00
|
2167-11-10 23:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Atorvastatin / simvastatin
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo F PMH of CAD, PVD, COPD, CVA on ASA/Plavix presented to
her PCP with altered mental status, cough, and relative hypoxia
from baseline. On arrival, patient states she went to her PCP
today for help filling out a form. She notes a cough "for a
year". Denies fever, vomiting, abd pain, cp, diarrhea, or leg
swelling.
.
In ER:
Triage Vitals: 97.7, 72, 134/66, 18, 98% RA
Meds Given: ceftriaxone
Radiology Studies:CXR
Consults called: none
.
Cough × ___ years. She has had diarrhea for the past ___ days. No
F/C. No nausea or vomiting. She reports pain with urination and
increased frequency of urination x a couple days but then tells
me that she has had it for months. She has lost 40 lbs recently.
No rashes or changes in her skin. No night sweats. Increased
frequency of urination. No sore throat. No sick contacts. No
chest pain. Chronic shortness of breath x years without new
worsening.No belly pain. No new msk sx. No new neuro sx.
Productive cough x ___ years. No rashes. No recurrent stroke sx.
PAIN SCALE: ___.
.
ROS: 10-point ROS negative except as noted above in HPI
Past Medical History:
PMH
L leg claudication
CAD
peripheral vascular disease, bilateral carotid stenosis
COPD Gold stage III
h/o CVA
incontinence
hyperlipidemia
hypothyroidism
OCD
vertigo
PSH
L fem-AK popliteal bypass graft with non-reversed saphenous vein
graft ___
LLE angiogram ___ (Patent b/l CIA stents, stenosis of L
femoral-above-knee bypass graft both at the proximal and the
distal anastomotic sites, stenosis of L iliac artery beyond the
stent, patent popliteal artery and 2-vessel runoff to the foot)
R CEA (___)
L CEA (___)
pacemaker
Social History:
___
Family History:
Father with strokes in ___, then major stroke at ___.
Mother cancer d. ___ (breast).
All siblings deceased: sister, breast ca.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 97.7, P 77, BP 152/57, RR 24, O2Sat 92% on RA
GENERAL: Chronically ill appearing ___ year old female
HEENT: anicteric, dry MM
CV: RRR, no murmur, normal S1 and S2, no ___ edema
Pulm: RLL crackles and diminshed breath sounds
GI: soft, distended, hard brown stool in rectal vault
Neuro: normal attention, AAOx3, but confused
Skin: warm and dry
Psych: depressed mood
GU: catheter present
.
DISCHARGE PHYSICAL EXAM:
VS: AF, 97.5, 158/73, 75, 20, 93% on RA
Pain: zero out of 10
Gen: NAD
HEENT: anicteric
Pulm: CTAB, + dry cough
Abd: soft, NT, NABS
Ext: no edema
Neuro: AAOx3, fluent speech
Skin: PPD placed on right forearm
Pertinent Results:
ADMISSION LABS:
___ 07:56PM BLOOD WBC-11.3* RBC-4.37 Hgb-12.9 Hct-37.1
MCV-85# MCH-29.6 MCHC-34.8 RDW-15.9* Plt ___
___ 07:56PM BLOOD Neuts-73.8* Lymphs-17.9* Monos-6.0
Eos-2.0 Baso-0.3
___ 07:56PM BLOOD Glucose-81 UreaN-14 Creat-0.9 Na-140
K-4.0 Cl-105 HCO3-22 AnGap-17
___ 08:11PM BLOOD Lactate-1.4
___ 09:21PM URINE Color-Yellow Appear-Hazy Sp ___
___ 09:21PM URINE Blood-NEG Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
___ 09:21PM URINE RBC-2 WBC-2 Bacteri-FEW Yeast-NONE Epi-1
DISCHARGE LABS:
___ 07:19AM BLOOD Glucose-80 UreaN-15 Creat-0.7 Na-140
K-3.7 Cl-108 HCO3-23 AnGap-13
___ 07:19AM BLOOD Calcium-8.9 Phos-4.2 Mg-2.0
MICROBIOLOGY:
___ Blood Culture x 2 sets: No Growth, FINAL PENDING
.
___ Urine Culture: >100K CFU E. coli (FINAL PENDING)
.
IMAGING:
___ CT HEAD
IMPRESSION:
No acute intracranial abnormality.
.
___ CXR (PA/LAT)
IMPRESSION:
No acute cardiopulmonary abnormality.
.
Brief Hospital Course:
___ yo F with CAD/PVD, CVA, who presents from PCP office with
altered mental status, found to have UTI.
.
# Altered mental status / # toxic-metabolic encephalopathy
# UTI
Patient with altered mental status in PCP ___. On admission,
noted to have mild leukocytosis and UA consistent with UTI.
Started on empiric ceftriaxone, with improvement in mental
status and resolution of leukocytosis. Blood cultures with no
growth to date. Urine culture preliminary growing E. coli.
Previous urine culture had demonstrated E. coli sensitive to
fluoroquinolone, but not sensitive to Bactrim, so patient
transitioned to PO ciprofloxacin. She remained stable on
ciprofloxacin. She will be discharged to complete a total of a
7 day course of antibiotics.
.
.
# CAD/PVD/CVA
Stable. Continued ASA, Plavix and statin.
.
# Hypothyroidism: stable, continued home levothyroxine.
.
# COPD
Stable O2 sat's on room air. Chronic cough without change and
no new sputum production. No wheeze on exam. Patient continued
on home inhalers, including Advair, Spiriva and PRN albuterol.
.
# PPD placement
Per PCP and HCP request, PCP placed to screen patient for
outpatient adult daycare placement. PPD placed on right forearm
and marked on ___ at 5AM. Will need to be read between 5AM
___ and 5AM ___.
.
TRANSITIONAL ISSUES:
1. f/u final microbiology data and tailor antibiotic therapy
accordingly
2. read PPD (patient arranged to have home ___
3. Complete course of antibiotics for UTI
4. PENDING STUDIES AT TIME OF DISCHARGE
### ___ Blood cultures: no growth to date, final PENDING
### ___ Urine culture: >100K CFU E. coli (final PENDING)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Bisacodyl ___AILY:PRN constipation
3. Clopidogrel 75 mg PO DAILY
4. Docusate Sodium 100 mg PO DAILY:PRN constipation
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Levothyroxine Sodium 88 mcg PO DAILY
7. Tiotropium Bromide 1 CAP IH DAILY
8. Multivitamins 1 TAB PO DAILY
9. Psyllium 1 PKT PO DAILY
10. ClomiPRAMINE 150 mg PO HS
11. ClonazePAM 0.5 mg PO QHS:PRN anxiety
12. Pravastatin 40 mg PO HS
13. Lovaza (omega-3 acid ethyl esters) 2 gram oral BID
14. Milk of Magnesia 30 mL PO DAILY:PRN constipation
15. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
16. Clotrimazole Cream 1 Appl TP BID
17. DiphenhydrAMINE 25 mg PO Q6H:PRN itching
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
2. Aspirin 81 mg PO DAILY
3. Bisacodyl ___AILY:PRN constipation
4. ClonazePAM 0.5 mg PO QHS:PRN anxiety
5. Clopidogrel 75 mg PO DAILY
6. Docusate Sodium 100 mg PO DAILY:PRN constipation
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. Levothyroxine Sodium 88 mcg PO DAILY
9. Milk of Magnesia 30 mL PO DAILY:PRN constipation
10. Tiotropium Bromide 1 CAP IH DAILY
11. Multivitamins 1 TAB PO DAILY
12. Pravastatin 40 mg PO HS
13. ClomiPRAMINE 150 mg PO HS
14. Clotrimazole Cream 1 Appl TP BID
15. DiphenhydrAMINE 25 mg PO Q6H:PRN itching
16. Lovaza (omega-3 acid ethyl esters) 2 gram oral BID
17. Psyllium 1 PKT PO DAILY
18. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every 12 hours
Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Likely urinary tract infection
Altered mental status, likely toxic-metabolic encephalopathy
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 to the hospital after being noted to be
confused at your PCP's office. Work-up in the hospital suggests
a urinary tract infection, so you were started on antibiotics,
with improvement in your symptoms. You will need to complete a
course of oral antibiotics.
.
You had a PPD test placed on your right forearm in the morning
of ___. This is a tuberculosis screening test for you to
qualify for adult day care. This PPD will need to be read by a
qualified medical professional between 5AM on ___ and 5AM on
___.
.
Please take your medications as listed.
.
Please see your physicians as listed.
.
Followup Instructions:
___
|
10672034-DS-7
| 10,672,034 | 23,212,405 |
DS
| 7 |
2138-12-22 00:00:00
|
2138-12-23 07:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
nephrolithiasis
flank pain
Major Surgical ___ Invasive Procedure:
NAME OF OPERATION: ___, right retrograde pyelogram,
right ureteral stent insertion.
History of Present Illness:
___ year old male with history of right nephrolithiasis s/p R
ESWL today with Dr. ___ at ___. After being discharged
to home, he developed severe
right flank pain, nausea, and vomiting and so he called an
ambulance which brought him to ___ where he underwent a CT
scan and was found to have a column of tiny stones within the
right distal ureter extending to the right UVJ.
Past Medical History:
CHEST PAIN
HYPERTENSION
HYPERLIPIDEMIA
NEPHROLITHIASIS
H/O ERECTILE DYSFUNCTION
PAST SURGICAL HISTORY:
MENISCUS REPAIR
HERNIORRPAHY
s/p ESWL as noted above
Social History:
___
Family History:
Other PROSTATE CANCER Pt doesn't know
whether father
___ mother's
___ Started
___ screening
___ ___
___ CANCER -- Mother &
maternal uncles
___ their ___
-- Pt had
colonosocpy ___
___: Polyps
___
transverse
___ and
___
(polypectomy);
___ mucosa
___ ___
___ showed
"fragments of
adenoma" --
___
colonoscopy ___
___
Father ___ ___ STROKE
Physical Exam:
WdWn male, NAD, AVSS
Interactive, cooperative
Abdomen soft, Nt/Nd
Flank pain improved.
Lower extremities w/out edema ___ pitting and no report of calf
pain
Pertinent Results:
___ 12:49PM BLOOD WBC-14.1* RBC-4.71 Hgb-14.3 Hct-42.3
MCV-90 MCH-30.4 MCHC-33.8 RDW-12.5 RDWSD-41.0 Plt ___
___ 12:49PM BLOOD Neuts-75.4* Lymphs-16.7* Monos-6.7
Eos-0.5* Baso-0.1 Im ___ AbsNeut-10.64* AbsLymp-2.36
AbsMono-0.94* AbsEos-0.07 AbsBaso-0.02
___ 12:49PM BLOOD ___ PTT-25.2 ___
___ 12:49PM BLOOD Glucose-139* UreaN-21* Creat-1.1 Na-143
K-4.0 Cl-101 HCO3-27 AnGap-15
___ 12:49PM BLOOD Lactate-2.3*
/___ pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
Mr. ___ was admitted to Dr. ___ for
nephrolithiasis management with known right ureteral stones ___
setting of ESWL earlier today ___ at ___ and
underwent urgent cystoscopy, right retrograde pyelogram, right
ureteral stent insertion for decompression. Mr. ___ tolerated
the procedure well and recovered ___ 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.
Intravenous fluids, Toradol and Flomax were given to help
facilitate passage of stone fragments and control pain. At
discharge on POD1, patients pain was controlled with oral pain
medications, tolerating regular diet, ambulating without
assistance, and voiding without difficulty. Mr. ___ was
explicitly advised to follow up as directed as the indwelling
ureteral stent must be removed and ___ exchanged. He should
follow up with Dr. ___. Urinalysis was concerning for UTI so
he was discharged with a short term course of antibiotics. Since
discharge, the urine culture has finalized as negative.
Medications on Admission:
Active Medication list as of ___:
Medications - Prescription
ATORVASTATIN - atorvastatin 40 mg tablet. 1 tablet(s) by mouth q
hs
LISINOPRIL - lisinopril 10 mg tablet. 1 tablet(s) by mouth daily
SILDENAFIL [VIAGRA] - Viagra 100 mg tablet. 1 tablet(s) by mouth
once daily as needed for sexual activity
Medications - OTC
ASPIRIN - aspirin 81 mg tablet,delayed release. 1 (One)
tablet(s)
by mouth once a day - (OTC)
Discharge Medications:
1. 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
2. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
RX *ibuprofen 600 mg ONE tablet(s) by mouth Q8hrs Disp #*25
Tablet Refills:*0
3. Senna 8.6 mg PO BID
4. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 3 Days
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg ONE
tablet(s) by mouth twice a day Disp #*6 Tablet Refills:*0
5. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin [Flomax] 0.4 mg ONE capsule(s) by mouth DAILY
Disp #*14 Capsule Refills:*0
6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
7.RETURN TO WORK
Mr. ___ was incapacitated ___.
He may return to work without restrictions effective ___.
Discharge Disposition:
Home
Discharge Diagnosis:
NEPHROLITHIASIS; RIGHT ureteral stones.
URINALYSIS concerning for UTI
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 ___ your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments ___
the indwelling ureteral stent (if there is one).
-The kidney stone may ___ may not have been removed ___ there
may fragments/others still ___ process of passing.
-You may experience some pain associated with spasm of your
ureter.; This is ___. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ureteral stents MUST be removed ___ 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 ___
your urine--this is ___ 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 ___ 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.
-You may be given prescriptions for a stool softener ___ a
gentle laxative. These are over-the-counter medications that
may be health care spending account reimbursable.
-Colace (docusate sodium) may have been prescribed to avoid
post-surgical constipation ___ constipation related to use of
narcotic pain medications. Discontinue if loose stool ___
diarrhea develops. Colace is a stool-softener, NOT a laxative.
-Senokot ___ any gentle laxative) may have been prescribed to
further minimize your risk of constipation.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity ___ sports for 4 weeks
Followup Instructions:
___
|
10672112-DS-10
| 10,672,112 | 29,497,850 |
DS
| 10 |
2142-03-30 00:00:00
|
2142-03-30 16:53:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Zantac / Levaquin
Attending: ___.
Chief Complaint:
cough, sputum and fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient with SOB, cough and fever of 101 identical to prior.
Initially treated as on o/p with levaquin for 2 days but
developed ___ rash to it and was swithced to augementin and
without improvement but with the development of diarrhea.
Patient was at ___ on ___ and given IV antibiotics
though the actualy abx were not documented and she was
discharged yesterday on PO azithromycin as a single agent. She
continued to spike to 101. Her PCP sent her for an admission and
IV antibiotics.
Past Medical History:
1. Bicuspid aortic valve
2. Mild to moderate aortic regurgitation- Pt's last echo was
___ with a LVEF of >55%, ___ AR, trivial MR, and 1+ TR.
3. Recurrent pneumonias and sinus infections
4. C5 and C7 radiculopathy
Social History:
___
Family History:
Pt's father had a DVT. Her mother had a heart murmur and died of
lung CA at age ___. She reports that her maternal uncles both
died of MIs.
Physical Exam:
ON ADMISSION:
T 98 BP 120/60 P80 RR18 Sats 97% RA
Patient coughing up a lot. Productive - yellow sputum
HEENT: no xanthalasma, Pupils RRE
JVP: nl venous pressure, a and v wave
Car: no bruit or transmitted murmur
Thy: not enlarged, no bruit
Lungs: Rhonchi at right lower ___ that dont clear with cough.
No
rales, wheeze or rub.
Heart: RRR No gallop, click, rub.
Grade ___ AR murmur. ___ systolic murmur at apex and
base.
Abd: soft and non tender. no palpable masses. Nl bowel sounds.
Ext: No edema, clubbing or cyanosis. Full pedal pulses
bilaterally.
ON DISCHARGE:
T 98 BP 128/70 P70 RR16 Sats 96% RA
Patient hardly coughing.
Lungs: Rhonchi at right lower ___. No
rales, wheeze or rub.
Heart: RRR No gallop, click, rub.
Grade ___ AR murmur. ___ systolic murmur at apex and
base.
Abd: soft and non tender. no palpable masses. Nl bowel sounds.
Pertinent Results:
___ 03:13PM URINE HOURS-RANDOM
___ 09:42AM LACTATE-1.5
___ 09:40AM GLUCOSE-118* UREA N-15 CREAT-0.7 SODIUM-138
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-28 ANION GAP-14
___ 09:40AM WBC-5.2 RBC-4.44 HGB-12.4 HCT-38.6 MCV-87
MCH-28.0 MCHC-32.2 RDW-14.3
___ 09:40AM PLT COUNT-251
Brief Hospital Course:
PNEUMONIA: Patient with undertreated CAP pneumonia for assorted
reasons. The etiology of her recurrent RLL Pna's is not
abundantly clear, though Dr. ___ has raised the possibility
of bronchiectasis and she admits to coughing while eating. She
has not had a decent trial of traditional CAP treatment with her
having an allergic reaction to levaquin, diarrhea with
augmentin, getting a mystery antibiotic at ___ then getting
discharged without pneumococcus coverage. Patient also had
diarrhoea, likely a drug response from augmentin, has been
on-going and could also have contributed to malabsorption of her
antibiotics. She was treated in-house with IV Ceftriaxone 1g
Q24H (intended 7 day course, start date ___ and PO Augmentin
500mg Q24H (intended 5 day course, start date ___. She did
very well on these and was switched over to oral therapy on
___. Her oral therapy consisted of Cefpodoxine 200mg BID
and Azithromycin 500mg q24H. She was discharged on ___ and
will be followed up by her PCP and Dr. ___.
DIARRHEA:
Patient has had ___ episodes of loose stool since she started
augmentin on ___. C.diff cultures were sent off and came
back negative. Augmentin being a classic drug that causes
diarrhoea seemed to be the likely cause of her diarrhoea. Her
diarrhoea resolved with 12 hours of her being an in-patient at
the ___.
Medications on Admission:
alendronate - 70 mg Tablet once weekly on ___
fluticasone - 50 mcg Spray, Suspension
lisinopril - 20 mg Tablet
aspirin - 81 mg Tablet
calcium carbonate-vitamin D3 [Calcium 500 + D]
multivitamin
omega-3 fatty acids [Fish Oil]
resveratrol
Discharge Medications:
1. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
Disp:*1 bottle* Refills:*2*
2. pseudoephedrine HCl 30 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for headache.
3. azithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 1 days: Stop on ___.
Disp:*2 Tablet(s)* Refills:*0*
4. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 3 days: stop on ___.
Disp:*12 Tablet(s)* Refills:*0*
5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. alendronate 70 mg Tablet Sig: One (1) Tablet PO QSAT (every
___.
8. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Community Acquired Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted to the ___ on ___ with couging up green
sputum and fevers. ___ were evaluated and treated here for a
pneumonia with intravenous antibiotics. ___ improved on these
medications and will go home with oral antibiotics and have
follow up in Dr. ___.
Please continue taking:
alendronate - 70 mg Tablet once weekly on ___
fluticasone - 50 mcg Spray two puffs in each nostril once daily
lisinopril - 20 mg Tablet once daily
aspirin - 81 mg Tablet once daily
calcium carbonate-vitamin D3 [Calcium 500 + D] once daily
Please START the following mediciations at home:
Cefpodoxine 200mg one tablet twice per day for three days until
___
Azithromycin 500mg one tablet for one day until ___
It was a pleasure looking after ___ at the ___
Followup Instructions:
___
|
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DS
| 10 |
2177-11-15 00:00:00
|
2177-11-15 19:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Banana
Attending: ___.
Chief Complaint:
Worse headache of life
Major Surgical or Invasive Procedure:
ACOM aneurysm embolization and coiling on ___.
History of Present Illness:
This is a ___ speaking ___ year old female with history
of headaches that complains of new worse headache of her life
that woke her from sleep yesterday at 10:30 pm. At that time she
complained of photophobia and difficulty feeling her left leg.
She seemed "distant" per her family and vomited several times.
Past Medical History:
PMHx:none
PSHx: tubal ligation
Social History:
Social Hx:denies smoking, denies tobacco
Physical Exam:
On admission:
PHYSICAL EXAM:
O: T:97.6 BP: 118 /84 HR:60 R 16 99% O2Sats
Gen: WD/WN, with photophobia, in discomfort
HEENT: Pupils: 3mm, reactive,EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT,ND
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift.
Sensation: Intact to light touch, proprioception, pinprick and
vibration bilaterally.
Reflexes: Normal bilaterally
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Upon discharge:
A&O x3. PERRL. EOM intact. No pronator drift. Full strength.
Gate unsteady: has been using a walker.
Pertinent Results:
___ CTA Head/Neck:
IMPRESSION:
1. Diffuse subarachnoid hemorrhage with extension into the
ventricles.
Interval stability of ventricular size.
2. Inferiorly projecting saccular aneurysm at the right aspect
of the anterior communicating artery and measuring approximately
4 x 3 mm.
3. Otherwise, CTA head and neck show no evidence of stenosis,
dissection or occlusion. There is no internal carotid artery
stenosis by NASCET criteria.
___ CT Head:
IMPRESSION:
1. Diffuse bilateral subarachnoid hemorrhage extending into the
sulci,
cisterns, and ventricles. Intraventricular redistribution of
blood.
2. No evidence of hydrocephalus.
COMMENT ON ATTENDING REVIEW:
The lateral and third ventricles have increased in size,
indicating
obstructive hydrocephalus, probably due to increased blood in
the sylvian
adueduct.
___ CT head - Diffuse subarachnoid hemorrhage which is
unchanged. No infarct or hydrocephalus.
___ CXR
Radiology Report CHEST PORT. LINE PLACEMENT Study Date of
___ 11:50 AM PICC line with tip in the mid SVC.
___ CTA head
1. Mild narrowing of the M1 segment of the left middle cerebral
artery,
suggestive of vasospasm.
2. Narrowing and irregularity of the basilar artery, also
suggestive of
vasospasm.
___ EKG
Sinus bradycardia with sinus arrhythmia
___ CXR
Left PIC line ends in the upper SVC. No pneumothorax, pleural
effusion,
mediastinal widening. Lungs clear. Heart size normal.
___ CT head
Evolution of subarachnoid hemorrhage involving the sulci and
cisterns
bilaterally with no extension into the ventricular system. No
new evidence of hemorrhage or territorial infarction.
___ CT head
Stable diffuse hydrocephalus. Decreasing bifrontal subarachnoid
hemorrhage. No evidence for new abnormalities.
Brief Hospital Course:
Ms. ___ is a ___ y/o F who complained of the WHOL last night.
She vomited en route to the OSH. Upon arrival she underwent a CT
head which showed a diffuse SAH. She was then transferred to
___ and underwent further evaluation which revealed an ACOM
aneurysm. She underwent coiling of the ACOM aneurysm in the
morning. Post-operatively she remained intact.
On the overnight ___ into ___, the patient appeared more
lethargic with complaints of headache. A CT head was obtained
which showed enlargement of her ventricles. She was continued to
be monitored carefully in the ICU. The lethargy was attributed
to narcotics. She obtained a 500 cc bolus to maintain a positive
I/O balance.
On ___ Patient was continued to be frequently monitored in the
ICU with Q1 hour neuro checks. Daily TCDs were negative for
vasospasm. She continued on nimodopine and a dex taper.
On ___ Patient continued on Q1 hour neuro checks. She complained
of ___ headache. Daily TCDs were obtained which revealed mild
vasospasm in the R MCA with a mean velocity of 130. A screening
non contrast head CT which revealed stable ventriculomegaly and
patients exam was stable. Repeat TCD on ___ showed xxx. She
remained stable.
On ___, The Keppra was discontinued. The patient was maintained
at a fluid volume even status and her neurological exam was
stable.
On ___, The neurological exam was stable.
On ___, It was determined that transcranial dopplers were not
required. The underwent CTA. The patient was deemed
appropriated for transfer to the floor. A physical therapy
consult was placed and the patient foley catheter was
discontinued. The patient's intravenous fluids were decreased
to 75/cchr.
On ___ Patient remains neurologically intact and stable. Her IVF
were continued at 75cc/hr. ___ and OT were consulted.
On ___ Patient's exam remains stable. Her IVF were continued at
75 cc/hr. Patient reported intermitted minor chest pain. She
underwent a CXR which was normal, and EKG which showed NSR. Her
electrolytes were within normal limits. Cardiac enzymes were
checked and negative.
On ___, patient remained intact, but reported chest pain and
when she pointed to where the pain was located it was the
pectoralis major muscles. ___ was consulted and cleared for home
with ___ and OT. She reported back pain and was started on a
muscle relaxant. Her IVF were discontinued. A head CT was
ordered to evaluate hydrocephalus. Her CT indicated moderate
hydrocephalus but otherwise stable.
On ___ she was kept in patient for further observation and
her exam remained stable.
On ___, the patient exam remained stable. She was able to
ambulate with assistence. Decided not to proceed with VP shunt
placement for ___. Repeat CT head revealed Stable
diffuse hydrocephalus. Decreasing bifrontal subarachnoid
hemorrhage. No evidence for new abnormalities
On ___ Patient's exam remained stable. It was determined by
___ and case management the patient would be safe to discharge
home with services. Patient was discharged home in stable
condition with instructions for follow. She is to follow up in 1
week with a repeat image to discuss the possibilty of VP shunt.
Medications on Admission:
ASA 81mg daily
Discharge Medications:
1. Nimodipine 60 mg PO Q4H
RX *nimodipine 30 mg 2 capsule(s) by mouth every four (4) hours
Disp #*120 Capsule Refills:*0
2. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H:PRN headache
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___
tablet(s) by mouth every six (6) hours Disp #*45 Tablet
Refills:*0
3. Diazepam 2 mg PO Q8H:PRN muscle spasm
4. Docusate Sodium 100 mg PO BID
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*45 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
ACOM aneurysm
lethargy
Subarachnoid hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Medications:
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
When you go home, you may walk and go up and down stairs.
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
No heavy lifting, pushing or pulling (greater than 5 lbs) for 1
week (to allow groin puncture to heal).
After 1 week, you may resume sexual activity.
After 1 week, gradually increase your activities and distance
walked as you can tolerate.
No driving until you are no longer taking pain medications
What to report to office:
Changes in vision (loss of vision, blurring, double vision, half
vision)
Slurring of speech or difficulty finding correct words to use
Severe headache or worsening headache not controlled by pain
medication
A sudden change in the ability to move or use your arm or leg or
the ability to feel your arm or leg
Trouble swallowing, breathing, or talking
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call ___ for transfer to closest
Emergency Room!
Followup Instructions:
___
|
10672760-DS-14
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| 14 |
2140-02-29 00:00:00
|
2140-02-29 13:11:00
|
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 hallux wound
Major Surgical or Invasive Procedure:
___: Left hallux debridement to bone (Dr. ___
History of Present Illness:
This is a ___ male with a history of PAD, T1DM, HTN, and HLD
with
an infected left hallux ulcer. The patient presents to clinic
after taking a week of oral antibiotics with worsening redness
and purulence from the medial left hallux ulcer. He underwent
an
angioplasty of his posterior tibial artery in ___ with
vascular surgery. He is scheduled for debridement of the toe
tomorrow. He currently denies any fever, chills, nausea,
vomiting, shortness of breath, and chest pain.
Past Medical History:
Past Vascular History:
___: left lower extremity angiogram and balloon
angioplastry of behind knee popliteal artery
___: left lower extremity angiography w/ percutaneous
transarterial angioplasty of left popliteal stenosis and left
anterior tibial artery occlusion
___: RLE dx angio
___: R ___ toe amputation
Past Medical History:
PERIPHERAL VASCULAR DISEASE
HYPERTENSION
DIABETES TYPE I
DIABETIC NEUROPATHY
DUPUYTREN'S CONTRACTURE
TOBACCO ABUSE
Hx of ALCOHOL ABUSE
CAROTID STENOSIS
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Exam:
GEN: NAD, A&Ox3
HEENT: NTAC
Cards: RRR
Lungs: CTAB, No respiratory distress
Abd: Soft, NT, ND
Left Lower Extremity Focused Exam: Dopplerable ___ pulses b/l.
Gross sensation slightly diminished b/l. Left hallux with ulcer
at the medial IPJ with fibropurulent drainage and probes to
bone.
Hallus is erythematous and edematous. Nail plate is absent.
Discharge Exam:
General: Aox3, NAD
HEENT: NCAT
Lungs: No respiratory distress, breathing comfortably
Cards: RRR, extremities well perfused
ABD: Soft, nontender, ___ Focused exam: Left hallux surgical site with sutures intact,
minimal serous drainage. No signs of dehiscence. No signs of
purulence. Erythema and edema significantly improved. Able to
wiggle all digits without pain. Cap refill <3sec
Pertinent Results:
___ 10:50AM GLUCOSE-199* UREA N-30* CREAT-1.7* SODIUM-136
POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-22 ANION GAP-14
___ 10:50AM estGFR-Using this
___ 10:50AM WBC-10.3* RBC-4.25* HGB-12.4* HCT-38.2*
MCV-90 MCH-29.2 MCHC-32.5 RDW-12.3 RDWSD-40.2
___ 10:50AM NEUTS-81.5* LYMPHS-11.1* MONOS-5.8 EOS-0.7*
BASOS-0.5 IM ___ AbsNeut-8.41* AbsLymp-1.14* AbsMono-0.60
AbsEos-0.07 AbsBaso-0.05
___ 10:50AM PLT COUNT-352
___ 06:40AM BLOOD WBC-5.2 RBC-3.80* Hgb-11.4* Hct-33.8*
MCV-89 MCH-30.0 MCHC-33.7 RDW-12.1 RDWSD-39.2 Plt ___
___ 06:05AM BLOOD WBC-7.9 RBC-3.66* Hgb-10.9* Hct-32.4*
MCV-89 MCH-29.8 MCHC-33.6 RDW-11.9 RDWSD-38.3 Plt ___
Brief Hospital Course:
This is a ___ male with a history of PAD, T1DM, HTN, and HLD
with
an infected left hallux ulcer. The patient presented to clinic
on ___ after taking a week of oral antibiotics with worsening
redness
and purulence from the medial left hallux ulcer. He underwent
an
angioplasty of his posterior tibial artery in ___ with
vascular surgery. He was admitted to Podiatric Surgery and
scheduled for debridement of the left hallux on ___. The
patient was taken to the operating room on ___ for left hallux
debridement, 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 with a forefoot offloading shoe 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
heel touch only to left foot in surgical shoe. ___ also use
___ forefoot offloading shoe which will be dispensed at post
op appointment. He was given prescriptions for ciprofloxacin and
clindamycin for post op antibiotics. Given oxycodone for pain
management as needed. 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. Losartan Potassium 50 mg PO QHS
2. Atorvastatin 40 mg PO QPM
3. Glargine 28 Units Dinner
Humalog 7 Units Breakfast
Humalog 7 Units Lunch
Humalog 7 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
4. Clopidogrel 75 mg PO DAILY
5. Aspirin 81 mg PO DAILY
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 50 mg PO QHS
2. Atorvastatin 40 mg PO QPM
3. Glargine 28 Units Dinner
Humalog 7 Units Breakfast
Humalog 7 Units Lunch
Humalog 7 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
4. Clopidogrel 75 mg PO DAILY
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*20 Tablet Refills:*0
2. Clindamycin 300 mg PO Q6H
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every six (6)
hours Disp #*40 Capsule Refills:*0
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: inpatient order
RX *oxycodone 5 mg ___ tablet(s) by mouth q4-6 hours Disp #*30
Tablet Refills:*0
4. Glargine 28 Units Dinner
Humalog 7 Units Breakfast
Humalog 7 Units Lunch
Humalog 7 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Clopidogrel 75 mg PO DAILY
8. Losartan Potassium 50 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Left hallux infection, osteomyelitis
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
to the Podiatric Surgery service for your left foot infection.
You were taken to the operating room during your admission and
given IV antibotics.
You are being discharged home with the following instructions:
ACTIVITY:
There are restrictions on activity. Please remain weight
bearing to your left heel until your follow up appointment and
using your walker for balance. You should keep this site
elevated when ever possible (above the level of the heart!)
No driving until cleared by your Surgeon.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your foot/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 in a hot tub for 4
weeks after surgery or until cleared by your physician.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
DIET:
There are no special restrictions on your diet postoperatively.
Poor appetite is not unusual for several weeks and small,
frequent meals may be preferred.
FOLLOW-UP APPOINTMENT:
Be sure to keep your medical appointments.
If a follow up appointment was not made prior to your discharge,
please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are ___
through ___.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE.
Followup Instructions:
___
|
10672760-DS-16
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| 16 |
2140-07-28 00:00:00
|
2140-07-28 16:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Cough, shortness of breath
Major Surgical or Invasive Procedure:
___:
1. Coronary artery bypass graft x 5. Total arterial
revascularization.
2. Skeletonized left internal mammary artery sequential grafting
to diagonal and left anterior descending arteries.
3. Skeletonized in situ right internal mammary artery sequential
grafting to obtuse marginal 1 and obtuse marginal 2.
4. Left radial artery graft to posterior descending artery.
5. Endoscopic harvesting of the left radial artery.
History of Present Illness:
Mr. ___ is a ___ year old man with a history of diabetes
mellitus, hypertension, hyperlipidemia, and peripheral vascular
disease. He was discharged ___ s/p L popliteal to DP bypass with
ipsilateral transposed GSV. The hospital course was complicated
by acute kidney injury and difficult to control diabetes
mellitus for which ___ was consulted.
Mr. ___ states that he woke up several times the night before
admission with shortness of breath and unable to lie flat. He
reports he felt like he had
sputum caught in the middle of his chest which he tried to cough
up, however, he was only able to cough up scant amounts of
sometimes blood tinged sputum. He denies fevers, chest pain,
nausea or vomiting. Symptoms persisted until he arrived at the
ED. Initial trop 1.30. Cath revealed 90% LM and 80% RCA. We are
consulted for evaluation for revascularization.
Past Medical History:
- HTN
- DM1 c/b diabetic neuropathy
- tob use
- PVD
- Carotid stenosis
- Dupuytren's contracture
- alcohol abuse
- OSA- does not use his CPAP
Past Surgical History:
s/p R ___ toe amputation ___
s/p L popliteal to DP bypass w ipsilateral transposed GSV
___
R eye surgery
R shoulder surgery
Social History:
___
Family History:
Father - died of MI at age ___.
Uncle - also had MI, age unknown.
Physical Exam:
ADMISSION PHYSICAL EXAM:
BP: 143/74 HR: 82 RR: 18 O2 sat: 96% RA Pain Score: ___
Height: 71" Weight: 99.4
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: diminished at bases bilaterally [x]
Heart: RRR [x] Irregular [] Murmur []
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: LLE w/ staples (recent L popliteal to DP bypass) -
mild erythema
R great toe amp
Varicosities: None []
Neuro: Grossly intact [x]
Pulses:
DP Right: doppler Left: doppler
___ Right: doppler Left: doppler
Radial Right: cath site Left: p
Carotid Bruit: none appreciated
DISCHARGE PHYSICAL EXAM:
98.4
PO 127 / 63
L Sitting 80 16 95 Ra
.
General: c/o intolerable incisional pain.[x]
Neurological: A/O x3 [x] Moves all extremities [x] Chemically
paralyzed [] sedated [] Follows commands [x]
HEENT: PEERLA []
Cardiovascular: RRR [x] Irregular [] Murmur [] Rub [] Paced
[]
Respiratory: Decreased at the bases bilaterally [x] No resp
distress [x] Intubated []
GU/Renal: Urine clear []
GI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] NT [x]
Extremities:
Right Upper extremity Warm [x] Edema 1+
Left Upper extremity Warm [x] Edema 1+
Right Lower extremity Warm [x] Edema 1+
Left Lower extremity Warm [x] Edema 1+
Pulses:
DP Right:p Left:p
___ Right:p Left:p
Radial Right:p Left:p
Skin/Wounds: Dry [x] intact []
Sternal: CDI [x] no erythema or drainage [x]
Sternum stable [x] Prevena [x]
Lower extremity: Right [] Left [x] CDI [] staples, incision
erythematous at groin
Upper extremity: Right [] Left [x] CDI [x]
Pertinent Results:
ADMISSION LABS
==================
___ 03:30PM BLOOD WBC-11.5* RBC-3.84* Hgb-11.6* Hct-35.3*
MCV-92 MCH-30.2 MCHC-32.9 RDW-12.7 RDWSD-42.7 Plt ___
___ 03:30PM BLOOD Neuts-83.7* Lymphs-9.1* Monos-5.8
Eos-0.5* Baso-0.5 Im ___ AbsNeut-9.65* AbsLymp-1.05*
AbsMono-0.67 AbsEos-0.06 AbsBaso-0.06
___ 03:30PM BLOOD ___ PTT-30.2 ___
___ 03:30PM BLOOD Glucose-171* UreaN-26* Creat-1.5* Na-138
K-4.6 Cl-101 HCO3-24 AnGap-13
___ 03:30PM BLOOD CK(CPK)-148
___ 03:30PM BLOOD CK-MB-5 proBNP-7597*
___ 03:30PM BLOOD cTropnT-0.90*
___ 03:34PM BLOOD Lactate-1.3
PERTINENT INTERVAL LABS
=========================
___ 06:49PM BLOOD cTropnT-0.96*
___ 02:00AM BLOOD CK-MB-4 cTropnT-1.30*
___ 09:05AM BLOOD CK-MB-4 cTropnT-1.24*
___ 05:43PM BLOOD proBNP-___*
___ 11:00PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
___ 11:00PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 11:00PM URINE Color-Straw Appear-Clear Sp ___
DISCHARGE LABS
=================
Chest CT ___
1. Bilateral small pleural effusions and bibasilar septal
thickening could
represent interstitial pulmonary edema.
2. Extensive coronary calcifications.
3. Mildly prominent mediastinal lymph nodes could be reactive.
4. 6 mm ground-glass micronodule in the right upper lobe.
RECOMMENDATION(S): For an incidentally detected single
ground-glass nodule smaller than 6mm, no CT follow-up is
recommended.
Cardiac Catheterization ___
right dominant.
LM: 90% stenosis in the distal segment.
LAD: 50% stenosis in the proximal segment. Diagonal - 70%
stenosis in
the proximal and mid segments.
LCx: 70% stenosis in the proximal and mid segments.
RCA: 80% stenosis in the mid segment.
Carotid Ultrasound ___
Right ICA <40% stenosis. Left ICA 50-69% stenosis.
.
___ 04:59AM BLOOD WBC-8.6 RBC-3.02* Hgb-8.9* Hct-28.3*
MCV-94 MCH-29.5 MCHC-31.4* RDW-12.9 RDWSD-44.1 Plt ___
___ 10:45AM BLOOD ___
___ 03:07AM BLOOD ___ PTT-30.3 ___
___ 04:59AM BLOOD UreaN-30* Creat-1.7* Na-135 K-4.1 Cl-98
HCO3-24 AnGap-13
___ 10:45AM BLOOD Glucose-274* UreaN-41* Creat-2.5* Na-135
K-4.4 Cl-99 HCO3-20* AnGap-16
___ 02:04AM BLOOD Glucose-147* UreaN-22* Creat-1.8* Na-137
K-5.1 Cl-106 HCO3-21* AnGap-10
___ 01:27AM BLOOD ALT-26 AST-33 LD(LDH)-245 AlkPhos-85
TotBili-0.4
Brief Hospital Course:
HOSPITAL COURSE
He ruled in for non-ST elevation myocardial infarction and was
started on Heparin drip. A transesophageal echocardiogram was
significant for LVEF 37%, moderate regional LV systolic
dysfunction with akinesis, hypokinesis of apex/distal inferior
walls, and overall moderately depressed LV function. A cardiac
catheterization demonstrated multivessel and left main coronary
artery disease. Surgical revascularization was recommended. He
underwent routine preoperative testing and evaluation. He
remained stable and was taken to the operating room on ___
for coronary artery bypass grafting x 5. Please see operative
note for further details. He tolerated the procedure well and
was transferred to the CVICU in stable condition for recovery
and invasive monitoring.
He weaned from sedation, awoke neurologically intact and was
extubated on POD 1. Beta blocker was initiated and he was
diuresed toward his preoperative weight. He remained
hemodynamically stable and was transferred to the telemetry
floor for further recovery. ___ followed for glucose
management. He was evaluated by the physical therapy service
for assistance with strength and mobility. By the time of
discharge on POD 5 he was ambulating freely, the wound was
healing, and pain was controlled with oral analgesics. He was
discharged to ___ on ___ in good condition with
appropriate follow up instructions. He will follow-up with
vascular surgery as an outpatient for staple removal.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. krill-om-3-dha-epa-phospho-ast 1,000-230-60 mg oral DAILY
4. Cialis (tadalafil) 20 mg oral daily PRN sexual activiy
5. Atorvastatin 40 mg PO QPM
6. Losartan Potassium 50 mg PO DAILY
7. Glargine 27 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
2. Furosemide 20 mg PO DAILY Duration: 7 Days
3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4)
hours Disp #*60 Tablet Refills:*0
4. Isosorbide Dinitrate 5 mg PO TID radial graft Duration: 6
Months
5. Metoprolol Tartrate 50 mg PO TID
6. Ranitidine 150 mg PO DAILY
7. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
8. Atorvastatin 80 mg PO QPM
9. Glargine 27 Units Breakfast
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
10. Aspirin 81 mg PO DAILY
11. Clopidogrel 75 mg PO DAILY
12. HELD- Cialis (tadalafil) 20 mg oral daily PRN sexual activiy
This medication was held. Do not restart Cialis until follow-up
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
- CAD
- NSTEMI
- HTN
- DM1 c/b diabetic neuropathy
- tob use
- PVD
- Carotid stenosis
- Dupuytren's contracture
- alcohol abuse
- OSA- does not use his CPAP
Past Surgical History:
s/p R ___ toe amputation ___
s/p L popliteal to DP bypass w ipsilateral transposed GSV
___
R eye surgery
R shoulder surgery
Discharge Condition:
Alert and oriented x3, non-focal
Ambulating, deconditioned
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema 1+
Discharge Instructions:
Prevena instructions
· The Prevena Wound dressing should be left on for a total
of 7 days post-operatively to receive the full benefit of the
therapy. The date of Day # 7 should be written on a piece of
tape on the canister to ensure that the nurse from the ___ or
___ facility knows when to remove the dressing and inspect the
incision. If the date is not written, please alert your nurse
prior to discharge.
· You may shower, however, please avoid getting the
dressing and suction canister soiled or saturated.
· You will be sent home with a shower bag to hold the
suction canister while bathing.
· If the dressing does become soiled or saturated, turn
the power off and remove the dressing. The entire unit may then
be discarded. Should this happen, please notify your ___ nurse,
so they may make plans to see you the following day to assess
your incision.
· Once the Prevena dressing is removed, you may wash your
incision daily with a plain white bar soap, such as Dove or
___. Do not apply any creams, lotions or powders to your
incision and monitor it daily.
· If you notice any redness, swelling or drainage, please
contact your surgeon's office at ___.
.
Please shower daily -wash incisions gently with mild soap, no
baths or swimming, look at your incisions daily
Please - NO lotion, cream, powder or ointment 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
Clearance to drive will be discussed at follow up appointment
with surgeon
No lifting more than 10 pounds for 10 weeks
Encourage full shoulder range of motion, unless otherwise
specified
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10672798-DS-17
| 10,672,798 | 25,570,042 |
DS
| 17 |
2155-07-12 00:00:00
|
2155-07-13 08:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
hydrochlorothiazide
Attending: ___
Major Surgical or Invasive Procedure:
___ Colonoscopy
___ ultrasound-guided biopsy of the spleen
attach
Pertinent Results:
ADMISSION LABS
==============
___ 03:50PM BLOOD WBC-8.5 RBC-3.13* Hgb-7.6* Hct-25.2*
MCV-81* MCH-24.3* MCHC-30.2* RDW-17.4* RDWSD-50.6* Plt ___
___ 03:50PM BLOOD Neuts-80.6* Lymphs-11.1* Monos-7.5
Eos-0.1* Baso-0.2 Im ___ AbsNeut-6.85* AbsLymp-0.94*
AbsMono-0.64 AbsEos-0.01* AbsBaso-0.02
___ 07:02PM BLOOD ___ PTT-27.1 ___
___ 03:50PM BLOOD Glucose-655* UreaN-23* Creat-1.5* Na-125*
K-5.1 Cl-94* HCO3-23 AnGap-8*
___ 03:50PM BLOOD ALT-<5 AST-6 LD(LDH)-180 AlkPhos-67
TotBili-0.2
___ 03:50PM BLOOD Albumin-3.2* Calcium-8.6 Phos-1.9* Mg-1.6
Iron-14*
___ 03:50PM BLOOD calTIBC-186* VitB12-735 Folate-9
Hapto-353* Ferritn-193 TRF-143*
___ 09:30PM BLOOD Ret Aut-0.8 Abs Ret-0.03
OTHER PERTINENT LABS
=====================
___ 07:05AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 07:05AM BLOOD CRP-75.2*
___ 06:41AM BLOOD b2micro-4.5*
MICRO
=====
___ 01:07AM URINE Color-Straw Appear-Hazy* Sp ___
___ 01:07AM URINE Blood-NEG Nitrite-POS* Protein-TR*
Glucose-1000* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5
Leuks-LG*
___ 01:07AM URINE RBC-3* WBC-64* Bacteri-FEW* Yeast-NONE
Epi-<1
___ 01:07AM URINE CastHy-1*
___ 1:07 am URINE Source: ___.
**FINAL REPORT ___
REFLEX URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING/OTHER STUDIES
=====================
___ LENIs
Nonocclusive deep venous thrombosis within proximal left
popliteal vein.
___ Knee XR
The osseous structures are diffusely demineralized. No acute
fracture or
dislocation. Small joint effusion. Minimal degenerative
spurring is seen in the medial compartment of the knee. Small
superior patellar enthesophyte. Mild prepatellar soft tissue
swelling. No suspicious lytic or sclerotic osseous
abnormalities. No radiopaque foreign body or concerning soft
tissue calcification.
___ CT head
1. Findings concerning for a likely chronic subdural hematoma
with hypo and
hyperdense components, over the left frontal convexity. The
hyperdense
components are age-indeterminate but cannot exclude an acute or
subacute
process.
2. There is a focal hypodensity at the inferior left frontal
lobe near the
gyrus rectus which is concerning for a prior contusion injury.
___ Neck U/s
Transverse and sagittal images were obtained of the superficial
tissues of the right neck. In the region of the patient's
palpable abnormality, there is a normal-appearing lymph node
measuring up to 0.2 cm in short axis. No other abnormalities
are detected in the right neck.
___ CT Head
Stable small subdural hematoma along the left frontal cerebral
convexity. No new sites of intracranial hemorrhage.
___ Colonoscopy
Diffuse friability, granularity, erythema, and ulceration in
rectum compatible with diversion colitis. Segmental continuous
edema, erythema, erosion, friability, exudate, and granularity
with contact bleeding noted in colon from ostomy to 40cm. There
was sparing from 40cm to the cecum. Terminal ileium normal.
___ CT A/p
1. Interval enlargement of the spleen with development of
multiple
hypoenhancing lesions measuring up to 2.5 cm concerning for
infiltrative
process such as lymphoma or in the spectrum of extramedullary
hematopoiesis.
Differential diagnosis includes abscesses
___ CT Chest
1. No evidence of intrathoracic malignancy.
2. Small bilateral pleural effusions with associated compressive
atelectasis.
3. Please refer to separate report of CT abdomen and pelvis
performed on the
same day for description of the subdiaphragmatic findings.
___ SPLEEN ULTRASOUND
Multiple hypoechoic variable-sized rounded splenic lesions.
These lesions are amenable to ultrasound-guided biopsy.
___ Cytogenetics Tissue: SPLEEN
Chromosome analysis was not possible because the culture set up
from this splenic lesion core biopsy did not produce mitotic
cells.
DISCHARGE LABS
==============
CBC/COAGS
___ 06:54AM BLOOD WBC-4.7 RBC-3.22* Hgb-8.2* Hct-27.4*
MCV-85 MCH-25.5* MCHC-29.9* RDW-22.3* RDWSD-68.5* Plt ___
___ 06:54AM BLOOD ___ PTT-66.7* ___
CMP
___ 06:54AM BLOOD Glucose-153* UreaN-34* Creat-1.1 Na-135
K-5.2 Cl-99 HCO3-26 AnGap-10
___ 06:54AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.2
OTHER NUTRITION
___ 03:50PM BLOOD calTIBC-186* VitB12-735 Folate-9
Hapto-353* Ferritn-193 TRF-143*
DIABETES
___ 07:02AM BLOOD %HbA1c-8.5* eAG-197*
HEPATITIS
___ 07:05AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
OTHER
___ 06:41AM BLOOD b2micro-4.5*
Brief Hospital Course:
TRANSITIONAL ISSUES
===================
[ ] Discharge Hgb 8.2
[ ] Discharge Cr 1.1
[ ] Discharged on warfarin, though displayed poor understanding
of dosing of medication. Please closely follow his INR. Next INR
should be drawn on ___. He will require 3 months of
anticoagulation as provoked DVT (___). INR on discharge
2.0.
[ ] He has a history of medication noncompliance with his
diabetes regimen. ___ was consulted to try to simplify his
diabetes regimen, as detailed below. IF ___ follow up is
preferred, please contact ___ Central Appointment at (___) or email ___.
[ ] Please obtain repeat INR and FSBG on ___. We
discharged him on 7.5mg warfarin daily (for one week, please
adjust as indicated by INR), and added Repaglinide at dinnertime
to compensate for removal of dinnertime insulin.
[ ] Hep B nonimmune, so will need Hep B vaccine series
[ ] His spleen biopsy was nondiagnostic, and hematology oncology
recommended outpatient PET/CT scan. They have set up an
appointment and imaging time.
[ ] Can consider discontinuing PPI after 1 month (___)
if symptoms have resolved.
[ ] Need for tooth extraction, but is on warfarin now. Patient
has private dentist that he wants to see upon discharge.
Recommend at least 1 month of uninterrupted anticoagulation
(AC), though preferably should complete 3 month of AC and then
get dental procedure done. Patient should see outpatient dentist
post discharge and see how urgent this procedure is and what his
dentist recommends regarding timing off AC.
BRIEF HOSPITAL COURSE
======================
Mr. ___ is a ___ man with a history of type 2
diabetes, hypertension, large bowel obstruction s/p colostomy,
poor social support at home, deficiencies in cognitive
functioning, and recent traumatic subarachnoid hemorrhage who
presented with hyperglycemia, anemia with concern for
gastrointestinal bleed, and left lower extremity deep venous
thrombosis (DVT). For his DVT, he was started on a heparin drip
which was bridged to warfarin. He underwent colonoscopy with
biopsy, which showed pouchitis and colitis. He had a CT
abdomen/pelvis which showed multiple splenic lesions, which were
biopsied and nondiagnostic, prompting recommendation for further
outpatient work-up with hematology oncology. His diabetes
medication regimen was also optimized to maximize non-injectable
medications.
=============
ACUTE ISSUES
=============
#Provoked DVT
#Non-occlusive popliteal vein clot
Patient was found to have a non-occlusive popliteal vein clot,
considered provoked given recent hospitalization and prolonged
immobility. No evidence of pulmonary embolus. Given concern for
acute anemia, GIB with oozing colitis, risk of falls, and head
bleed, discussed anticoagulation with neurosurgery and GI teams
with plan to start heparin drip with subsequent coumadin bridge,
given easy reversibility of the latter. He was successfully
bridged to warfarin with 48 hour overlap period. Given history
of medication noncompliance with diabetes regimen, had
considered DOAC or Lovenox; however, neurosurgery, in the
context of head bleed, recommended against those agents, with
preference for warfarin, given easy reversibility. Will plan for
3 months of anticoagulation as provoked DVT.
#Iron Deficiency Anemia
#Gastrointestinal bleed
Patient admitted with Hgb 7.6, from 12.6 on ___, and
hematochezia. Patient was transfused as needed and remained
hemodynamically stable. Colonoscopy ___ showed pouchitis and
colitis up to cecum with terminal ileum sparing, with very
friable and oozing mucosa, concerning for IBD, and biopsy was
taken. Given cachexia/weight loss/lymphadenopathy and bright red
blood per rectum, there was also concern for malignancy;
however, no findings of mass seen on colonoscopy. CRP was
elevated at 75.2. Biopsy showed severely active chronic colitis,
without evidence of inflammatory bowel disease or malignancy. He
was placed on a proton pump inhibitor for a 1 month course, plan
to end ___.
#Severe Malnutrition
#Cervical Lymphadenopathy
#Splenic lesions
Patient was noted to have right-sided cervical lymphadenopathy
on exam. He has also had weight loss, which raises concern for
malignancy. He does also have poor dentition and supposed to get
teeth extracted so palpated LN could be reactive LAD. Neck U/s
on ___ showing normal-appearing LNs with no abnormality.
Colonoscopy did not show mass; it did show mucosal friability
and inflammation. CT A/P showed multiple hypoenhancing splenic
lesions measuring up to 2.5 cm concerning for infiltrative
process such as lymphoma or in spectrum of extramedullary
hematopoiesis. CT chest negative. LDH negative. Beta 2
macroglobulin mildly elevated. Splenic biopsy was inconclusive,
and hematology/oncology recommended outpatient PET/CT scan.
#Hyperglycemia
#Type 2 diabetes mellitus
Patient was admitted with significant hyperglycemia but no
evidence of DKA/HHS. He showed initial improvement with addition
of long acting insulin. Discharged home on Glargine 22u in the
morning and Repaglinide at breakfast and dinner.
#Tooth Pain
Patient reported significant left-sided dental pain. Poor
dentition on exam with gum tenderness, erythema, no clear
collection. Soft tissue swelling overlying. Patient needs teeth
extraction, but will defer to the outpatient. He completed a 5
day course of amoxicillin.
#H/o traumatic SAH
Patient has a small frontal SAH. Repeat imaging on admission and
upon reaching therapeutic heparin PTT was stable. No neurologic
deficits. Neurosurgery following, with discussion re:
anticoagulation as above.
CHRONIC ISSUES:
===============
#H/o VRE UTI, bacteroides vulgarsi bacteremia
#Asymptomatic Bacteriuria
At ___ in ___, he received 2 weeks of antibiotics. Urine
culture with >100K of GNR; however, remained asymptomatic and
therefore deferred treatment.
#Afib
Per report from ___ records. Patient has been in sinus rhythm.
He was anticoagulated as above.
#BPH
Patient continued on home meds
#CODE: full presumed
#CONTACT: Brother ___ ___
Pt seen and examined on day of discharge. Stable. >30 min
spent on d/c activities
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 12.5 mcg PO DAILY
2. CARVedilol 3.125 mg PO BID
3. Tamsulosin 0.4 mg PO QHS
4. Finasteride 5 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using novolog Insulin
7. Lisinopril 10 mg PO DAILY
8. Ferrous GLUCONATE 240 mg PO DAILY
9. Simethicone 120 mg PO QID:PRN constipation
10. Docusate Sodium 100 mg PO BID
11. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO TID
RX *acetaminophen 650 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
2. Lidocaine Viscous 2% 15 mL PO TID:PRN tooth pain
RX *lidocaine HCl [Lidocaine Viscous] 2 % take 15mL three times
a day as needed Disp ___ Milliliter Milliliter Refills:*0
3. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
4. Pantoprazole 40 mg PO Q24H Duration: 8 Days
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*7
Tablet Refills:*0
5. Repaglinide 0.5 mg PO BIDWM
take at breakfast and at dinner with food
RX *repaglinide 0.5 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
6. Warfarin 7.5 mg PO DAILY16 leg clot
RX *warfarin 2.5 mg 3 tablet(s) by mouth once a day Disp #*21
Tablet Refills:*0
7. Glargine 22 Units Breakfast
RX *blood sugar diagnostic ___ Aviva Plus test strp] use
with glucose meter Disp #*100 Strip Refills:*0
RX *insulin glargine [Lantus Solostar U-100 Insulin] 100 unit/mL
(3 mL) AS DIR 22 Units before BKFT; Disp #*2 Package Refills:*0
RX *blood-glucose meter ___ Aviva Plus Meter] use as
directed Disp #*1 Each Refills:*0
RX *lancets ___ Softclix Lancets] as directed once a day
Disp #*100 Each Refills:*0
8. Docusate Sodium 100 mg PO BID
9. Ferrous GLUCONATE 240 mg PO DAILY
10. Finasteride 5 mg PO DAILY
11. Levothyroxine Sodium 12.5 mcg PO DAILY
12. Lisinopril 10 mg PO DAILY
13. MetFORMIN (Glucophage) 1000 mg PO BID
RX *metformin 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
14. Simethicone 120 mg PO QID:PRN constipation
15. Tamsulosin 0.4 mg PO QHS
16. HELD- CARVedilol 3.125 mg PO BID This medication was held.
Do not restart CARVedilol until you speak with your primary care
provider about why you were taking this medication.
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSES
=================
Gastrointestinal bleed
Deep venous thrombosis
Splenic Lesions
SECONDARY DIAGNOSES
====================
Type II Diabetes
Hypertension
History of subarachnoid hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were noted to have high blood sugars and low blood counts
in clinic.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had a colonoscopy to look into your gut which showed
inflammation. We also took a sample of the tissue in your
colon, which did not show cancer or inflammatory bowel disease
that would require further treatment.
- You were found to have a blood clot in your leg. You were
placed on blood-thinning medications to treat this.
- You also underwent full body imaging, given recent weight
loss. Based on this imaging, we took a sample of your spleen,
which was inconclusive. Because of this, we strongly recommend
that you continue to meet with our hematology/oncology team and
undergo imaging per their recommendation.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please continue to take all of your medications and follow-up
with your appointments as listed below. It is very important
that you take the warfarin and insulin every day as prescribed.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10673450-DS-9
| 10,673,450 | 29,538,861 |
DS
| 9 |
2176-10-11 00:00:00
|
2176-11-26 19:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
History obtained through prior notes/signout. No contact info is
listed.
.
Mr. ___ is a ___ year old man with reported h/o epilepsy, not
currently on AEDs (was on them in past) and EtOH abuse who
presented to ___ ED s/p fall with head laceration. Patient was
at his friend's house yesterday, noted to be walking and
talking, then stopped and fell to the ground. He hit his head
and had LOC. He was brought in to the ED by EMS.
.
In the ED, initial vs were: 98 109 138/80 18 89%. The patient
was initially AOx2, following some commands, +tremor on exam,
c/o CP, back pain, and abdominal pain. Labs notable for anion
gap 21, sOsms 287, stox and utox negative. CXR, CT head, Cspine,
and torso with no e/o acute process. Patient then noted to be
tachycardic to the 140-150s, tremulous, and was increasingly
confused. EKG with sinus tach. Patient was given 4L IVF, Ativan
10mg for concern for EtOH withdrawal. Given increasing lethargy,
patient was intubated for airway protection. Neuro was consulted
for possible seizure activity: limited exam given that the
patient was sedated with benzos. They will re-evaluate. Vitals
prior to transfer: P ___ BP 116/101 RR 16 O2sat 96% on the vent.
L facial laceration was sutured.
.
On admission to the MICU, the patient was intubated and sedated,
not following commands. Has since had labs which are remarkable
only for mild hypokalemia and elevated AST (41) and CBC showing
thrombocytopenia to 101. Negative tox screen. Has been on CIWA
protocol but not scoring. Neuro has recommended 24 hour EEG for
seizure workup. Has had negative CT head and C-spine. CXRs
unremakarkable. CT ___ showed fatty liver, as well as
lesions in the lung and pancreas. He was extubated this AM, and
has since had stable vital signs except for mild tachycardia.
Vitals on transfer: T 98.6 BP 116/81 P 85 RR 16 SaO2 93% RA.
.
On the floor, vitals are stable. Pt is AAOx1 (to person but not
place or time. He states he is from ___ and that his real
name is ___. He is unsure why he was hospitalized, but
states he was previously in prison at ___. Also states he
gets his care out of ___. Says he has had
prior seizures after discontinuing alcohol use. Denies
agitation, hallucinations, headache, tremor, sweating, chest
pain, abdominal pain, nausea.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
?seizure disorder
EtOH use
?emphysema
?lung cancer
Social History:
___
Family History:
unknown
Physical Exam:
On admission:
Vitals: T: BP: 116/81 P: 85 R: O2:
General: disheveled elderly AAOx1, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear. Poor dentition.
No tongue lacerations.
Neck: supple, JVP not elevated, no LAD
Lungs: Wheezes present bilaterally, L>R. No rales or 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
Skin: no petichiae, palmar erythema, spider angiomata.
Neuro: AAOx1 (to person, not place or time). Blind in left eye.
discharge exam:
97.4 118/70 97 18 95% RA
GEN: disheveled, dressed in jeans and jacket, malodorous male,
NAD. AOx3. Bruise and bandage over L eye
Gait: normal gait
Pertinent Results:
ADMISSION LABS:
WBC-6.3 RBC-5.12 Hgb-16.9 Hct-50.1 MCV-98 MCH-32.9* MCHC-33.7
RDW-14.3 Plt ___ PTT-24.5 ___
Glucose-149* UreaN-7 Creat-0.8 Na-139 K-4.1 Cl-96 HCO3-22
AnGap-25*
ALT-35 AST-41* LD(___)-191 CK(CPK)-175 AlkPhos-87 TotBili-0.6
___ 10:52AM BLOOD cTropnT-<0.01
___ 07:38PM BLOOD CK-MB-3 cTropnT-<0.01
___ 03:22AM BLOOD CK-MB-4 cTropnT-<0.01
Albumin-4.0 Calcium-7.3* Phos-2.6* Mg-2.1
ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
ABG: Type-ART Rates-/___ Tidal V-500 FiO2-100 pO2-421* pCO2-49*
pH-7.35 calTCO2-28 Base XS-0 AADO2-240 REQ O2-48 -ASSIST/CON
Intubat-INTUBATED
Urine: unremarkable
.
DISCHARGE LABS:
WBC-7.8# RBC-4.82 Hgb-15.8 Hct-46.5 MCV-97 MCH-32.7* MCHC-33.9
RDW-13.9 Plt ___
Calcium-9.1 Phos-2.8 Mg-2.1
.
CT HEAD WITHOUT CONTRAST (___): There is no acute
hemorrhage, edema, mass effect, or territorial infarction. There
are large bilateral and symmetrical areas of encephalomalacia in
the frontal lobes as well as in the temporal lobes which may be
from prior traumatic injury. The ventricles are enlarged
consistent with atrophy. There is periventricular white matter
hypodensity likely related to small vessel ischemic disease.
There is mucosal thickening in the right maxillary sinus. The
remainder of the visualized paranasal sinuses, mastoid air cells
and middle ear cavities are clear. There is no fracture. There
is left frontal soft tissue swelling.
IMPRESSION:
1. No acute intracranial process.
2. Encephalomalacic areas in the frontal and temporal lobes
likely from prior trauma.
3. Right maxillary mucosal thickening.
.
CT C-SPINE WITHOUT CONTRAST (___): Contiguous axial imaging
was obtained through the cervical spine without the
administration of intravenous contrast material. Coronal and
sagittal reformats were completed.
FINDINGS: There is no acute fracture, prevertebral soft tissue
swelling or
malalignment. Vertebral body heights and disc spaces are
preserved. No
critical central canal stenosis is present. There is minimal
right paraseptal emphysema as well as a calcified punctate
granuloma in the right lung apex. Soft tissues are unremarkable.
IMPRESSION: No acute fracture or malalignment.
.
CT CHEST, ABDOMEN AND PELVIS WITH CONTRAST (___):
1. No acute intrathoracic or intra-abdominal traumatic process.
No acute
fracture.
2. Two 5mm right upper lobe pulmonary nodules. Recommend
follow-up CT in 12 months.
3. Two hypodense lesions in the head and uncinate process of the
pancreas,
which could represent the sequela of prior pancreatitis, but a
cystic neoplasm cannot be excluded (ie. side branch IPMN).
Recommend MRCP for further characterization.
4. Fatty liver.
5. Diverticulosis without diverticulitis.
6. Enlarged prostate gland.
.
CHEST X-RAY (___), evaluation of pt after intubation: The ET
tube tip is 5-7 cm above the carina. The airways are delineated
unremarkably. Lungs are essentially clear except for minimal
bibasilar atelectasis. No appreciable pleural effusion or
pneumothorax noted.
.
CHEST X-RAY (___): ET tube is in standard placement and a
nasogastric tube would need to be advanced 5 cm to be sure all
side ports are in the stomach. Aside from a band of atelectasis
in the left lower lung, lungs are clear. Heart size is normal
and there is no pleural abnormality.
.
EEG (___): PENDING
Brief Hospital Course:
Mr. ___ is a ___ year old man with ?h/o seizures and EtOH use
with ?withdrawal seizures, who was admitted s/p fall, found to
be lethargic and tachycardic, intubated for airway protection in
the ED after several doses of Ativan.
.
#. s/p Fall: differential diagnosis is syncope vs seizure vs
arrhythmia. As patient admits to seizures after alcohol
discontinuation (although he is unreliable historian), most
likely is alcohol withdrawal seizures, although EtOH level
negative by the time he arrived in the ED. Unclear time of last
ingestion and UTox unremarkable. Did not score on CIWA in the
ICU, however was given ativan in the ED out of concern for
seizures. He was found to be incontinent with altered mental
status on admission, also suspicious for seizure. CT head
unremarkable for acute intracranial process or subdural hematoma
___ fall. Cardiac enzymes negative. Neuro was consulted and did
not recommend any antiepileptic drugs. EEG showed no evidence of
epileptiform activity. Pt will require suture removal 1 week
from admission.
.
#. AMS: Unclear etiology - patient AOx2 on admission, then
increasingly altered and lethargic in the ED. Concern for EtOH
and ?post-ictal state as above. CT head unremarkable.
Electrolytes, stox, and utox, also unremarkable. Afebrile, UA
and CXR negative for infection. This could be his baseline. He
currently states he is "Superman"; delusions/hallucinations
could be indicative of underlying psych disorder vs. delirium
tremens (the latter less likely as has no autonomic instability
right now). Patient was seen by psychiatry, who recommended
depakote and low dose haldol, which patient agreed to take. Pt
threatening to leave hospital AMA, and psych consult found that
he was competent to make decisions and did not meet ___
qualifications.
.
#. Respiratory Failure: Patient intubated in the ED for airway
protection. No acute process on CXR or CT chest. Extubated the
day after admission with no persistent respiratory following
extubation.
.
#. Tachycardia: Patient with sinus tachycardia to the 140-150s
in the ED. Given Ativan in the ED for possible withdrawal due to
EtOH history and tremor on exam. Also given a total of 4L IVF,
which may have helped as well as tachycardia subsequently
improved. No s/s to suggest infection at this time. Not hypoxic,
so PE less likely.
.
#. h/o EtOH: patient has h/o EtOH use, and states that he has
had seizures after discontinuing EtOH in past (unreliable
historian). Unknown whether he has had delirium tremens. He was
started on MVI, thiamine, folate and placed on a CIWA scale but
did not require any benzos. Social work was consulted, found
patient has no family/friend support. He does go to ex-wife's
home monthly to pick up disability checks.
.
#. Thrombocytopenia: Platelet count 101, with unclear baseline.
Consider chronic liver disease given h/o EtOH and fatty liver
seen on CT torso. Possible med effect, but unknown medication
list. No s/s of active bleeding at this time. AST elevated.
.
#. Pulmonary nodules: 2 5mm pulmonary nodules seen on CT chest.
Pt endorses history of "mild lung cancer". Will need f/u CT.
.
#. Pancreatic hypodensities: ?prior pancreatitis vs malignancy.
Will need non-urgent MRCP for further characterization.
Medications on Admission:
unknown
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
5. haloperidol 1 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
1. Fall
Secondary diagnosis:
2. Alcohol withdrawal
3. Alcoholism
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital after hitting your head and
passing out. You went to the ICU and were briefly put on a
ventilator to protect your airway. After you were extubated, you
had confusion. You were seen by neurology for your seizures, who
did an EEG which did not show seizures or epileptiform
discharges. You were also seen by psychiatry who recommended
that you take haldol, which could help organize your thoughts
better.
Please go to the emergency room or an acute care clinic in 5
days to have the stitches removed from your face.
These NEW medications were started for you:
- Haldol 1 mg by mouth every 12 hours
- Thiamine 100 mg by mouth daily
- Folic acid 1 mg by mouth daily
- Multivitamin 1 tablet by mouth daily
- Famotidine (Pepcid) 20 mg by mouth every 12 hours
Thiamine, folic acid and multivitamin are important for you to
take because of your heavy alcohol use. Pepcid is also important
to use while you continue to use alcohol, as it will help
protect your stomach so that your stomach will not bleed.
Followup Instructions:
___
|
10673457-DS-14
| 10,673,457 | 24,634,897 |
DS
| 14 |
2130-06-09 00:00:00
|
2130-06-13 17:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending: ___
Chief Complaint:
Shortness of breath and chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization - ___
History of Present Illness:
Mr. ___ is a ___ year old male with a history of asthma,
HTN, diabetes, CAD s/p anterolateral STEMI s/p PTCA,
catheter-thrombectomy and DES to proximal LCX-OM (___) and
unrevascularized rPDA who presents to with shortness of breath
and central chest pain. The patient was seen the in the ED on
___ for an asthma exacerbation. After an unremarkable chest
xray, whe was given albuterol inhaler and prescribed 60mg
Prednisone for 4 day course. The patient notes that after
receiving nebulizers and a dose of steroids in the ED, his
symptoms of shortness of breath began to improve. He took his
2nd dose of steroids on ___ and continued the albuterol as
needed. However, by the evening of ___ the patient began
having allergy symptoms with itching eyes and soon re-developed
had progressive shortness of breath and soon developed chest
pain over left chest wall. He was on the phone with his daughter
who is a ___ and recommended that he go to the hospital. The
patient tried his albuterol inhaler with no benefit. He was
brought in by EMS and received a neb enroute with some
improvement. Pt says the neb improved his breathing and chest
pain pain.
ED COURSE
In the ED intial vitals were: ___ 24 100% while
receiving nebulizers treatment. CXR showed no signs pneumonia or
intrathoracic process. The labs were sent off and significant
for
Trop-T: 03:00 <0.01 -> 0:600 0.04 -> 12:00 0.05
D-Dimer: 2191
143 | 104 | 24 AGap=16
--------------<173
4.5 | 28 | 1.3
13.8>12.9/39.8<255
Orders:
___ 03:24 IH Albuterol 0.083% Neb Soln 1 NEB
___ 03:24 IH Ipratropium Bromide Neb 1 NEB
___ 04:09 PO Acetaminophen 650 mg
___ 07:28 PO Aspirin 324 mg
___ 09:31 PO/NG Atorvastatin 80 mg
___ 09:31 IV Heparin 1000 UNIT
___ 09:32 IV Heparin gtt
___ 12:18 IH Albuterol 0.083% Neb Soln 1 NEB
___ 12:42 IH Ipratropium Bromide Neb 1 NEB
The patient was given duonebs and Tylenol with noticeable
improvement. However, given the patients cardiac history and
persistent chest pain with mildly elevated troponin, cardiology
was consulted. EKG shows signs of old posterior MI, no dynamic
changes. Recent stress TTE inconclusive due to low workload.
Cardiology recommended ASA, high potency statin, unfractionated
gtt, check D-dimer and admit to cardiology. The patient received
a CTA prior to admission which although a suboptimal study,
showed no obvious signs of PE.
The patient denies any fevers, chills, runny nose, coughing,
nausea/vomiting, abdominal pain or new leg swelling.
Vitals on transfer: 97.7 81 ___ 97% RA
On the floor patient reports still having some difficulty
breathing, noting he has audible wheezing. The patient states he
feels some numbness/tingling sensation in his right arm and left
finger tips.
Past Medical History:
- CAD s/p anterolateral STEMI s/p PTCA, catheter-thrombectomy,
and DES to proximal LCX-OM ___
- HTN
- HLD
- diabetes
- asthma
- anxiety
- depression
- hypogonadism
.
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
Weight: 94.3
VS: T=98.1 BP=144/98 HR=101 RR=20 O2 sat= 100% on RA
GENERAL: Well developed middle age male in NAD. Oriented x3.
Mood, affect appropriate. Understands ___ to some extent,
prefers ___. Audble wheezing during conversation, but able
to speak in full sentences.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP slightly elevated.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: Diffuse expiratory wheezing throughout.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM:
=========================
Vitals: 98.3 ___ 97%RA
Discharge Weight: 89.0
GENERAL: Well developed middle age male in NAD. Oriented x3.
Mood, affect appropriate. Understands ___ to some extent,
prefers ___.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP slightly elevated.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: mild expiratory wheezing L>R
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
ADMISSION LABS:
===============
___ 03:00AM BLOOD WBC-13.8* RBC-4.22* Hgb-12.9* Hct-39.8*
MCV-94 MCH-30.6 MCHC-32.4 RDW-13.5 RDWSD-46.6* Plt ___
___ 03:00AM BLOOD Neuts-81.0* Lymphs-8.5* Monos-9.6
Eos-0.0* Baso-0.1 Im ___ AbsNeut-11.20* AbsLymp-1.17*
AbsMono-1.33* AbsEos-0.00* AbsBaso-0.01
___ 03:32PM BLOOD ___ PTT-41.5* ___
___ 03:00AM BLOOD Glucose-173* UreaN-24* Creat-1.3* Na-143
K-4.5 Cl-104 HCO3-28 AnGap-16
___ 03:00AM BLOOD cTropnT-<0.01
___ 06:09AM BLOOD cTropnT-0.04*
___ 12:17PM BLOOD D-Dimer-2191*
DISCHARGE LABS:
=================
___ 06:45AM BLOOD WBC-8.9 RBC-4.38* Hgb-13.4* Hct-40.4
MCV-92 MCH-30.6 MCHC-33.2 RDW-13.5 RDWSD-46.3 Plt ___
___ 06:45AM BLOOD ___ PTT-26.4 ___
___ 06:45AM BLOOD Glucose-108* UreaN-17 Creat-0.9 Na-136
K-4.0 Cl-102 HCO3-25 AnGap-13
___ 06:45AM BLOOD Calcium-9.7 Phos-3.8 Mg-2.0
PERTINENT FINDINGS:
=====================
Labs:
------
___ 03:00AM BLOOD cTropnT-<0.01
___ 06:09AM BLOOD cTropnT-0.04*
___ 12:17PM BLOOD cTropnT-0.05*
___ 09:05PM BLOOD CK-MB-5 cTropnT-0.03*
___ 06:15AM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-356*
___ 12:17PM BLOOD D-Dimer-2191*
IMAGING/STUDIES:
-----------------
++CXR ___:
IMPRESSION:
No evidence of pneumonia.
++CTA Chest ___:
IMPRESSION:
Slightly suboptimal evaluation of subsegmental pulmonary
arterial branches due to contrast bolus timing and patient
respiratory motion. Otherwise, no evidence of pulmonary
embolism. No acute aortic abnormality.
++Dobutamine Stress Test:
INTERPRETATION: ___ yo man with HL, HTN and DM, multiple
admission
for asthma exacerbation, h/o anterolateral MI and s/p PCI to
LCx, no
intervention to 60-70% rPDA was referred to evaluate his
shortness of
breath and an atypical chest discomfort. The patient was
administered 15
mcg/kg/min of Dobutamine over 4 minutes. No chest, back, neck or
arm
discomforts were reported by the patient during the procedure.
No
significant ST segment changes were noted. The rhythm was sinus
with
occasional isolated VPBs and one ventricular couplet. One APB
was noted.
Resting systolic and diastolic hypertension with an appropriate
hemodynamic response noted with the Dobutamine infusion.
IMPRESSION: No anginal symptoms or ischemic ST segment changes.
Echo
report sent separately.
EHCHO REPORT FOR STRESS TEST:
The patient received intravenous dobutamine beginning at 15
mcg/kg/min, increasing to 30mcg/kg/min and 45 mcg/kg/min in 3
minute stages plus 0 mg atropine. In response to stress, the ECG
showed no ST-T wave changes (see exercise report for details).
There is resting systolic and diastolic hypertension with normal
blood pressure and heart rate responses to stress.
Resting images were acquired at a heart rate of 95 bpm and a
blood pressure of 164/108 mmHg. These demonstrated regional left
ventricular systolic dysfunction with akinesis of the posterior
wall and hypokinesis of the lateral wall and apex. The remaining
segments contracted wel (LVEF = 49 %). Right ventricular free
wall motion is normal. There is no pericardial effusion. Doppler
demonstrated trace aortic regurgitation and trace mitral
regurgitation with no aortic stenosis or significant resting
LVOT gradient.
At low dose dobutamine [15mcg/kg/min; heart rate 90 bpm, blood
pressure 194/104 mmHg], there was mild augmentation of all left
ventricular segments except the akinetic posterior wall. At
mid-dose dobutamine [30 mcg/kg/min; heart rate 164 bpm, blood
pressure 194/104 mmHg), there was appropriate augmentation of
all left ventricular segments escept the akinetic posterior
wall. At peak dobutamine stress [45 mcg/kg/min and 0 mg
atropine; heart rate 150 bpm, blood pressure 194/104 mmHg), no
new regional wall motion abnormalities were identified. Baseline
abnormalities persist.
IMPRESSION: no ECG changes with 2D echocardiographic evidence
old posterior infarct and also with lateral wall viability.
++Cardiac Catheterization ___:
Dominance: Right
LMCA: The LMCA had minimal luminal irregularities.
LAD: The proximal LAD had mild plaquing. D1 was a large vessel.
The adjacent bifurcating D2 had diffuse disease to 60% in the
longer lateral pole. The mid LAD had a 50% stenosis after D2.
The distal
LAD was mildly tortuous before wrapping slightly around the
apex. Flow in the LAD was pulsatile and slightly delayed,
consistent with microvascular dysfunction.
Ramus intermedius: The ramus intermedius was tortuous with
delayed pulsatile flow consistent with microvascular
dysfunction.
LCX: The proximal CX was retroflexed and supplied an atrial
branch and a tiny OM1. The stent in the major OM2 was patent;
the distal OM2 had diffuse disease to 40% with delayed pulsatile
flow consistent
with microvascular dysfunction. The jailed distal AV groove CX
had a mild stenosis just after the OM and was diminutive
supplying a small LPL.
RCA: The RCA had mild plaquing proximally to 30%. The mid RCA
had mild luminal irregularities. Flow in the RCA was pulsatile,
consistent with microvascular dysfunction. There was mild
plaquing in the distal RCA before the RPDA. The proximal RPDA
was 35% stenosed after its first lateral sidebranch (improved
from the prior angiogram). The RPDA gave off additional
laterally oriented sidebranches. There was a branching RPL
vessel. The distal AV groove RCA extended well up the LV and
supplied an atrial/nodal branch.
IMPRESSION:
1. Moderate single vessel CAD in the LAD with diffuse
atherosclerosis and diffuse slow flow consistent with
microvascular dysfunction. Patent prior stent in the major OM
and improved proximal RPDA lesion.
2. Normal left ventricular diastolic function
Brief Hospital Course:
ASSESSMENT AND PLAN
Mr. ___ is a ___ year old male with a history of asthma,
HTN, diabetes, CAD s/p anterolateral STEMI s/p PTCA,
catheter-thrombectomy and DES to proximal LCX-OM (___) and
unrevascularized rPDA who presents to with shortness of breath
and central chest pain.
# CORONARIES: CAD s/p anterolateral STEMI s/p PTCA,
catheter-thrombectomy and DES to proximal LCX-OM (___) and
unrevascularized rPDA
# PUMP: LVEF 50-55% in ___, Mild regional dysfunction c/w CAD,
with low-normal global systolic function. Mildly dilated
thoracic aorta
# RHYTHM: Sinus Rhythm
# Chest pain/NTSEMI: patient is s/p anterolateral STEMI s/p
PTCA, catheter-thrombectomy and DES to proximal LCX-OM (___)
and un-revascularized rPDA since then. TTE from ___ showed mild
regional dysfunction c/w CAD, with low-normal global systolic
function. Stress test ___ was limited by poor functional
exercise capacity, unable to achieve target heart rate.
Troponins were noted to be mildly elevated from
0.01->0.04->0.05->0.03. The patient received full dose ASA in ED
and started on heparin gtt. CTA showed no signs of PE and no EKG
changes consistent with R heart strain to explain chest pain in
setting of shortness of breath. Further discussion with the
patient with ___ interpreter revealed that the chest pain
had been going on for >1mo, not thought to be cardiac, more
muscular in nature. Patient was not taking any of his heart
medications due to cost and lack of insurance. Patient underwent
a dobutamine stress test (due to asthma exacerbation and
previous failure to complete exercise stress test) which showed
wall motion changes, however he underwent a cardiac cath on ___
that showed no stentable disease (though diffuse CAD was
present, no culprit lesions). Ultimately, he was restarted on
metoprolol tartrate 50mg BID, 81mg daily, and Lisinopril 10mg
daily.
# CAD s/p DES to proximal LCX-OM on ___: Has a history of
STEMI in ___, with DES in proximal LCX-OM and unrevascularized
rPDA. Stress test showed wall motion changes, appears chronic,
cath showed diffuse CAD with no indication for intervention as
discussed above. Patient was continued ASA 81mg daily and
atorvastatin 80mg daily.
#Asthma Exacerbation: Severe wheezing was treated with
completion of 5 days of 40mg prednisone burst as well as
frequent duonebs. Air movement and breathing improved
significantly at time of discharge. Metoprolol was initially
held in the setting of asthma flare and given dobutamine stress
test. Was discharged on ___ 10mg daily and inhaler
changed to symbicort and ventolin due to decreased cost.
Counseled on importance of daily symbicort use.
___: Patient presented with SCr of 1.3 (baseline Cr 1.0,
admission 1.3). Suspect in setting of poor PO intake. Received
contrast with CTA chest, and was given 1L post hydration. SCr
quickly improved to 0.9. Once SCr normalized patient was
restarted on lisinopril.
# HTN: Patients systolic blood pressures were in the 140s. After
asthma exacerbation was resolved, patient was started on
metoprolol tartrate 50mg BID and lisinopril 20mg daily. These
medications were selected due to cost (on target $4
prescriptions).
# HLD: Continued home atorvastatin 80mg daily.
# DM: Patient denies having diabetes. A1c from ___ is 6.9
indicating diabetes. Patient was on metformin, however, he no
longer has it on his medication list. He was started on sliding
and scale and diabetic diet in hospital, though he often refused
insulin. Patient was not discharged on diabetic medications, but
was counseled on diabetes.
#Seasonal Allergies: Stable, worse during ___ and ___.
Patient was given Diphenyhydramine 25mg daily PRN.
#GERD: Symptoms were stable. Continued home omeprazole 20mg
daily.
#Medication compliance: Patient states that he has been unable
to take his listed medications due to cost which insurance has
not been covering. PACT team worked with patient to find
medications available at ___, ___, and ___ for
significantly cheaper. See med changes under medication list.
TRANSITIONAL ISSUES:
====================
[ ] Will need ongoing support for medication adherence
[ ] He will need to follow up with Financial Assistance
[ ] ___ need titration of his anti-hypertensives as an
outpatient
[ ] A1c 6.9 in ___, not on diabetes medication, should
likely begin regimen.
# CODE: Full
# CONTACT: ___ ___
HCP ___daughter) ___
___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Albuterol Inhaler 1 PUFF IH Q6H:PRN sob
3. Vitamin D 800 UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
3. Montelukast 10 mg PO DAILY
RX *montelukast 10 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
5. Vitamin D 800 UNIT PO DAILY
6. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
RX *budesonide-formoterol [Symbicort] 160 mcg-4.5 mcg/actuation
1 puff inhaled twice a day Disp #*3 Inhaler Refills:*0
7. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
8. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
9. Metoprolol Tartrate 50 mg PO BID
RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
10. Albuterol Inhaler 1 PUFF IH Q6H:PRN sob
RX *albuterol sulfate [Ventolin HFA] 90 mcg 1 inhaled Q6 Disp
#*3 Inhaler Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
=========
- Asthma Exacerbation
- Coronary artery disease
- Acute kidney injuries
SECONDARY:
============
- Hypertension
- Hyperlipidemia
- Seasonal allergies
- GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to ___ for
shortness of breath.
WHAT HAPPENED DURING YOUR HOSPITAL STAY?
=========================================
- You were found to be in an asthma exacerbation and were
continued on oral steroids and nebulizers. Your breathing
quickly improved.
- You were noted to have elevated cardiac enzymes, concerning
for heart attack. You were started on heparin, a blood thinner,
and this quickly resolved. You underwent a stress test that
showed your heart movement was irregular under stress.
- You underwent a cardiac catheterization which showed coronary
artery disease, but no areas that required a stent to be placed.
- You were re-started on your outpatient medications. We
recognized that your medications are expensive, so we have
converted them to reflect medications that are cheaper through
___, ___ and ___ pharmacy.
- Once you were deemed stable, you were discharged.
WHAT SHOULD YOU DO FOLLOWING DISCHARGE?
=========================================
- You should continue to take your medications as prescribed.
- You should follow up with your primary care doctor,
___, and Pulmonologist (lung doctor)
It was pleasure taking care of you during hospital stay. if you
have any questions about the care you received, please do not
hesitate to ask.
Sincerely,
Your Inpatient ___ Cardiology Team
Followup Instructions:
___
|
10673550-DS-14
| 10,673,550 | 23,645,243 |
DS
| 14 |
2129-10-13 00:00:00
|
2129-10-14 22:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Mechanical fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with PMH of HTN who presents s/p fall and an episode of
fecal incontinence. Patient fell while preparing food in the
kitchen. She caught herself on a chair and soiled herself.
Patient denies associated dizziness, LOC, or injury. Per
grandson, she has been soiling herself more frequently lately.
Presented to ED with clothes covered in feces and poor hygeine.
In the ED, initial vital signs were T 97.4, P 77, BP 110/80, R
18, O2 sat 99% on RA. CT head showed no acute intracranial
abnormality. CT spine showed no fracture. CXR showed no acute
thoracic injury.
On the floor, T 97.9, HR 76, BP 134/84, RR 20, O2 sat 95% RA.
Patient reports feeling fine. She does not know why she is here
and repeatedly asked to go home.
Past Medical History:
Hypertension
Gout
Diverticulosis
Mild asthma
Seasonal allergies
Osteoarthritis
Social History:
___
Family History:
Lung cancer (mother and brother, both deceased).
Physical Exam:
Admission Physical Exam
Vitals: T 97.9, HR 76, BP 134/84, RR 20, O2 sat 95% RA
General: AAOx1 (self), NAD
HEENT: NCAT, sclera anicteric, PERRLA, MMM, oropharynx clear
Neck: Supple, no JVD, no LAD
CV: RRR, nl S1/S2, no MRG
Lungs: CTAB, no wheezes/rales/rhonchi
Abdomen: Soft, NTND, reducible ventral hernia, normal bowel
sounds
GU: Deferred
Ext: Non-tender, no cyanosis/clubbing/edema, pulses 2+
Neuro: AAOx1, CN II-XII grossly intact, moving all extremities
Skin: No obvious lesions
Discharge Physical Exam
Vitals: T 97.6, HR 77, BP 150/78, RR 18, O2 sat 100% RA
General: AAOx1-2 (self, knows she is in hospital), NAD
HEENT: NCAT, sclera anicteric, PERRLA, MMM, oropharynx clear
Neck: Supple, no JVD, no LAD
CV: RRR, nl S1/S2, no MRG
Lungs: CTAB, no wheezes/rales/rhonchi
Abdomen: Soft, NTND, reducible ventral hernia, normal bowel
sounds
GU: Deferred
Ext: Non-tender, no cyanosis/clubbing/edema, pulses 2+
Neuro: AAOx1, CN II-XII grossly intact, moving all extremities
Skin: No obvious lesions
Pertinent Results:
Admission labs:
___ 04:20PM BLOOD WBC-11.1 7 Hgb-13.2 Hct-40.4 Plt ___
___ 04:20PM BLOOD ___ PTT-38.1 ___
___ 04:20PM BLOOD Glucose-116 UreaN-31 Creat-1.5 Na-144
K-7.9 Cl-107 HCO3-23 AnGap-22
Discharge labs:
___ 07:15AM BLOOD WBC-8.2 Hgb-12.2 Hct-37.9 Plt Ct-98
___ 07:15AM BLOOD Glucose-77 UreaN-22* Creat-1.0 Na-143
K-4.0 Cl-106 HCO3-27 AnGap-14
Imaging:
CT head: No acute intracranial abnormality. Age-related volume
loss and
mild chronic small vessel ischemic disease.
CT spine: 1. No fracture. Mild anterolisthesis of C5 on 6,
likely degenerative. Severe multilevel degenerative changes with
multilevel moderate spinal canal and neural foraminal narrowing.
If there is high clinical concern for cord injury, recommend an
MRI. Partially calcified left thyroid nodule.
CXR:
No acute intrathoracic injury identified. Markedly tortuous
aorta with aneurysmal dilatation of the ascending aorta. This
can be further assessed with a dedicated chest CTA.
Brief Hospital Course:
___ yo F with PMH of HTN who presents s/p fall and an episode of
fecal incontinence.
Acute Problems
# Mechanical fall. Patient presented to the ED after falling and
soiling herself at home. CT head/spine obtained in the ED showed
no acute intracranial abnormality or fracture. CXR showed no
acute thoracic injury or evidence of pneumonia. Patient was
admitted to Medicine for further evaluation. On arrival to the
floor patient was afebrile and vital signs were within normal
limits. ___ and OT were consulted. Both expressed concern
regarding patient's mobility, fall risk, and ability to perform
ADLs. Given risk of delirium in rehab facility, decision was
made with family to send patient home with 24 hour care.
#Tortuous aorta: Chest imaging notable for tortuous aorta with
aneurysmal dilation. This can be further evaluated with CT chest
and echocardiogram.
#left thyroid nodule: noted on CT c-spine. This can be further
evaluated with thyroid ultrasound.
#Degenerative cervical disk disease: Noted on CT c-spine.
Chronic Problems
# Hypertension. Not on antihypertensive medications at home.
Patient normotensive to slightly hypertensive while admitted.
# Gout. Home allopurinol and NSAIDs held while admitted. Patient
did not c/o pain.
# Chronic renal failure. Baseline Cr is 1.7 per PCP. Patient's
Cr was at or below this level for the entirety of her
hospitalization.
Transitional Issues
- incidental findings on imaging that can be better evaluated
with additional studies.
1. CT c-spine showed calcified thyroid nodule - can be better
assessed with thyroid ultrasound.
2. CXR showed tortuous aorta with aneurysmal dilation - can be
better assessed with CT chest and echocardiogram.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. flurbiprofen *NF* 100 mg Oral BID
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. flurbiprofen *NF* 100 mg Oral BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Mechanical fall
Discharge Condition:
AAOx1 (self). Ambulation with assistance or with use of a
cane/walker. Patient denies pain at this time.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you while you were a patient at
___. You were admitted after
falling at home. During your time with us you were evaluated by
physical therapy and occupational therapy. Both were concerned
about your mobility and risk of falling going forward. Because
of this, you are being sent home with nursing care.
Followup Instructions:
___
|
10673897-DS-12
| 10,673,897 | 25,627,647 |
DS
| 12 |
2191-06-26 00:00:00
|
2191-06-26 19:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dizzyness, abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ ___ speaker presents to ED with abdominal pain x 1
month that acutely worsened yesterday. The patient reported that
her pain was localized to the suprapubic area and RLQ. She
reported feeling "gassy" and that her pain was worse after
meals, but constant. She denies any n/v/fevers/constipation. She
also states that over last 5 months has had episodes where her
abdomen becomes distended (gassy) and then releives when she
passes gas. She also reports a 1 month hx of BRBPR with bowel
movements as well as a recent 2week period with heavy bleeding.
Patient also asked for possible domestic violence counseling.
The interview is limited by the patients ___.
In the ED, initial VS 98.0, 96, 111/75, 18, 100% on RA. The
patient's initial work-up was not revealing of a potential
source of her abdominal pain. The patient was initially
discharged from the ED, but while walking out of the ED, the
patient felt dizzy and fell towards the nurse walking with her.
She was lowered to the ground by the nurse, but never had any
LOC or headstrike. EKG showed NSR with HR 74, no evidence of
ischemic changes. Vitals remained stable. The patient was
subsequently brought back to the ED.
The patient reports that her LMP ___ and that her periods have
been very heavy - it lasted 2 weeks and had multiple blood
clots. She denies any hematuria or changes in her stools. Labs
at this time notable for Hct 27.1 (MCV 75, baseline in ___
~35), ALT 41, nml lipase, nml Chem7. HCG negative. UA not
consistent with UTI. Recent ___ clinic visit for BV with normal
pelvic exam at that time. The patient was subsequently admitted
to medicine for management of her symptomatic anemia.
On the floor, vitals were stable, but the patient is extremely
anxious. Continues to have significant abdominal pain that she
localizes to the RLQ/suprapubic area.
Past Medical History:
Appendectomy
Anxiety
Fatty liver
Asthma
Vitamin D deficiency
Anemia
Social History:
___
Family History:
unremarkable
Physical Exam:
ADMISSION PE:
Vitals - T:97.3 BP: 110/70 HR: 85 RR: 18 02 sat:100RA
GENERAL: Pt in bed in significant distress
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, tender to palp in suprapubic area,
possible mass palpated in suprapubic region, may have been full
bladder, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PE:
Vitals - T:97.7 BP: 110/65 HR: 80 RR: 18 02 sat:100RA
GENERAL: Pt in bed in significant distress
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, tender to palp in suprapubic area,
possible mass palpated in suprapubic region, may have been full
bladder, no hepatosplenomegaly
RECTAL: Guiac negative. Minimal stool in vault. No masses.
Visible external hemorrhoids
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
___ 01:40AM BLOOD WBC-6.7 RBC-3.63*# Hgb-8.1* Hct-27.1*
MCV-75* MCH-22.3* MCHC-29.8* RDW-19.2* Plt ___
___ 01:40AM BLOOD Neuts-54.5 ___ Monos-6.2 Eos-3.8
Baso-0.4
___ 01:40AM BLOOD Glucose-140* UreaN-16 Creat-0.5 Na-139
K-3.7 Cl-106 HCO3-23 AnGap-14
___ 01:40AM BLOOD ALT-41* AST-27 AlkPhos-48 TotBili-0.2
___ 01:40AM BLOOD Albumin-4.4
___ 08:45AM BLOOD Iron-10*
___ 08:45AM BLOOD calTIBC-507* ___ Ferritn-6.9*
TRF-390*
___ 12:30AM URINE Color-Yellow Appear-Hazy Sp ___
___ 12:30AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
___ 12:30AM URINE RBC-0 WBC-5 Bacteri-FEW Yeast-NONE Epi-3
DISCHARGE LABS:
___ 05:40AM BLOOD WBC-4.2 RBC-3.60* Hgb-7.6* Hct-26.2*
MCV-73* MCH-21.2* MCHC-29.2* RDW-19.2* Plt ___
___ 05:40AM BLOOD Glucose-116* UreaN-16 Creat-0.5 Na-139
K-4.4 Cl-108 HCO3-24 AnGap-11
___ 05:40AM BLOOD Calcium-8.6 Phos-3.3 Mg-1.9
MICRO:
Urine Cx negative
STUDIES/IMAGING:
Pelvic US ___
The uterus is enlarged, measuring 16.6 x 8.1 x 9.3 cm. A
dominant fibroid in
the uterine body is 7.6 x 6.4 x 7.4 cm. The endometrium is
distorted by the
fibroid, measuring 7mm in thickness. The right and left ovaries
appear normal,
better seen transabdominally. There is no adnexal mass or free
fluid.
IMPRESSION:
Fibroid uterus. Normal ovaries.
Brief Hospital Course:
___ presents to ED with abdominal pain x 1 month and
symptomatic anemia.
ACUTE ISSUES THIS ADMISSION:
# Symptomatic anemia: Dx: heavy menstrual bleeding from uterine
fibroid - Pt with microcytic anemia, admission Hgb 7.9 lower
than recent baseline of 10 in ___. Appears to be ___ baseline
several years ago. US demonstrated 7cm urterine fibroid. OB/Gyn
consulted and recommended outpateint follow up for removal of
fibroid. There was some concern for aditional GI bleeding,
however guiac negative this admission and obvious external
hemorrhoids which would be consistent with patient's description
of rectal bleeding only with wiping and no dark colored stools.
Patient refused blood transfusion this admission despite
recommendation of primary team. She was discharged on iron and
was scheduled to have a repeat CBC drawn in 1 week and was to
f/u with her PCP regarding her anemia. She will f/u with
gynecology for definitive treatment of her fibroid which will
likely resolve her anemia.
# Domestic violence - patient asked to speak with counseler and
said that a gun was pointed towards her. SW met with the patient
this admission and contacted the ___ Violence Prevention
and Recovery to meet with pt. They will follow up with the
patient after discharge
TRANSITIONAL ISSUES:
# anemia - f/u with PCP to check blood work. Definitive
treatment with removal/tx of fibroid with ob/gyn as outpatient.
Pt started on iron supplementation and stool softeners to
prevent constipation and future hemorrhoidal bleeding this
admission.
Medications on Admission:
none
Discharge Medications:
1. Docusate Sodium 100 mg PO BID constipation
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
2. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
3. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides 8.6 mg 1 tab by mouth BID:PRN Disp #*60 Tablet
Refills:*0
4. Outpatient Lab Work
CBC (___) ICD 9 280.1 -Anemia - Fax results to:
___ Fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Dx:
-Uterine Fibroid
-Hemorrhoid
-Symptomatic Anemia
-Iron Deficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your
hospitalization. You were admitted for dizzyness and abdominal
pain. Your blood levels were quite low. We beleive this is
causing your dizzyness but you did not want to be transfused
this admission, despite our recomendations. You also were found
to have a large uterine fibroid which is likely causing most of
your blood loss. Your stool did not have any blood in it, but
you have some external hemmroids which may also have been
bleeding. Please follow up with your primary care doctor and the
gynecologist to treat your fibroid.
Sincerely,
Your ___ TEAM
Followup Instructions:
___
|
10674011-DS-11
| 10,674,011 | 20,436,269 |
DS
| 11 |
2148-01-14 00:00:00
|
2148-01-15 17:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Fosamax Plus D / atorvastatin / hydroxychloroquine
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS
===============
___ 11:52AM BLOOD WBC-6.6 RBC-4.82 Hgb-11.5 Hct-37.1
MCV-77* MCH-23.9* MCHC-31.0* RDW-17.5* RDWSD-44.7 Plt ___
___ 12:03PM BLOOD ___ PTT-33.6 ___
___ 11:52AM BLOOD Glucose-119* UreaN-17 Creat-0.6 Na-142
K-3.4* Cl-105 HCO3-24 AnGap-13
___ 11:52AM BLOOD ALT-20 AST-28 AlkPhos-115* TotBili-1.5
___ 11:52AM BLOOD Lipase-31
___ 11:52AM BLOOD cTropnT-<0.01
___ 11:52AM BLOOD Albumin-4.0 Calcium-9.3 Phos-3.9 Mg-2.1
___ 12:03PM BLOOD Lactate-1.7
DISCHARGE LABS
================
___ 07:37AM BLOOD WBC-7.2 RBC-4.34 Hgb-10.5* Hct-33.7*
MCV-78* MCH-24.2* MCHC-31.2* RDW-18.2* RDWSD-49.0* Plt ___
___ 07:37AM BLOOD ___ PTT-34.8 ___
___ 07:37AM BLOOD Glucose-111* UreaN-23* Creat-0.6 Na-141
K-3.6 Cl-105 HCO3-23 AnGap-13
___ 07:37AM BLOOD ALT-13 AST-20 LD(LDH)-242 AlkPhos-103
TotBili-1.0
___ 07:37AM BLOOD Albumin-3.3* Calcium-8.8 Phos-3.9 Mg-2.0
MICROBIOLOGY
=============
Urine Culture: No growth
Blood Culture: No growth
REPORTS
=======
___ CXR IMPRESSION:
Low lung volumes, which accentuate the bronchovascular markings.
Mild left base atelectasis, difficult to exclude component of
aspiration.
___ CT Head
IMPRESSION:
1. No acute intracranial hemorrhage.
2. Mild-to-moderate periventricular and subcortical white matter
disease.
3. Bilateral TMJ arthropathy.
___ RUQUS
DOPPLER EVALUATION:
The main portal vein is patent with hepatopetal flow.
The TIPS is patent and demonstrates wall-to-wall flow.
Portal vein and intra-TIPS velocities are as follows:
Main portal vein: 81.3 cm/sec, previously 18.8 cm/sec
Proximal TIPS: 79.9 cm/sec
Mid TIPS: 103 cm/sec
Distal TIPS: 73.2 cm/sec
Flow within the left portal vein is towards the TIPS shunt.
There is slow
flow within the right anterior portal vein though there is
luminal flow
directed towards the TIPS. Appropriate flow is seen in the
hepatic veins and
IVC.
Brief Hospital Course:
PATIENT SUMMARY
===============
This is a ___ year old female w/ scleroderma, PBC c/b esophageal
varices and portal gastropathy s/p TIPS on ___, who
presented with progressive confusion after her TIPS procedure.
She was diagnosed with acute hepatic encephalopathy, and treated
with lactulose and rifaxamin. Her mental status cleared, and she
was able to return home.
TRANSITIONAL ISSUES
===================
[] This was Ms. ___ first presentation of hepatic
encephalopathy after her TIPS procedure. She will be discharged
on lactulose 30mL TID, which should be adjusted to aim for ___
bowel movements per day, and rifaxamin 550mg daily to prevent
this from happening again.
[] She should have follow up with hepatology in the next 2
weeks. This has been scheduled for ___.
[] She presented on 81mg ASA, with unclear indication. Her PCP
should consider whether this medication is indicated. It was
held upon discharge.
[] Set up with AllCare home ___ at time of discharge.
#CODE: Full (presumed)
#CONTACT: ___ | Sister | ___
ACUTE ISSUES:
=============
#AMS
The patient presented roughly one week after TIPS procedure with
confusion and mild asterixis on exam. Initially, there was some
concern for infection in the form of pneumonia, and she was
given IV ceftriaxone empirically as there was some question of
consolidation on CXR. However, she showed no infectious signs or
symptoms, and antibiotics were discontinued. An ultrasound of
the TIPS graft showed patent TIPS, without evidence of ascites.
She was started on lactulose and rifaxamin, with marked
improvement in mental status. She will be discharged on
lactulose and rifaxamin.
#Primary Biliary Cholangitis without cirrhosis s/p TIPS
She continued on home Ursodiol 300 mg PO TID.
CHRONIC ISSUES:
===============
#HTN: Continued on home HCTZ 25mg q daily
#Chronic follicular lymphoma: She follows with Dr. ___,
___ stable.
#Chronic cough: Cetirizine was held in the setting of confusion
#GERD: Continued home Omeprazole 40 mg PO DAILY
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cetirizine 10 mg PO DAILY
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. Omeprazole 40 mg PO DAILY
4. Ursodiol 300 mg PO TID
5. Vitamin D 5000 UNIT PO DAILY
6. azelastine 0.15 % (205.5 mcg) nasal BID
7. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q2H:PRN
8. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Lactulose 30 mL PO TID
RX *lactulose 10 gram/15 mL (15 mL) 30 ml by mouth three times a
day Disp #*1 Bottle Refills:*0
2. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
3. rifAXIMin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
4. azelastine 0.15 % (205.5 mcg) nasal BID
5. Cetirizine 10 mg PO DAILY
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. Omeprazole 40 mg PO DAILY
8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q2H:PRN
9. Ursodiol 300 mg PO TID
10. Vitamin D 5000 UNIT PO DAILY
11. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until you see your primary care provider
___:
Home With Service
Facility:
___
___ Diagnosis:
FINAL DIAGNOSIS
================
Hepatic Encephalopathy
Primary Billiary Cholangitis
SECONDARY DIAGNOSES
===================
Hypertension
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital because you were acting confused
after your TIPS procedure.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were diagnosed with "Hepatic Encephalopathy". This was
caused by a build up of toxins that are normally cleared by your
liver.
- You were given medications called lactulose and rifaximan to
help you get rid of built-up toxins. These are excreted in your
stool.
- An ultrasound of your TIPS showed that everything was normal.
- You were feeling much better, and were ready to leave the
hospital.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to take all of your medications and follow-up
with your appointments as listed below. You should adjust the
amount of lactulose you take so that you have ___ bowel
movements per day. If you are becoming more confused, you should
take additional doses of lactulose.
We wish you the ___!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10674024-DS-3
| 10,674,024 | 24,846,770 |
DS
| 3 |
2114-01-15 00:00:00
|
2114-01-15 13:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: PLASTIC
Allergies:
Penicillins / latex / lidocaine
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___ guided drainage of infected abdominal wall seroma, ___
History of Present Illness:
___ PMHx morbid obesity s/p gastric bypass with significant
weight loss s/p abdominoplasty with panniculectomy at ___
___ (___) p/w abdominal abscess. She relates
increased abomdinal pain and girth since the abomdinal drain was
accidentally dislodged and discontinued several weeks ago. Over
the last several weeks and most strikingly over the last ___
days, she had increased pain and fever and presented to ___
___ where a CT abdomen/pelvis showed a possible abscess at
her surgical site. She also notes that a new opening ___ her
skin appeared at ___. Given concern for sepsis,
she was transferred to ___ from ___. She
received zosyn prior to transfer to ___. En route to ___,
she was hypotensive and received 1 L IVF.
___ the ED, initial vitals: 98 115 95/54 20 100% Nasal Cannula
Exam was notable for: Palpable fluid collection at the lower
abdomen under the surgical incision, breakage of surgical
incision at the right lateral aspect which is actively draining
serosanguineous fluid.
Plastic surgery saw the pt ___ the ED and felt that she had a
likely infected seroma that would be best managed with
intravenous antibiotics and drainage by interventional
radiology.
Labs were notable for: WBC 16.6 (96% PMN) INR 1.3 Lactate 1.6
On transfer, vitals were: 97.4 85 102/52 20 100% Nasal Cannula
On arrival to the MICU, pt endorses diffuse abdominal pain.
Past Medical History:
Morbid Obesity s/p bypass surgery s/p abdominoplasty with
panniculectomy
MEN1
Social History:
___
Family History:
MEN 1 ___ several siblings, mother, maternal aunts, maternal
uncles.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98.0 BP: ___ P: 97 R: 24 O2: 100% RA
WEIGHT: 70.4 kg
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: No JVD
LUNGS: CTAB anteriorly
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, diffusely tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly.
Right flank with erythema and two round skin ulcers. The
superior ulcer is draining serosanguinous material. Left flank
with large palpable fluid collection that is tender to
palpation.
EXT: WWP, no ___ edema
SKIN: Right flank erythema with two incisions, superior
incision draining serosanguinous fluid
NEURO: Grossly intact, moving all extremities
Pertinent Results:
==ADMISSION LABS==
___ 09:10PM BLOOD WBC-16.6* RBC-3.67* Hgb-8.0* Hct-27.2*
MCV-74* MCH-21.8* MCHC-29.4* RDW-15.9* RDWSD-42.3 Plt ___
___ 09:10PM BLOOD Neuts-96* Bands-0 Lymphs-3* Monos-1*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-15.94*
AbsLymp-0.50* AbsMono-0.17* AbsEos-0.00* AbsBaso-0.00*
___ 09:10PM BLOOD Hypochr-1+ Anisocy-OCCASIONAL Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL
___ 09:10PM BLOOD ___ PTT-26.6 ___
___ 09:01PM BLOOD Lactate-1.6
Imaging:
US-guided drainage of seroma ___
IMPRESSION:
Successful US-guided placement of an ___ pigtail catheter
into the
collection. Samples was sent for microbiology evaluation.
Removal of 100 cc purulent fluid.
CXR ___:
IMPRESSION:
No acute cardiopulmonary process.
MICRO:
___ 12:43 pm ABSCESS Source: abscess.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
FLUID CULTURE (Preliminary):
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___
___.
ANAEROBIC CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary):
ACID FAST SMEAR (Preliminary):
ACID FAST CULTURE (Preliminary):
__________________________________________________________
___ 9:00 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 8:39 pm SWAB Source: R abd wall.
**FINAL REPORT ___
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
__________________________________________________________
___ 8:55 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
Brief Hospital Course:
___ PMHx morbid obesity s/p gastric bypass with significant
weight loss s/p abdominoplasty with panniculectomy at ___
___ (___) p/w abdominal abscess.
# Sepsis: On admission, pt meets ___ SIRS criteria (leukocytosis
and tachycardia). She also has a presumed source (abdominal
wound). She also had hypotension that was fluid responsive.
# Infected Seroma: Pt s/p recent abdominal surgery. She has had
increased abdominal pain and girth over the last several days.
She now has a leukocytosis, tachycardia, and mild hypotension.
Imaging from ___ is suggestive of an infectious
intraabdominal collection. Plastic surgery saw the pt ___ the ED
and recommended medical management with IV antibiotics and ___
drainage of collection. ___ drained 100 cc's of pus from her
left-sided collection, wound swab growing MRSA, pigtail left ___
place. Her antibiotics were narrowed to vancomycin alone, PICC
was placed given difficult access. She received Oxycodone 2.5 mg
PO Q4H PRN pain. She was called out to the plastic surgery
service. Given that she continued to have pain ___ her RLQ, a
bedside I&D was performed. She tolerated this procedure well and
her exam continued to improve. ID recommended 1 week of IV
vancomycin followed by 1 week of Bactrim PO which was ordered.
# S/p Gastric Bypass: Continued tums, B12, MVI, calcitriol
At the time of discharge, the patient was doing well, afebrile
with stable vital signs, tolerating a regular diet, ambulating,
voiding without assistance, and pain was well controlled. She
was discharged home with ___ services.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 500 mg PO TID W/MEALS
2. Vitamin B-12 (cyanocobalamin (vitamin B-12)) 1,000 mcg
sublingual DAILY
3. Calcitriol 0.25 mcg PO DAILY
4. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Calcitriol 0.25 mcg PO DAILY
2. Calcium Carbonate 500 mg PO TID W/MEALS
3. Multivitamins 1 TAB PO DAILY
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Do not drink alcohol or drive while taking this medication.
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4H: PRN Disp #*30
Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Vitamin B-12 (cyanocobalamin (vitamin B-12)) 1,000 mcg
sublingual DAILY
7. Acetaminophen 325-650 mg PO Q6H:PRN pain
8. Vancomycin 1000 mg IV Q 12H
RX *vancomycin 500 mg 2 vials IV every twelve (12) hours Disp
#*28 Vial Refills:*0
9. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 7 Days
to start after vancomycin is complete
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
infected seroma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for treatment for an infected
seroma. Your wounds required incision and drainage as well as ___
drain placement. Please follow these discharge instructions:
Followup Instructions:
___
|
10674383-DS-18
| 10,674,383 | 26,902,133 |
DS
| 18 |
2173-10-28 00:00:00
|
2173-10-28 19:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
gabapentin
Attending: ___
Chief Complaint:
SYncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with PMH of HLD, CHF, HTN, DM on metformin, and GERD who
presents with 2 episodes of loss of consciousness. At 1:50 ___,
she was eating lunch with her friend and said she needed
restroom. While sitting and had not tried to stand up, she
became
unresponsive and her head rolled back. She had some mild jerks
but did not fall out of the chair. This lasted about 30 minutes
she came to. After about a minute, she had a similar episode of
unresponsiveness with minimal jerking. When she woke this time
after about 30 seconds, she was alert and oriented to talk to
the
EMTs. She denies any tongue biting, urinary or fecal
incontinence. She did not fall out of her chair at any at this
point and had no head strike. Prior to these episodes, the only
complaint she has is that she felt like she needed to use the
restroom. She denied any headache, vision changes, palpitation,
lightheadedness, nausea, vomiting, vision changes or
diaphoresis.
She also denied any chest pain or shortness of breath. Since
then, she has no complaints. She has had no more episodes. She
has not changed her medications recently and has been taking
them
as prescribed and denies any missed dosages.
She thinks that she is still taking amlodipine even though this
was recently held by her PCP since she reported dizziness.
She denies any recent fevers, chills, nausea or vomiting. She
denies any cough, sick contacts, or been outside the country
recently. She is otherwise been in her normal state of health.
She had one episode of syncope "years ago" when she was sitting
on the toilet, had used it and then fell off the toilet seat
without injury. Her am BS have been in the ___ and have been
well
controlled.
Past Medical History:
DIABETES MELLITUS- last HgbA1c = 7.4 % in ___
HYPERLIPIDEMIA
HYPERTENSION
GASTROESOPHAGEAL REFLUX
Social History:
SOCIAL HISTORY:
Country of Origin: ___
Marital status: Widowed
Children: Yes: 3 sons
Lives with: Alone; Other: son lives downstairs
Lives in: Apartment
Work: ___
Sexual activity: Denies
Domestic violence: Denies
Tobacco use: Never smoker
Smoking cessation No
counseling offered:
Alcohol use: Rare
Recreational drugs Denies
(marijuana, heroin,
crack pills or
other):
Wallks with a cane. No recent falls. She and her son order out.
Her son sometimes cooks. She pays her own bills. She does not
drive.
Family History:
FAMILY HISTORY:
Confirmed with patient on admission
Relative Status Age Problem Onset Comments
Mother ___ ___ LUNG CANCER (pt unsure)
Father ___ ___ PROSTATE CANCER
PGM Deceased BREAST CANCER
Physical Exam:
98.0 PO 186 / 75 L Sitting 73 16 98 Ra
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
No carotid bruits b/l
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 05:24AM BLOOD WBC-5.5 RBC-3.94 Hgb-11.6 Hct-35.6 MCV-90
MCH-29.4 MCHC-32.6 RDW-12.8 RDWSD-42.5 Plt ___
___ 05:24AM BLOOD Glucose-143* UreaN-20 Creat-1.2* Na-140
K-4.2 Cl-104 HCO3-26 AnGap-10
CT HEAD:
FINDINGS:
There is no evidence of acute territorial
infarction,hemorrhage,edema, or
mass. There is prominence of the ventricles and sulci
suggestive of
involutional changes. Periventricular, subcortical, and
deepwhite matter
hypodensities are nonspecific, but likely reflect the sequela of
chronic
microvascular infarction.
There is no evidence of fracture. Small osteoma arises from the
inner table
of the right frontal bone. The visualized portion of the
paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The
visualized portion
of the orbits are unremarkable apart from bilateral lens
replacements. Dense
atherosclerotic calcifications are noted within the cavernous
carotid
arteries.
IMPRESSION:
No acute intracranial abnormality. No acute fracture.
ECHO:
IMPRESSION: Mild symmetric LVH with normal biventricular
systolic function. Moderately
thickened AV leaflets without AS. Mildly thickened MV with
trivial MR. ___ MAC. Mild pulmonary
hypertension.
Brief Hospital Course:
SUMMARY/ASSESSMENT:
Ms. ___ is a ___ female with a past medical history
and findings noted above who presents with syncope after eating
while sitting.
ACUTE/ACTIVE PROBLEMS:
# SYNCOPE
Pt presented with 2 episodes of syncope with a story most
consistent with vasovagal syncope. Her orthostatic vitals were
normal. Her telemetry was unremarkable except for 1st degree
AVB. Her Echo did not show concerning findings (mild LVH with
normal LV function, mild pulm HTN). Cardiology was consilted who
felt that she had vasovagal syncope. Suspicion for seizures was
low. Pt was advised to review medications with her PCP.
#HYPOGLYCEMIA, T2DM:
- pt admitted with with BG - 52 upon arrival to the floor which
improved with
eating. Held metformin on admission, resumed at discharge.
CHRONIC/STABLE PROBLEMS:
#HTN:
continued Lisinopril and b-b and amlodipine. Lasix was briefly
held while pt was given IVF. Pt advise to review BP meds with
PCP.
# HLD: continue statin/asa
#ANEMIA: iron continued
#GERD: continue PPI.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. CARVedilol 6.25 mg PO BID
5. Vitamin D 1000 UNIT PO DAILY
6. Ferrous GLUCONATE 324 mg PO TID
7. Furosemide 20 mg PO 3X/WEEK (___)
8. Lisinopril 20 mg PO DAILY
9. MetFORMIN (Glucophage) 500 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. amLODIPine 2.5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. amLODIPine 2.5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. CARVedilol 6.25 mg PO BID
6. Ferrous GLUCONATE 324 mg PO TID
7. Furosemide 20 mg PO 3X/WEEK (___)
8. Lisinopril 20 mg PO DAILY
9. MetFORMIN (Glucophage) 500 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Vasovagal syncope
Hypertension
Type 2 DM
Discharge Condition:
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear ___,
___ were admitted after an episode of unresponsiveness. Your
blood pressure and heart rate and rhythms were monitored and
were found to be stable. ___ were seen by the cardiology team
who did not feel like your symptoms were related to your heart.
An Ultrasound of your heart was also normal. Your symptoms were
likely due to a vasovagal response (when ___ faint because your
body overreacts to certain triggers). Make sure to stay
hydrated!
Sincerely,
Your ___ team.
Followup Instructions:
___
|
10674420-DS-15
| 10,674,420 | 23,203,507 |
DS
| 15 |
2177-06-08 00:00:00
|
2177-06-08 17:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Prochlorperazine / citalopram / indomethacin / Celebrex / Cipro
/ bupropion / Aleve / Amitriptyline / lisinopril / amlodipine
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o male with sig PMHx of COPD, chronic lower back pain s/p
L4-S1 fusion, spinal cord stimulator and chronic opioid therapy
p/w severe low back pain, fatigue admitted from ED for O2
saturation of 88% on room in ED.
Mr. ___ follows with pain management clinic here at ___
(Dr. ___. Patient has implanted SCS
device that is scheduled to be removed in near future in order
to obtain an MRI. He states that he has felt exhausted over the
past few days despite being in bed all day. He decided to go
the ED because he was worried he might decide to hurt himself
and texted
his sister as much. She encouraged him to go the ED. Pain has
recently been an ___ bialteral lower back not extending down
legs, with associated left midline (not saddle) upper leg
numbness. He is currently on acetaminophen/oxycodone, has been
trialed on methadone but had terrible constipation. He is so
tired of the pain he stated in the ED he wanted to his mouth on
the tail pipe of his car. He was ___ which was lifted
prior to admission.
ROS notable for weight loss of 15 lb in last six months, chronic
sinus infection followed by ENT. Of note his last outpatient
pain note includes a transient O2 saturation of 88%. He has no
productive cough at baseline however he has chronic green nasal
discharge, no dyspnea. He denies any pleuritic chest pain,
hemoptysis, recent immobility, or hormonal therapy. He denies
any
saddle anesthesia, bowel or bladder incontinence.
In the ED:
=========
Initial vitals were:
99.5 107 146/94 18 95% RA
Exam notable for:
GEN: NAD, A&Ox3. Fatigued affect.
HEENT: NC/AT
CV: normal RRR, no MRG
PULM: CTAB
ABD: soft non tender non distended
EXT: ___ muscle strength b/l. Decreased sensation to anterior
left thigh. Severe TTP lower back at level of L4-S1.
Labs notable for:
144 99 23* 70
----------------
4.8 30 0.9
7.1 16.0 192
------------------
48.4
LFTs: wnl
UA: neg
Urine Cx: pnd
Urine Oxycodone: Positive
Imaging was notable for:
CTA Chest ___
IMPRESSION:
1. No evidence of pulmonary embolism or acute thoracic aortic
abnormality.
2. Diffuse bronchial wall thickening and subsegmental mucous
impaction compatible with chronic airway inflammation.
3. Mild mediastinal and hilar lymphadenopathy, possibly
reactive.
4. Moderate to severe centrilobular emphysema with probable mild
superimposed interstitial lung disease.
5. No intrathoracic malignancy definitively identified.
6. 4 mm right lower lobe pulmonary nodule. Please see
recommendations for follow-up imaging.
CXR PA and Lat ___
IMPRESSION:
Increased interstitial opacities bilaterally could suggest a
chronic interstitial abnormality in a background of moderate
emphysema, findings which would be better assessed with
dedicated nonemergent CT of the chest. Patchy opacities in the
lung bases likely reflect atelectasis. No definite intrathoracic
malignancy identified.
Patient was given:
Home COPD Medications: Albuterol Neb, Ipratropium Bromide Neb,
Tiatropium Bromide,
Prednisone 40mg X2
IV Morphine 2mg X1, IV Dilaudid 1mg X1, Oxycodone 10mg X 2,
Oxycodone 15mg X2
Upon arrival to the floor, patient reports no back pain,
confirms no dyspnea. Endorses occasional passive suicidal
ideation, denies currently, denies active suicidal ideation or
intent.
Past Medical History:
BACK PAIN
TOBACCO ABUSE
HYPERCHOLESTEROLEMIA
INSOMNIA
DEPRESSION
CHRONIC LOW BACK PAIN
HYPERTENSION
PRE-DIABETES
ERECTILE DYSFUNCTION
TACHYARRHYTHMIA S/P ABLATION
DEPRESSION (talk therapy with Dr. ___ ascribes this to
dealing with his son)
Social History:
___
Family History:
Father died at ___ secondary to EtOH cirrhosis,
Mother died at ___ from lung cancer (never smoker)
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
VITAL SIGNS: 97.9 PO 133 / 83 R Lying 75 20 90 Ra
GENERAL: tired appearing man in NAD lying on left side
HEENT: no scleral icterus, mucosa moist
NECK: no adenopathy
CARDIAC: RRR, +s1s2, ___ holosystolic murmur
LUNGS: hyperresonant, CTAB
ABDOMEN: NABS, no tenderness to palpation
EXTREMITIES: warm well perfused, distal pulses 2+
NEUROLOGIC: CN2-12 intact, motor ___ SLR negative bilateral,
decreased sensation over L L3 distribution only
SKIN: actinic keratosis scattered on face, no Hoover's sign,
mild yellowing of nails without clubbing
=======================
DISCHARGE PHYSICAL EXAM
=======================
VS: T:97.4 BP:119 / 79 HR:88 RR:18 SaO2:94 ra
GENERAL: Tired appearing man lying in bed and speaking with me
comfortably
HEENT: Pupils approx 6mm, equal and reactive. Mucuous membranes
moist.
CARDIAC: S1/S2 regular, ___ holosystolic murmur, no s3/s4
LUNGS: Mildly prolonged expiratory phase, hyperresonant, clear
to auscultation
ABDOMEN: Non-tender, non-distended, bowel sounds auscultated.
Foreign body palpated on L lower back.
EXTREMITIES: Warm well perfused, distal pulses 2+, no edema.
NEUROLOGIC: CN2-12 intact, straight leg raise negative
bilaterally, decreased sensation on L anterior thigh,
SKIN: Actinic keratosis on face
Pertinent Results:
============================
ADMISSION LABORATORY RESULTS
============================
___ 11:18PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS*
cocaine-NEG amphetmn-NEG oxycodn-POS* mthdone-NEG
___ 11:18PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 05:18PM GLUCOSE-70 UREA N-23* CREAT-0.9 SODIUM-144
POTASSIUM-4.8 CHLORIDE-99 TOTAL CO2-30 ANION GAP-15
___ 05:18PM ALT(SGPT)-9 AST(SGOT)-16 ALK PHOS-102 TOT
BILI-0.4
___ 05:18PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
===========================
DISCHARGE/PERTINENT RESULTS
===========================
___ 05:50AM BLOOD WBC-8.6 RBC-4.63 Hgb-15.1 Hct-46.2
MCV-100* MCH-32.6* MCHC-32.7 RDW-13.6 RDWSD-49.9* Plt ___
============
MICROBIOLOGY
============
___ 11:18 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
=======
IMAGING
=======
--___ CHEST (PA & LAT)----
IMPRESSION:
Increased interstitial opacities bilaterally could suggest a
chronic
interstitial abnormality in a background of moderate emphysema,
findings which would be better assessed with dedicated
nonemergent CT of the chest. Patchy opacities in the lung bases
likely reflect atelectasis. No definite intrathoracic
malignancy identified.
--___ CTA CHEST----
IMPRESSION:
1. No evidence of pulmonary embolism or acute thoracic aortic
abnormality.
2. Diffuse bronchial wall thickening and subsegmental mucous
impaction compatible with chronic airway inflammation.
3. Mild mediastinal and hilar lymphadenopathy, possibly
reactive.
4. Moderate to severe centrilobular emphysema with probable mild
superimposed interstitial lung disease.
5. No intrathoracic malignancy definitively identified.
6. 4 mm right lower lobe pulmonary nodule. Please see
recommendations for
follow-up imaging.
RECOMMENDATION(S): For incidentally detected single solid
pulmonary nodule smaller than 6 mm, no CT follow-up is
recommended in a low-risk patient, and an optional CT in 12
months is recommend in a high-risk patient.
Brief Hospital Course:
=================
SUMMARY STATEMENT
=================
___ y/o male with sig PMHx of COPD, chronic lower back pain s/p
L4-S1 fusion, spinal cord stimulator and chronic opioid therapy
p/w severe low back pain, fatigue admitted from ED for O2
saturation of 88% on room in ED.
====================
ACUTE MEDICAL ISSUES
====================
# Chronic low back pain:
S/p spinal cord stimulator. Presented to ED with hope of
removal. Concerned that his low oxygen saturation would end up
being a contraindication to removal, and therefore wanted to
have the date of this procedure advanced. Spoke with Dr.
___ indicated this hypoxia would not be a
contraindication to removal, and he plans to proceed with
removal on the previously scheduled date of ___. No
red flag symptoms, no pain on evaluation upon arrival to floor.
He was continued on his home oxycodone regimen while
hospitalized. Also treated with acetaminophen. The patient had
run out of all home percoset, and according to ___, he was
written for a 30d supply 13 days ago. Discussed with patient the
need to have these prescriptions managed by his pain clinic, but
we did write him for a 5 day supply to bridge him to his next
appointment.
#Hypoxemia and COPD:
Appears at baseline on review of OMR, goal would be 88-92% on RA
for COPD. He reports intermittent compliance with inhalers but
no increased dyspnea nor sputum production. A CTA was negative
for PE, but did detect a 4mm incidental nodule in the RLL. The
patient expressed a particular concern that his hypoxemia would
present a contraindication to his spinal cord stimulator
removal, but this does not appear to be the case after
discussion with his pain specialist, Dr. ___. He was
continued on his home inhalers with oxygen saturations in the
high 80's to low 90's on room air.
#Depression:
In the ED, the patient expressed a plan of putting his mouth on
a tailpipe. At that time, he was put on ___, but this
morning was re-evaluated and thought not to meet ___ criteria
by the consulting psychiatry team. His medical team spoke to him
at length regarding this comment, and he insisted he does not
have any thoughts of not wanting to be alive, or any plan or
intent to harm himself. He did express some frustration and
hopelessness as his long history of back pain, that he can no
longer play golf, and also that he has struggled greatly to care
for his adult son who had addiction problems. He suggested part
of the reason he made this comment was to increase his
likelihood of hospitalization so that his back pain could be
addressed. I reaffirmed the difficulty of dealing with these
challenging situations. He said that if he was ever going to
hurt himself "I would have done it a long time ago." His
greatest support continues to be his wife. He does not have any
weapons in his house.
# Systolic ejection murmur: Consistent with aortic stenosis, may
consider outpatient TTE.
# 4 mm right lower lobe pulmonary nodule. For incidentally
detected single solid pulmonary nodule smaller than 6 mm, no CT
follow-up is recommended in a low-risk patient, and an optional
CT in 12 months is recommend in a high-risk patient.
- this was reviewed with the patient in detail and he understand
that follow up CT in ___ year is recommended.
===================
TRANSITIONAL ISSUES
===================
- New Meds: None
- Stopped/Held Meds: None
- Changed Meds: None
- Post-Discharge Follow-up Labs Needed: None
- Incidental Findings: 4 mm right lower lobe pulmonary nodule.
For incidentally detected single solid pulmonary nodule smaller
than 6 mm, no CT follow-up is recommended in a low-risk patient,
and an optional CT in 12 months is recommend in a high-risk
patient.
- Discharge weight: 79.4kg
# CODE: full (presumed)
# CONTACT: wife ___ ___
[] Arrange close followup with psychiatrist
[] Consider TTE for systolic murmur
[] Consider f/u CT in 12 months for 4mm RLL nodule
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 25 mg PO DAILY
2. Mirtazapine 45 mg PO QHS
3. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
wheezy, shortness of breath
4. Tiotropium Bromide 1 CAP IH DAILY
5. ClonazePAM 0.5-1 mg PO DAILY:PRN anxiety, insomnia
6. Atenolol 25 mg PO DAILY
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. Atorvastatin 40 mg PO QPM
10. Furosemide 20 mg PO DAILY:PRN leg swelling
11. oxyCODONE-acetaminophen ___ mg oral QID:PRN
12. sildenafil 20 mg oral DAILY:PRN
13. Aspirin 81 mg PO DAILY
14. Albuterol Sulfate (Extended Release) 4 mg PO Q12H
Discharge Medications:
1. Percocet (oxyCODONE-acetaminophen) ___ mg oral Q6H:PRN
Duration: 5 Days
RX *oxycodone-acetaminophen [Percocet] 10 mg-325 mg 1 tablet(s)
by mouth Q6:PRN Disp #*20 Tablet Refills:*0
2. Albuterol Sulfate (Extended Release) 4 mg PO Q12H
3. Aspirin 81 mg PO DAILY
4. Atenolol 25 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. ClonazePAM 0.5-1 mg PO DAILY:PRN anxiety, insomnia
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Furosemide 20 mg PO DAILY:PRN leg swelling
9. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
wheezy, shortness of breath
10. Losartan Potassium 25 mg PO DAILY
11. MetFORMIN (Glucophage) 500 mg PO BID
12. Mirtazapine 45 mg PO QHS
13. oxyCODONE-acetaminophen ___ mg oral QID:PRN Back pain
14. sildenafil 20 mg oral DAILY:PRN
15. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Chronic back pain
Secondary Diagnoses:
COPD with hypoxia
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
- You were admitted to the hospital because of your pain and
because your oxygen level was low, and because you had thoughts
of wanting to hurt yourself
WHAT HAPPENED IN THE HOSPITAL?
- We treated your back pain and found that your oxygen level was
about where it normally is for you
WHAT SHOULD YOU DO AT HOME?
- Continue taking your pain medication as agreed upon with your
pain clinic
- If you have thoughts of wanting to hurt yourself, make sure
you follow the safety steps we discussed. Reach out to your
sister, call your doctor, or go to an emergency department.
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team
Followup Instructions:
___
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2164-08-06 14:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
amoxicillin
Attending: ___.
Chief Complaint:
Pain s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ man who presents after a fall down
stairs on ___ (3 days ago), sustained blunt trauma to R hip.
Denies headstrike, -LOC. No syncope/palpitations/dizziness, no
preceeding symptoms, patient slipped. Right hip rapidly
developed large, firm, painful area of soft tissue swelling.
Pain became so bad patient decided to be evaluated at ___ on ___. Hematocrit at that time was 35.9. Patient had
Xrays showing no thoracic injury, positive for soft tissue
swelling of right trochanteric region/inferolateral right
buttock.
CT A/P showed large right posterior buttock hematoma, stretching
from the iliac crest down to the femoral greater trochanter,
estimated SI extent 16 cm, greatest short axis dimension about
19
cm by 7 cm. Surrounded by right buttock edema medially, superior
laterally.
Patient did well with PO pain meds and was sent home with
crutches, but on AM ___, patient was watching television when
he developed shortness of breath, L arm pain, L jaw pain, and L
chest tightness as well as acute palpitations/tachycardia.
Patient also complained of increasing right buttock pain.
Returned to ___ with concern for possible MI; received
ASA ___t ___, Troponin was negative, but hematocrit was found to
have dropped from 36-->25. HR 120, BP 110/40. EKG showed no
stemi, no acute ischemia. Patient is transferred to ___
for trauma evaluation.
Currently he endorses no chest/jaw/arm pain. Does complain of
right buttock pain but notes no increase in pain.
Past Medical History:
Obesity
Social History:
___
Family History:
- Mother with CAD
- Father with CVA
Physical Exam:
Gen: NAD
HEENT: CN II-XII grossly intact, PEERL, EOMI.
CV: RRR. +murmur
Pulm: CTAB
Abd: Soft NTND
Ext: Full ROM. Significant ecchymosis over the left buttock,
right buttock and right hamstrings. This area is significantly
tender to palpation.
Brief Hospital Course:
The patient presented to the Emergency Department on ___.
Upon arrival to ED the patient was evaluated and had a CT scan
performed which revealed a large hematoma in the patient's right
buttock without signs of extravasation. The patient was also
found to have a markedly decreased hematocrit. Given these
findings, the patient was admitted to ___ for monitoring.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed with oral narcotics and
acetamenophen as needed.
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.
GI/GU/FEN:
The patient was initially kept NPO, however, he was advanced to
a regular diet when his hematocrit stabilized. Patient's intake
and output were closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
None
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*20 Capsule Refills:*0
2. Acetaminophen 650 mg PO Q6H
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Do not drive or operate machinery while taking this medication!
RX *oxycodone 5 mg 1 tablet(s) by mouth Q4H:PRN Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Fall
Right-sided hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ after a fall. You developed a large
hematoma and chest pain so you were admitted for observation.
Your chest pain work-up was negative for any coronary etiology
and those symptoms have resolved. Your hematocrit has been
stable and your pain is under control. You are ready to be
discharged home to continue your recovery. Please note the
following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Followup Instructions:
___
|
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2183-04-26 21:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ male current smoker with hx of HFrEF
with recovered EF(EF 50% ___ non ischemic likely alcohol
induced cardiomyopathy diagnosed ___ ___ who presents with
worsening shortness of breath over the past ___ days. Patient
was diagnosed with non-ischemic cardiomyopathy to ___ ___ ___
and was followed by Dr. ___, with an extensive cardiomyopathy
workup that was negative so the etiology was thought to be ___
his heavy alcohol use. He had improvement of LVEF to 50% on Echo
___. He was most recently seen by ___ ___
cardiology clinic ___ ___, but was lost to follow-up.
He has not taken his cardiac medication (furosemide 20mg,
lisinopril 40mg, metoprolol succinate ER 100mg) ___ a year.
Patient is a ___ and states that he had a boat trip a few
days prior to presentation and experienced worsening shortness
of breath both on exertion and at rest. Given his shortness of
breath he took a single Lasix tablet from another member of his
boating party who happened to have a heart condition. He
endorses orthopnea (sleeps with 2+ pillows) and PND. He also
noticed swelling of his legs which he does not have at baseline.
Additionally, patient describes intermittent chest pressure that
radiates to his flank with exertion but denies any significant
chest pain with rest. The pain is as severe as ___ but resolves
with rest. Last was ___ ambulating from the parking lot to the
emergency department.
Of note, Patient reports an intermittent non-productive cough
over the last few months that has acutely worsened over the last
few days. He denies fevers, but reports chills. Patient does
have a longtime smoking history but no known diagnosis of COPD
or asthma.
___ the ED initial vitals were T 97.8F, HR 118, BP 146/83, RR 26,
O2 sat 98% RA.
Past Medical History:
ADHD
Palpitations - several years ago, per his cardiologist, it was
normal
Social History:
___
Family History:
Grandfather had a heart attack at age of ___. Dad with
hypertension.
Physical Exam:
============================
ADMISSION PHYSICAL EXAMINATION
============================
VS: T99.7 PO 118 / 67 HR106 RR16 O2Sat 91% Ra Wt. 116.12 kg
GENERAL: Well developed, well nourished man ___ NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink.
NECK: Supple. JVP of 13 cm.
CARDIAC: PMI located ___ ___ intercostal space, midclavicular
line. regular rate and rhythm. Normal S1, S2. ___ blowing murmur
best heard ___ the LL mid-clavicular line, S4 gallop. No thrills
or lifts.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. bilateral crackles up to
mid-thorax
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Trace edema bilaterally. WARM, well perfused. No
clubbing, cyanosis
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
============================
DISCHARGE PHYSICAL EXAMINATION
============================
GENERAL: Not ___ acute distress - Breathes comfortably.
HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI.
Pink conjunctiva.
NECK: Supple. JVP below the clavicle with patient ___ upright
position.
CARDIAC: Normal rate, regular rhythm. Normal S1/S2. Blowing
murmur heard best ___ L mid-clavicular line. S4 gallop. No
thrills or lifts.
LUNGS: Clear to auscultation bilaterally. No chest wall
deformities or tenderness.
ABDOMEN: Soft, non-tender, non-distended. No palpable
hepatomegaly or splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
NEURO: Face is symmetric, moving
Pertinent Results:
============
ADMISION LABS
============
___ 04:50AM BLOOD WBC-17.8* RBC-4.12* Hgb-12.4* Hct-36.8*
MCV-89 MCH-30.1 MCHC-33.7 RDW-14.6 RDWSD-46.6* Plt ___
___ 04:50AM BLOOD Neuts-71.9* Lymphs-16.8* Monos-7.9
Eos-2.3 Baso-0.4 Im ___ AbsNeut-12.76* AbsLymp-2.98
AbsMono-1.41* AbsEos-0.40 AbsBaso-0.07
___ 04:50AM BLOOD ___ PTT-29.6 ___
___ 04:50AM BLOOD Glucose-91 UreaN-14 Creat-1.1 Na-142
K-4.1 Cl-106 HCO3-22 AnGap-14
___ 04:50AM BLOOD ALT-38 AST-42* AlkPhos-71 TotBili-0.6
___ 06:45AM BLOOD Lipase-23
___ 04:50AM BLOOD proBNP-4084*
___ 04:50AM BLOOD cTropnT-<0.01
___ 03:03PM BLOOD Calcium-8.8 Phos-2.5* Mg-1.9
___ 05:32AM BLOOD %HbA1c-4.9 eAG-94
___ 06:45AM BLOOD Triglyc-52 HDL-47 CHOL/HD-2.4 LDLcalc-55
___ 06:45AM BLOOD TSH-0.97
___ 05:24AM BLOOD ___ CRP-259.7*
==============
DISCHARGE LABS
=============
___ 08:44AM BLOOD WBC-9.5 RBC-4.86 Hgb-13.9 Hct-42.0 MCV-86
MCH-28.6 MCHC-33.1 RDW-13.8 RDWSD-43.9 Plt ___
___ 08:44AM BLOOD Neuts-53.3 ___ Monos-7.0 Eos-7.7*
Baso-1.5* Im ___ AbsNeut-5.05 AbsLymp-2.82 AbsMono-0.66
AbsEos-0.73* AbsBaso-0.14*
___ 08:44AM BLOOD ___ PTT-29.7 ___
___ 11:00AM BLOOD Parst S-NEGATIVE
___ 08:44AM BLOOD Glucose-90 UreaN-25* Creat-1.0 Na-136
K-5.1 Cl-99 HCO3-24 AnGap-13
___ 08:44AM BLOOD ALT-316* AST-97* LD(LDH)-244 AlkPhos-75
TotBili-0.3
___ 08:44AM BLOOD Calcium-9.4 Phos-3.5 Mg-2.4
=============
MICROBIOLOGY
=============
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
URINE CULTURE (Final ___: NO GROWTH.
Staph aureus Preop PCR (Final ___: S. aureus Negative;
MRSA Negative.
___ 2:47 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
Blood Culture, Routine (Final ___: NO GROWTH.
=======
IMAGING
=======
CT chest - ___
1. Diffuse, upper lobe predominant ground-glass opacities,
without septal thickening or pleural effusions. Differential
considerations include pulmonary edema (despite absence of
septal thickening), viral pneumonia, or pneumocystis pneumonia
(if immunocompromised).
2. Mediastinal lymphadenopathy, likely reactive.
Brief Hospital Course:
Mr. ___ is a ___ with PMHx of HFrEF with recovered EF
(EF50% ___ ___ non-ischemic cardiomyopathy (likely
alcohol-induced) who presented with worsening dyspnea and cough
___ the setting of medication non-compliance and likely CAP, c/f
acute HFrEF exacerbation.
ACUTE ISSUES:
=============
#Community Acquire Pneumonia
#Leukocytosis
Patient presented with SOB, tachypnea, and cough with CXR
showing bilateral focal consolidations ___ the right upper lower
and left upper lung fields concerning for multifocal pneumonia.
WBC notably elevated at 17.8 on admission likely ___ CAP. Due to
the acuity of his presentation he was initially started on
vancomycin, cefepime, and azithromycin. After his clinical
status improved he was narrowed to CAP treatment with
ceftriaxone and azithromycin.
#HFrEF Exacerbation
Etiology likely ___ CAP ___ addition to medication non-adherence.
Patient's last known EF: 50% ___ ___. Patient was diagnosed with
non-ischemic cardiomyopathy with EF: ___ ___ ___ and was
followed by Dr. ___, with an extensive cardiomyopathy workup
that was negative including normal TSH, negative HIV, negative
___, suggesting a non-ischemic cardiomyopathy ___ known EtOH use
disorder. No valvulopathy mentioned on last known echo, however
presented with MR on exam likely ___ dilated cardiomyopathy.
Doubt utility placing ___ mitral clip. Volume management may
improve degree of MR. ___ patient was started on captopril and
diuresed with furosemide. TTE showed Dilated left ventricle with
severe global systolic dysfunction. Moderate to severe
functional mitral regurgitation. Moderate tricuspid
regurgitation. Mild pulmonary hypertension.
# Eosinophilia
# LFTs
CBC w/ differential was rechecked on ___ and it was noted that
the patient had an elevated absolute eosinophil count up to
1.26. AST and ALT was also noted to be elevated up to the 400s.
Work-up for anaplasma and Lyme were sent but were pending at
time of discharge. CT chest was obtained and demonstrated
diffuse ground glass opacities ___ upper lobes of bilateral
lungs, which ID felt could be consistent with either viral
pneumonia, eosinophilic pneumonitis, or NSIP. Both transaminitis
and eosinophilia were improving at time of discharge and were
felt to be drug-induced secondary to either vancomycin or
cefepime, possibly ceftriaxone (although both LFTs and
eosinophils were improving while the patient was still on
ceftriaxone).
=============
CHRONIC ISSUES:
===============
#Anemia:
Patient admitted with Hgb 12.4 which appears to baseline as of
___. Most likely multifactorial etiology as patient has
known iron deficiency and also known etoh use disorder. MCV: 89.
B12 mildly deficient, ordered repletion.
#EtOh Use Disorder
When patient was initially diagnosed with his cardiomyopathy ___
___ he was drinking 15 beers/day. He now states he drinks on
average 6 beers/day. Last drink before coming to the hospital
was
11 days ago. Currently out of the window for withdrawal. No need
for CIWA.
TRANSITIONAL ISSUES:
==================
Discharge weight: 106.8 kg or 235.45 lb
Discharge Cr: 1.0
Discharge diuretic: torsemide 10mg QD
[ ] Cardiology:
- patient should be uptitrated on all medications to
goal-directed dosages.
- f/u chem-7 for monitoring of potassium and renal function on
current diuretic dose.
- Patient should have repeat TTE within three months to monitor
change ___ LVEF.
[ ] Primary care:
- Patient had eosinophilia and transaminitis that we think were
likely drug-induced. Please repeat a CBC w/ diff and LFTs to
confirm that both are improving still (absolute eosinophils were
0.73, AST 97, and ALT 316 at discharge).
- Patient will need repeat CT chest w/o contrast ___ ___ weeks to
monitor change ___ ground glass opacities. If worsening, consider
pulmonary evaluation for possible NSIP.
#CODE STATUS: Full
#CONTACT: ___ (wife) ___
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Lisinopril 15 mg PO DAILY
RX *lisinopril 5 mg 3 tablet(s) by mouth once daily Disp #*90
Tablet Refills:*0
3. Metoprolol Succinate XL 12.5 mg PO DAILY
RX *metoprolol succinate [Kapspargo Sprinkle] 25 mg 0.5 (One
half) capsule(s) by mouth once a day Disp #*90 Capsule
Refills:*0
4. Spironolactone 12.5 mg PO DAILY
RX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth once
daily Disp #*15 Tablet Refills:*0
5. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*90 Tablet Refills:*0
6. Torsemide 10 mg PO DAILY
RX *torsemide 10 mg 1 tablet(s) by mouth Once a day Disp #*90
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Pneumonia
Secondary Diagnoses:
Acute exacerbation of systolic heart failure
Drug-induced eosinophilia
Drug-induced liver injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear ___,
It was a privilege caring for you at ___.
WHY WAS I ___ THE HOSPITAL?
- You were admitted to the hospital because were short of breath
WHAT HAPPENED TO ME ___ THE HOSPITAL?
- ___ the hospital you were diagnosed with pneumonia and a
worsening of your heart failure.
- You were given antibiotics for the infection ___ your lungs.
- You were also given medication to improve your circulation.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please take your medications as prescribed:
- Torsemide 10mg once daily
- Lisinopril 15mg once daily
- Metoprolol 12.5mg once daily
- Spironolactone 12.5mg once daily
- Weigh yourself every morning, call doctor if weight goes up
more than 3 lbs.
- Please call to schedule an appointment with a new primary care
doctor. We will try to schedule you with an appointment to see a
cardiologist.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10674713-DS-21
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2181-10-19 00:00:00
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2181-10-19 19:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Peanut / lisinopril
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
___ Intubated
___ Rigid Bronchoscopy
___ Bronchoscopy
___ Extubated
___ Intubated
___ Rigid Bronchoscopy
___ Bronchoscopy
___ Extubated
History of Present Illness:
___ with ESRD on HD, hypertension, asthma, h/o seizures who
presents with dyspnea. Of note, patient was admitted to
___ from ___ for PRES, acute
hypoxemic respiratory failure requiring intubation. Course was
complicated by a seizure, hyperkalemia, poorly-controlled
hypertension. She was deemed to be failing PD, and was
transitioned to HD via a right tunneled catheter. Since she left
the hospital on ___, she's had ongoing dyspnea, which seemed
to
get worse on the night prior to presentation. Patient has had
difficulty sleeping and is unable to lie flat. Patient also
endorses cough that is not productive. Patient denies any
hemoptysis, history of malignancy, history of blood clot or leg
swelling. Patient denies fever, chills, chest pain at this time.
In the ED, initial vital signs were notable for: 98.3, 110,
165/94, 18, 100% RA
Exam notable for: prolonged expiration, expiratory wheezing
Labs were notable for:
WBC 16.3, H/H 9.3/30.3, plts 381
d-dimer 4122
___ 67966
TropT 0.08 -> 0.07, MB 3
Lipase 223
VBG ___
Studies performed include:
CTA chest - right upper, right lower, and left lower
subsegmental
pulmonary arteries. No evidence of right heart strain.
CXR - No acute cardiopulmonary abnormality. Resolution of
previously noted right perihilar opacity.
Patient was given:
Duoneb x4
Albuterol neb x1
IV heparin
home meds
Consults:
renal dialysis - no need for urgent HD, will likely get on the
schedule for HD tomorrow
Vitals on transfer: 99, 95, 156/83, 18, 99% RA
Upon arrival to the floor, patient is in significant respiratory
distress and sits at the edge of the bed tripoding despite O2
sat
100% RA. She has a hoarse voice and states she can't lie flat
because of dyspnea. She reports she has had these symptoms since
she was extubated at ___ a few days ago but they seem to be
getting worse. No throat or tongue swelling. Remainder or ROS
per
above otherwise negative.
Past Medical History:
Asthma
Hypertension
ESRD on HD (renal disease suspected to be ___ decreased nephron
mass from being born prematurely)
Anemia
Seizures
Social History:
___
Family History:
maternal aunt - breast cancer at age ___
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VITALS: T 98.1, BP 168/104, HR 99, RR 12, SpO2 100/RA
GENERAL: Alert and interactive. in substantial distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: No cervical lymphadenopathy appreciated. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Coarse upper airway sounds, no wheezes or rhonchi, good
air movement, increased work of breathing, tripoding
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. AOx3.
DISCHARGE PHYSICAL EXAM
=======================
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, Sclera anicteric and without injection. MMM,
voice soft and hoarse
NECK: Supple
CARDIAC: RRR, Audible S1 and S2. No murmurs/rubs/gallops.
LUNGS: CTAB. No r/r/w. No increased work of breathing.
Chest: dialysis catheter c/d/i
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. 2+ pulses
SKIN: Warm. No rash.
NEUROLOGIC: Alert, answering questions appropriately, moving all
extremities
Pertinent Results:
ADMISSION LABS
==============
___ 08:55AM BLOOD WBC-16.3* RBC-3.44* Hgb-9.3* Hct-30.3*
MCV-88 MCH-27.0 MCHC-30.7* RDW-14.6 RDWSD-46.0 Plt ___
___ 08:55AM BLOOD Glucose-90 UreaN-35* Creat-7.9* Na-132*
K-4.9 Cl-87* HCO3-24 AnGap-21*
___ 08:55AM BLOOD Albumin-4.1 Calcium-8.0* Phos-5.1* Mg-1.9
___ 09:00AM BLOOD ___ pO2-31* pCO2-48* pH-7.37
calTCO2-29 Base XS-1
DISCHARGE LABS
==============
___ 06:45AM BLOOD WBC-8.7 RBC-2.92* Hgb-8.1* Hct-25.6*
MCV-88 MCH-27.7 MCHC-31.6* RDW-14.4 RDWSD-45.3 Plt ___
___ 08:45AM BLOOD ___ PTT-47.1* ___
___ 06:45AM BLOOD Glucose-84 UreaN-41* Creat-8.2*# Na-131*
K-4.4 Cl-84* HCO3-22 AnGap-25*
RELEVANT IMAGING
================
CTA Chest ___
IMPRESSION:
1. Acute pulmonary emboli within right upper, right lower, and
left lower
subsegmental pulmonary arteries. No evidence of right heart
strain. No
pulmonary infarction.
2. 2.0 cm round hypodense region within the IVC, which may be
due to mixing
artifact, but is suspicious for thrombus. CTV of the abdomen
and pelvis is
recommended for further evaluation.
3. Moderate cardiomegaly.
4. Small volume ascites.
CTA Abd/Pelvis w/ Contrast ___
IMPRESSION:
1. No venous thrombosis in the inferior vena cava.
2. Expected findings related to patient's known end-stage renal
disease on peritoneal dialysis.
CT Neck w/ Contrast ___
IMPRESSION:
1. No definite mucosal mass identified height in the subglottic
region or
trachea. However if there is high clinical concern, direct
visualization
would be more definitive.
2. There is stenosis and narrowing of the subglottic region and
trachea in a
saber sheath pattern, compatible with tracheomalacia.
3. Thyroid goiter without focal nodule.
4. Additional findings described above.
Rigid Bronchoscopy ___
-Pseudomembrane through first ~5cm of trachea
-Tracheomalacia
Bronchoscopy ___
No airway obstruction seen. Severe trachomalacia
Brief Hospital Course:
Ms. ___ is a ___ y/o female with ESRD on HD, hypertension,
asthma, h/o seizures who presented with dyspnea, found to have
dyspnea in the setting of multifactorial upper airway disease
consisting of vocal cord granulomas, tracheal edema and
pseudomembrane.
ACUTE ISSUES:
=============
#Vocal cord granulomas iso recent intubation
# Acute hypoxic respiratory filure
Presented with worsening respiratory distress. ENT evaluated and
performed scope on ___. They found granulomas in the posterior
aspect of the left and likely on the right vocal fold, which was
the likely etiology of the hoarseness and stridor. They
recommended three doses of dexamethasone, which was completed on
___, as well as pantoprazole BID, saline nebs, and continued
air-way watch. She underwent bronchoscopy on ___ and ___
notable for tracheal edema and pseudomembrane as well as
tracheomalacia. MICU course c/b difficult extubation s/p first
bronchoscopy on ___ and patient was not extubated until ___
after second procedure to minimize interventions on inflamed
airway. She continued to have intermittent episodes of stridor
ont he floor that improved with racemic epi, however she also
required a one time repeat dose of dexamethasone. IP
re-evaluated the patient and felt that her continued stridor was
likely secondary to mucus buildup and inability to clear, but
there was some concern for redevelopment/inadequate excision of
her pseudomembrane. They recommended a repeat bronchoscopy, but
patient did not wish to stay inpatient further for this
procedure. She was warned about the risks of not undergoing this
evaluation and expressed understanding. She was scheduled to
follow-up with IP outpatient.
[] Patient should follow-up with IP on ___ for
further management and evaluation of her TBM and stridor.
[] She is being discharged on multiple inhalers and with
significant concern for continued stridor likely secondary to
inability to excrete mucus and psuedomembrane. She should be
monitored closely for further symptoms.
#Hemoptysis
Pt developed a small volume of hemoptysis on morning of ___
from unclear etiology likely secondary to granulomatous vocal
cords. Hemoglobin remained stable and patient showed no signs of
hemodynamic instability and did not have any repeat episodes.
#Multiple Subsegmental PE:
Multiple subsegmental PEs were found on CTA chest without
evidence of strain. Patient was started on a heparin drip with
attempt to transition to warfarin. Anticoagulation was held only
for bronchoscopy, with INR target of ___. The only inciting
factor was thought to be recent hospitalization. After extensive
discussion, once patient reached therapeutic INR range, her
heparin was discontinued and she was discharged, as she no
longer wished to stay in the hospital. Patient was discharged on
5mg of Warfarin with INR of 2.3.
[] Patient is being discharged on 5mg of Warfarin. She will need
to have close monitoring of her INR.
#Anemia:
Initially Hgb downtrednded through hospitalization, but then
stabilized. Most likely etiology was thought secondary to ESRD.
But there was some concern for GI bleed in the setting of
initiation of anticoagulation and no other clear sources of
bleeding. Further work-up did not seem appropriate in setting of
patient otherwise appearing stable.
CHRONIC ISSUES:
===============
# ESRD on HD
Did not appear fluid overloaded on exam through hospitalization,
with relatively stable electrolytes. Underwent hemodialysis on
___ schedule. Continued on home sevelamer with meals,
calcitriol and cinacalcet.
[] Patient is planned to undergo hemodialysis 5x a week. Her
next dialysis session should be ___. After that,
she can restart her normal schedule.
# Hypertension
Continued on home labetalol, amlodipine, torsemide, and
Irbesartan. Her labetalol and Irbesartan doses were increased,
but there was still significant difficulty controlling her blood
pressures.
[] Patient's blood pressure medications were increased while
inpatient. Please continue to monitor her blood pressure and
asses for further medication changes
#Seizure
No evidence of seizure activity during hospitalization.
Continued on home keppra.
TRANSITIONAL ISSUES
===================
[] Patient should follow-up with IP on ___ for
further management and evaluation of her TBM and stridor.
[] She is being discharged on multiple inhalers and with
significant concern for continued stridor likely secondary to
inability to excrete mucus and psuedomembrane. She should be
monitored closely for further symptoms.
[] Patient is being discharged on 5mg of Warfarin. She will need
to have close monitoring of her INR.
[] Patient is planned to undergo hemodialysis 5x a week. Her
next dialysis session should be ___. After that,
she can restart her normal schedule.
[] Patient's blood pressure medications were increased while
inpatient. Please continue to monitor her blood pressure and
assess for further medication changes.
#CODE: Full, confirmed
#CONTACT: ___, Mother, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Cinacalcet 120 mg PO DAILY
3. Labetalol 200 mg PO BID
4. sevelamer CARBONATE 1600 mg PO TID W/MEALS
5. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1
6. Torsemide 40 mg PO DAILY
7. Docusate Sodium 100 mg PO DAILY
8. Ferrous Sulfate 325 mg PO DAILY
9. LevETIRAcetam 500 mg PO QHS
10. Calcitriol 0.25 mcg PO DAILY
11. irbesartan 150 mg oral QHS
12. Cyanocobalamin 100 mcg PO DAILY
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 NEB INH q4hr PRN
Disp #*30 Vial Refills:*0
2. Cepacol (Sore Throat Lozenge) 1 LOZ PO PRN sore throat
RX *benzocaine-menthol [Sore Throat (benzocaine-menth)] 15
mg-3.6 mg Take 1 LOZ Q6HR Disp #*36 Lozenge Refills:*0
3. GuaiFENesin ER 1200 mg PO Q12H
RX *guaifenesin 1,200 mg 1 tablet(s) by mouth Q12HR Disp #*56
Tablet Refills:*0
4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1 NEB
INH Q6HR PRN Disp #*10 Ampule Refills:*0
5. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
6. Sodium Chloride 3% Inhalation Soln 15 mL NEB BID throat
swelling/cough
RX *sodium chloride 3 % 15 mL INH twice a day Disp #*10 Vial
Refills:*0
7. Sodium Chloride Nasal ___ SPRY NU BID:PRN nasal irritation
8. Warfarin 5 mg PO DAILY16
RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth daily Disp
#*14 Tablet Refills:*0
9. Warfarin 5 mg PO DAILY16
10. Cinacalcet 90 mg PO DAILY
11. irbesartan 225 mg oral QHS
RX *irbesartan 150 mg 1.5 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
12. Labetalol 300 mg PO BID
RX *labetalol 300 mg 1 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*0
13. amLODIPine 10 mg PO DAILY
14. Calcitriol 0.25 mcg PO DAILY
15. Cyanocobalamin 100 mcg PO DAILY
16. Docusate Sodium 100 mg PO DAILY
17. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 Duration: 1 Dose
18. Ferrous Sulfate 325 mg PO DAILY
19. LevETIRAcetam 500 mg PO QHS
20. sevelamer CARBONATE 1600 mg PO TID W/MEALS
21. Torsemide 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
=======
Supraglottic Stenosis and Stridor
Vocal Cord Granuloma
Subsegmental bilateral pulmonary emboli
Hypertension
SECONDARY
=========
Anemia
End stage renal disease on hemodialysis
Seizures
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 at the ___
___.
Why did you come to the hospital?
- You were brought in to the hospital due to concerns for your
difficulty breathing.
What did you receive in the hospital?
- You were found to have inflammatory tissue around your vocal
cords, likely due to your recent intubation. Though you
continued to improve initially, you again developed difficulty
breathing secondary to a pseudomembrane requiring transfer to
the intensive care unit.
- While there, you underwent removal of the excess tissue with a
bronchoscope. Once you returned to the floor, there was concern
you continued to have some excess tissue causing your symptoms.
We recommended getting a repeat bronchoscopy, but per your
preference, scheduled you for further outpatient evaluation.
- Finally, during hospitalization, you were found to have
multiple blood clots in your lung. We started you on a blood
thinner, called warfarin, and monitored your blood levels until
you were therapeutic.
- You also started hemodialysis while here. This went without
complications.
What should you do once you leave the hospital?
- Please continue to take all medications as prescribed.
- You will need continued monitoring of your INR and if you
warfarin is appropriately dosed for you.
- You will need to follow-up with the Interventional
Pulmonologists. You can contact them at ___ if you do
not hear from them within the next few days for an appointment.
- Your next dialysis session should be ___. After
that you can return to your normal dialysis schedule.
- Please return to the emergency room if you have any increased
shortness of breath, chest pain, or other changes or symptoms
that concern you.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10674823-DS-21
| 10,674,823 | 21,929,863 |
DS
| 21 |
2135-08-28 00:00:00
|
2135-09-02 15:48:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
erythromycin (bulk) / Ampicillin / Bactrim DS
Attending: ___
Chief Complaint:
Hyperglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is ___ with history of HTN, HLD, DM2,
schizoaffective disorder who is being sent in from PCP office
with hyperglycemia. The patient has poorly controlled DM and, as
per PCP, ___, and therapist notes, there has been
concern that the patient in unable to take care of herself at
home. As per Dr. ___ patient's psychiatrist, the patient
has been more and more disorganized lately, and they are
concerned that this could be due to her underlying
schizoaffective disorder.
The patient reports that she stopped taking her insulin since
___ because she ran out of her needles. She has been too
"scared" to check her sugars at home, but reports that they have
been routinely higher than 500 over the last ___ months. She
was seen in the ED on ___ for high sugars. Per follow up note
from her PCP, she was subsequently seen at ___ and metformin
was added to her daily regimen.
She reports she has home nursing x3 week to help with sugars. In
terms of precipitating factors that could be contributing to her
hyperglycemia, she reports that she was having burning with
urination over the weekend with increased frequency and having
to get up at night to go to the bathroom. Has had these symptoms
twice over the past month. Was prescribed a course of Macrobid
in early ___, and ___ called HCA and was prescribed cipro
last ___. Did not pick up cipro from pharmacy, said symptoms
have now gone away.
ROS is positive for dizziness, (but reports that it is much
improved compared to previous admissions) and unintentional
weight loss. Per past records she weighed 189 pounds in ___
and is currently 153. She also reports some pain around her
neck ___ diagnosed neurpathy and numbness around her feet which
has been on-going. She denies any recent fevers or chills,
chest pain or palpitations, shortness of breath, abdominal pain,
changes in her BMs, early satiety or abdominal distention. She
does not know why she has been losing weight.
In the ED, initial vs were: T97 160/65 88 18 96RA. Labs were
notable for sugars >500, sodium of 126, without any anion gap.
She was given multiple doses of IV insulin and glucose on
transfer ~300s.
Past Medical History:
PMH:
- Schizoaffective disorder
- Colon cancer - T4N0M1 (mesenteric nodules), completely
resected ___ w/out chemo or radiation
- DM Type 2 - poorly controlled w/ last A1c > 10
- Diabetic retinopathy
- Osteoarthritis - cervical spine, bilateral hands
- Hypertension
- Hypercholesterolemia
- Benign ovarian mass s/p hyserectomy and bilateral
salpingo-oophorectomy in ___
Social History:
___
Family History:
Father died at ___ of an MI.
Mother died of dementia.
One brother with liver cancer, one brother with diabetes.
Physical Exam:
PHYSICAL EXAM
VS: 96.7 110/56 68 18 99RA
General: pleasant woman, NAD, sitting up comfortably at the edge
of the bed, alert and oriented, slightly tangential, but able to
answer my questions
HEENT: sclera anicteric, dry mucous membranes
neck: supple
CV: ___ SEM heard loudest at ___, otherwise RRR S1 S2
lungs: clear to auscultation b/l
abdomen: soft, nontender, nondistended, +BS, no suprapubic
tenderness noted
back: no flank pain
extremities: no ___ edema noted, warm and wellperfused, 2+ DP
pulses
Neuro: CN ___ grossly intact, intact ___ muscle strength
PHYSICAL EXAM ON DISCHARGE:
General: pleasant woman, NAD
HEENT: sclera anicteric, dry mucous membranes
neck: supple
CV: ___ SEM heard loudest at RUSB, otherwise RRR S1 S2
lungs: clear to auscultation b/l
abdomen: soft, nontender, nondistended, +BS, no suprapubic
tenderness noted
back: no flank pain
extremities: no ___ edema noted, warm and wellperfused, 2+ DP
pulses
Neuro: CN ___ grossly intact, intact ___ muscle strength
Pertinent Results:
ADMISSION LABS
___ 04:26PM BLOOD Glucose-527* UreaN-20 Creat-0.8 Na-126*
K-4.2 Cl-88* HCO3-28 AnGap-14
___ 04:25PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 11:58PM GLUCOSE-295* K+-3.9
DISCHARGE LABS
___ 08:45AM BLOOD Glucose-197* UreaN-15 Creat-0.6 Na-134
K-3.7 Cl-100 HCO3-22 AnGap-16
___ 08:45AM BLOOD Calcium-9.1 Phos-3.6 Mg-1.7 Iron-49
___ 08:45AM BLOOD calTIBC-309 VitB12-720 Folate-19.2
Ferritn-223* TRF-238
___ 08:45AM BLOOD %HbA1c-13.5* eAG-341*
___ 08:45AM BLOOD TSH-1.0
___ 08:45AM BLOOD WBC-8.1 RBC-4.05* Hgb-12.0 Hct-33.9*
MCV-84 MCH-29.7 MCHC-35.5* RDW-12.5 Plt ___
FINDINGS: The imaged lung bases are clear. The heart and
pericardium are unremarkable. The liver enhances homogeneously,
and there are no focal hepatic lesions. The gallbladder is
normal. The pancreas is normal. The spleen is normal. The
adrenal glands are normal. The kidneys are normal. There is no
hydronephrosis. There is a tiny hiatal hernia. Otherwise, the
stomach is unremarkable. The small bowel is normal. There is
no evidence of obstruction. There is a large ventral hernia
containing small and large bowel without evidence of
obstruction. There is suture seen in the colon, the remaining
colon is normal. No free air. No free fluid. There is no
retroperitoneal or mesenteric lymphadenopathy.
PELVIS: The bladder is normal. The rectum is normal. The
uterus contains dystrophic calcification from likely a
dystrophic fibroid. The adnexa are not well seen. There is no
free fluid in the pelvis. There is no pelvic or inguinal
lymphadenopathy. The aorta is normal in caliber, and there are
moderate atherosclerotic
calcifications.
BONES: There are moderate degenerative changes of the lower
thoracic and lumbar spine. There is no acute bony abnormality.
IMPRESSION:
1. No evidence of metastatic disease.
2. Large ventral hernia containing fat, small and large bowel
is unchanged. No evidence of obstruction.
3. Tiny hiatal hernia.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with PMH significant
for HTN, HLD, DM2, schizoaffective disorder who is being sent in
from PCP office with hyperglycemia and inability to take care of
herself at home.
# DM2/hyperglycemia: The patient's sugars have been very
uncontrolled, mostly in the setting of her not taking her
insulin because she ran out of needles. However, will need to
exclude underlying infection, as well. The patient had dysuria
and increased frequency this past weekend, but UA from this
admission bland, urine culture pending. Patient's home insulin
regimen was continued with good result. Her blood sugars
dropped from >500 on admission to the 100's on discharge. A
follow up appointment was established with both ___ and ___
PCP to further discuss her insulin regimen and whether it can be
simplified. She is currently on 3 different insulins, and while
she understands her medications accurately, it may be
overwhelming for her.
# Weight loss/failure to thrive: The patient's providers are
concerned about weight loss. Documented to weigh 183 pounds in
___, and down to 159 this month. She has reported significant
barriers to getting adequate food given that there is no one
aournd to help her and she is totally dependent on the Ride to
get to the grocery store and the pharmacy for her medications.
Her schizoafective disorder may also be worsening as of late per
her last social work note, and is possibly contributing to
disorganization and inability to care for herself. She is also
a little unsure about what she should eat given her diabetes,
and frequently feels unwell, likely due to persistant
hyperglycemia/low insulin. However, given history of colon
cancer as well as benign ovarian mass, we obtained a CT abdomen
and pelvis to rule out new malignancy as an etiology for weight
loss. CT scan did not show obstruction or mass. Patient should
follow up with her regular oncologist as planned going forward.
# Schizoaffective disorder: likely contributing to weight loss,
failure to thrive and inability to take medications reliably as
above. Social worker, psychiatrist and PCP all agree the
patient would do better in assisted living. On presentation to
the hospital the patient was alert, oriented x3, somewhat
tangential and distracted but easy to redirect. She could
answer questions apprpriately. No depression or thoughts of
self harm. No frank delusions or hallicinations, although she is
somewhat preoccupied with the idea that her neighbors are
loitering outside her apartment and trying to eavesdrop on her.
Per conversation with PCP she ___ does not live in that
safe of a location, and for this reason as well may do better in
assisted living. Her home psychiatric medications were continued
during this admission.
# Hyponatremia: The patient was noted to be hyponatremia today
to 126, but after correcting for her glucose, sodium 136.
# HTN: Home atenolol and lisinopril were continued, blood
pressure was stable.
# HLD: Home statin was continued.
TRANSITIONAL ISSUES
- Patient's safety and ability to care for herself at home is
questionable. Per SW, a friend is helping her look into
assisted living facilities.
-please ensure f/u CT scan read with oncologist and f/u
colonscopy
-please monitor patient's weight given recent weight loss
-please ensure psychiatry f/u
-please consider toxoplasmosis screen if patient becomes acutely
confused given history of cat litter exposure consistently
-please ensure blood glucose monitoring given persistently high
blood sugars in 500s and poor compliance
-please ensure ___ f/u with HbA1c value of 13.5%
-please f/u iron studies with regards to patient's anemia
-please f/u TSH results
-please ensure daily ___ services continue as patient unable to
take her own medications
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 75 mg PO DAILY
2. Gabapentin 600 mg PO HS
3. Lisinopril 30 mg PO DAILY
4. Omeprazole 20 mg PO BID
5. QUEtiapine Fumarate 400 mg PO QHS
6. QUEtiapine Fumarate 25 mg PO DAILY:PRN anxiety
7. Rosuvastatin Calcium 20 mg PO DAILY
8. Sertraline 200 mg PO DAILY
9. pramipexole 0.5 mg Oral DAILY
10. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
11. Novalog 70/30 110 Units Breakfast
12.
13. Glargine 100 Units Bedtime Max Dose Override Reason: home
dose per pharmacy
14. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200
mg-unit Oral DAILY
Discharge Medications:
1. Atenolol 75 mg PO DAILY
2. Gabapentin 600 mg PO HS
3. Lisinopril 30 mg PO DAILY
4. Omeprazole 20 mg PO BID
5. QUEtiapine Fumarate 400 mg PO QHS
6. QUEtiapine Fumarate 25 mg PO DAILY:PRN anxiety
7. Rosuvastatin Calcium 20 mg PO DAILY
8. Sertraline 200 mg PO DAILY
9. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200
mg-unit Oral DAILY
10. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
11. pramipexole 0.5 mg ORAL DAILY
12. U-500 115 Units Breakfast
U-500 115 Units DinnerMax Dose Override Reason: severe insulin
resistance requires >200 units/day
RX *insulin syringe-needle U-100 [BD Insulin Syringe Ult-Fine
II] 31 gauge x ___ use for insulin up to 22 mark twice daily
Disp #*60 Syringe Refills:*3
RX *insulin regular hum U-500 conc [Humulin R U-500
"Concentrated"] 500 unit/mL (Concentrated) 110 units SC twice a
day Disp #*1 Vial Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___:
Primary:Hyperglycemia
Secondary: Type II diabetes, hypertension, hyperlipidemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms ___,
It was a pleasure having you here at the ___
___. You were admitted after you were found to have
high blood sugars. You were managed here with your home insulin
regimen and intravenous fluids. Please keep your appointments
below
Followup Instructions:
___
|
10674875-DS-2
| 10,674,875 | 28,088,193 |
DS
| 2 |
2183-12-22 00:00:00
|
2183-12-25 13:20:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Allergies/ADRs on File
Attending: ___
Chief Complaint:
Right-sided hemiparesis/sensation loss and facial droop, LUE
weakness, dysarathria and nonfluent aphasia.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old woman with fibromuscular
dysplasia, 2 prior CVAs in ___ and ___ with presenting
symptoms
of acute right hemiparesis with subsequent workup showing PFO
now
on warfarin (INR 2.7) who presents with acute onset right-sided
hemiparesis/sensation loss and facial droop, LUE weakness,
dysarthria and nonfluent aphasia.
She was sitting on her bed at home with her boyfriend who was
with her at the last well time of 19:30. Despite her 2 prior
strokes she has had aggressive physical therapy and is
independent and fully ambulatory at baseline. Around 19:30 she
felt a sudden onset of right sided face, arm, and leg weakness,
she describes as "feeling heavy". She tried to move from
side-to-side but found that her left arm was weak as well. She
noted a numbness/tingling sensation along the right half of her
body at onset. She called out to her boyfriend who noted slurred
speech and called EMS to take her to ___.
She arrived there by 10:30 and was taken for urgent CT scan
which
showed old left basal ganglia and right MCA territory infarct,
consistent with her prior strokes. At ___, her
exam
worsened (with unclear NIHSS), by family report she was not
moving at all and had minimal speech output. INR 2.7 and normal
chemistry and WBC count. She was transferred urgently to ___
for possibility of intraarterial therapy.
On arrival to ___, STAT Code Stoke was called with NIHSS of 10
acutely (for the combination of severe right hemiparesis, mild
LUE weakness, dysarthria, and nonfluent aphasia. She was taken
urgently for STAT repeat CT and CTA to assess acute infarct or
vessel cutoff. Of note, prior evaluation for Stroke was in ___
at ___ and imaging showed no obvious change on CT when the 2
sets of images were compared. Intraarterial therapy was
deferred
and she was admitted to Stroke Neurology for further assessment.
After ___ hours in the ED her dysarthria and nonfluent speech
greatly improved but significant right weakness persisted by
time
of admission.
Of note upon workup for her prior strokes in ___ she had
similar presentation of right sided weakness and slurred speech
but no left sided symptoms. She was found to have fibromuscular
dysplasia and reportedly had a TTE (unclear if TEE) showing a
PFO.
She has known history of bilateral carotid stenosis as well.
Aspirin was tried initially after the first stroke but after
multiple TIA-like events and a repeat stroke in ___, she was
placed on warfarin. Interestingly, she has a history of DVT in
her early ___, a family history of miscarriage and a mother
"with
clots all over her body" including a PE that required warfarin.
She has had no genetic testing for hypercoagulable disorders.
She was last seen at ___ as an ED consult for TIA in ___ at
which time CTA/CTP were normal and she was sent home without
admission.
On neuro ROS, the pt endorses mild headache no acute loss of
vision, blurred vision, diplopia, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
comprehending speech. No bowel or bladder incontinence or
retention.
On ___ 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:
- Fibromuscular dysplasia
- PFO
-hx of DVT
- DMII
- Iron deficiency anemia
- Neuropathy
- Prior embolic strokes to the left hemisphere. First in ___ and the second in ___. She is currently followed by
Dr. ___
at ___. She reports residual deficits that are subtle
with her right arm, that cause her to be clumsy.
- bilateral carotid stenosis (unknown grade)
Medications:
- Warfarin 12mg daily
- Celexa 40mg daily
Allergies: NKDA
Social History:
___
Family History:
Family history of DVT and PE in her mother,
sisters with multiple miscarriages. No family history of early
strokes or fibromuscular dysplasia
Physical Exam:
Vitals: 97 74 137/78 12 100% ra
___: 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
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: Eyes closed, alerts to loud voice and answers
yes/no appropriately. States age "___" and month ___
Can tell me her name but stutters on the first syllable and with
great effort. Unable to relate history. Language is nonfluent
with intact comprehension. She can repeat only the first
syllable of "Today is a sunny day in ___. Pt was able to
name
only "key" on the NIHSS card, and cannot read "You know how".
Speech was dysarthric. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
II: PERRL 4 to 2mm and brisk. VFF to confrontation by finger
wiggle
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: Significant right NLF 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, slightly increased tone in the right
arm/leg.
Acutely: Unable to hold right arm or leg antigravity. LUE can
hold antigravity 5 seconds. LLE can maintain resistance against
examiner with ___ strength.
-Sensory: Sensory loss to light touch and pinprick in face and
arms> lower extremities without clear evidence of extinction to
DSS
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 2 3 2
R 3 3 2 3 2
Plantar response was upgoing on the right, equivocal left.
-Coordination: Unable to assess ataxia due to weakness acutely
-Gait: Did not assess
Pertinent Results:
___ 05:30AM GLUCOSE-98 UREA N-16 CREAT-0.6 SODIUM-140
POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-26 ANION GAP-13
___ 05:30AM ALT(SGPT)-13 AST(SGOT)-14 LD(LDH)-144 ALK
PHOS-38
___ 05:30AM LIPASE-37
___ 05:30AM CK-MB-2 cTropnT-<0.01
___ 05:30AM CALCIUM-8.7 PHOSPHATE-3.9 MAGNESIUM-2.1
CHOLEST-188
___ 05:30AM %HbA1c-6.2* eAG-131*
___ 05:30AM TRIGLYCER-87 HDL CHOL-48 CHOL/HDL-3.9
LDL(CALC)-123
___ 05:30AM TSH-3.6
___ 05:30AM WBC-8.5 RBC-4.43 HGB-11.7* HCT-36.4 MCV-82
MCH-26.4* MCHC-32.1 RDW-17.8*
___ 05:30AM NEUTS-63.4 ___ MONOS-6.5 EOS-1.6
BASOS-1.2
___ 05:30AM PLT COUNT-287
___ 01:00AM GLUCOSE-122* UREA N-15 CREAT-0.7 SODIUM-137
POTASSIUM-3.4 CHLORIDE-102 TOTAL CO2-24 ANION GAP-14
___ 01:00AM estGFR-Using this
___ 01:00AM WBC-8.0 RBC-4.28 HGB-11.0* HCT-34.8* MCV-81*
MCH-25.7* MCHC-31.6 RDW-17.7*
___ 01:00AM NEUTS-68.4 ___ MONOS-6.0 EOS-1.5
BASOS-1.1
___ 01:00AM ___ PTT-40.6* ___
___ 01:00AM PLT COUNT-299
CT head ___
No acute intracranial abnormality. Chronic left basal ganglia
infarct with ex vacuo dilatation of the left lateral ventricle.
MRI however is more sensitive for the detection of acute
ischemia
CTA head and neck ___ prelim read
No evidence of dissection of the cervical vasculature. No
stenosis, aneurysm greater than 3 millimeter or other vascular
abnormality. 3D reformats to follow.
MR head ___
1. Tiny focus of restricted diffusion identified in the right
parietal lobe, only visible on the DWI sequence, measuring
approximately 3 x 4 mm in transverse dimension with no evidence
of hemorrhagic transformation, probably represents an acute
ischemic change.
2. Chronic areas of ischemia and prior ischemic hemorrhagic
event
demonstrated in the basal ganglia and caudate nucleus on the
left, causing ex vacuo dilatation of the lateral ventricle.
Chronic changes of ischemia are visualized in the left
cerebellar hemisphere.
Lower extremities ultrasound ___
No evidence of DVT in the bilateral lower extremities.
Brief Hospital Course:
___ is a ___ year old woman with fibromuscular
dysplasia, 2 prior CVAs in ___ and ___, PFO on warfarin (INR
3.5) who presents with acute neurological symptoms concerning
for
new ischemic lesion versus TIA. In the ED she had onset
right-sided hemiparesis/sensation loss and facial droop, LUE
weakness, dysarathria and nonfluent aphasia. CT shows no
obvious new infarct. CTA shows no vessel cutoff. MR head showed
a small restricted diffusion in the right occipital region which
we think is artifactual. Given her risk factors, her
presentation is concerning for TIA. For risk factor assessment:
LDL 123, a1c 6.2%. She was started on atorvastatin. To evaluate
for thromboembolic source in the setting of her known PFO, a
lower extremitiy u/s was done and showed no evidence of DVT.
___ evaluated her and cleared her to be discharged with home
___.
# Transitional issues:
- follow up with neurology (Neurologist in ___ or Dr. ___
based on ___ preference)
- follow up with PCP. Next INR check by ___
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
() Yes - () No
4. LDL documented? (x) Yes (LDL = 123 ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL >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: ()
Antiplatelet - (x) 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. Warfarin 12 mg PO DAILY
2. Citalopram 40 mg PO DAILY
Discharge Medications:
1. Citalopram 40 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
3. Warfarin 12 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Transient ischemic attack
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neuro exam: Non-focal
Discharge Instructions:
Dear Ms ___,
You were hospitalized due to symptoms of weakness and sensory
loss resulting from transient ischemic attack, a condition where
a blood vessel providing oxygen and nutrients to the brain is
transiently decreased. The brain is the part of your body that
controls and directs all the other parts of your body, so
decreased blood supply to the brain from being deprived of its
blood supply can result in a variety of symptoms.
Transient ischemic attack 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 attacks, we plan to
modify those risk factors. Your risk factors are:
PFO
diabetes
high cholesterol
New medication: atorvastatin 40mg daily for your high
cholesterol.
Please continue your home dose of warfarin starting ___
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below. PLease have your PCP check your INR ___
PLease work with physical therapy and occupational therapy.
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:
___
|
10675147-DS-3
| 10,675,147 | 28,162,856 |
DS
| 3 |
2163-07-21 00:00:00
|
2163-07-21 18:06:00
|
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:
___ Left heart and coronary catheterization
History of Present Illness:
___ M with h/o epilepsy and recently diagnosed afib and
cardiomyopathy (EF ___, likely tachyarrhythmia-induced) who
p/w increasing shortness of breath over the last ___ weeks.
Endorses DOE when climbing one flight of stairs, orthopnea, and
PND. Has felt "burning" pain in the ___ his chest when
lying flat over the last ~4 weeks, no diapheresis, improves with
turning on his side. No CP with exertion. Has noticed bilateral
leg swelling recently and a ~10 pound weight gain over the last
4 weeks. He also endorses a dry cough with no fever/chills.
He was seen in clinic today. He was volume overloaded, had
shortness of breath on exertion, and HR was found to be into the
140s. Admitted for diuresis, TEE/DCCV, and maybe an ischemic
eval.
In the ED, initial vitals were 96, 100/77, 140, 20, 97% RA
- Labs significant for: lactate 1.4, Cr 1.3 (baseline 0.9),
TropT <0.01, H&H 15.1/44.7.
- CXR: No acute cardiopulmonary process.
- Given Digoxin 250mcg x1
- Given Furosemide 20mg x1
- Cardiology consulted and recommended admission to ___ service,
digoxin load, lasix 20mg IV x 1, rivaroxaban, and cardioversion
tomorrow
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, hemoptysis, black stools
or red stools. He denies recent fevers, chills or rigors. He
denies exertional buttock or calf pain. All of the other review
of systems were negative.
Cardiac review of systems is notable for absence of
palpitations, syncope or presyncope.
Past Medical History:
Epilepsy
Hyperlipidemia
Blindness left eye secondary to trauma
Chronic low back pain
Umbilical hernia repair six to ___ years ago at ___
Social History:
___
Family History:
Mother age ___ with CAD, otherwise non-contributory.
Physical Exam:
Admission Physical Exam:
VS: 98.1, 100/80, 62, 96% RA
WT: 92.0 kg
GENERAL: WDWN M in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP elevated to 10 cm.
CARDIAC: Irregularly irregular rhythm, normal S1, S2. No
murmurs/rubs/gallops.
LUNGS: CTAB.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 1+ pitting edema to mid-shins
SKIN: No stasis dermatitis, ulcers, or scars.
Discharge Physical Exam:
VS: 98.0, 89-126/56-89, 88-131, 97-98% RA
WT: 89.6 <- 92.0 kg
I/O: 600cc/400+cc, ___
GENERAL: WDWN M in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with no JVD.
CARDIAC: Irregularly irregular rhythm, normal S1, S2. No
murmurs/rubs/gallops.
LUNGS: CTAB.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No edema.
SKIN: No stasis dermatitis, ulcers, or scars.
Pertinent Results:
Admission Labs:
----------------
___ 05:50PM BLOOD WBC-7.9 RBC-4.93 Hgb-15.1 Hct-44.7 MCV-91
MCH-30.6 MCHC-33.8 RDW-13.8 RDWSD-46.1 Plt ___
___ 05:50PM BLOOD Neuts-65.6 ___ Monos-6.9 Eos-0.8*
Baso-0.9 Im ___ AbsNeut-5.17 AbsLymp-2.02 AbsMono-0.54
AbsEos-0.06 AbsBaso-0.07
___ 05:50PM BLOOD ___ PTT-27.6 ___
___ 05:50PM BLOOD Glucose-130* UreaN-21* Creat-1.3* Na-140
K-4.4 Cl-104 HCO3-27 AnGap-13
___ 05:50PM BLOOD Calcium-9.6 Phos-4.3 Mg-1.9
___ 05:50PM BLOOD cTropnT-<0.01 proBNP-4477*
Non-Ischemic CM Work-Up:
___ 05:00AM BLOOD Ferritn-220
___ 05:00AM BLOOD ___
___ 05:00AM BLOOD PEP-AWAITING F ___ FreeLam-15.5
Fr K/L-0.55 IgG-1280 IgA-119 IgM-73 IFE-PND
___ 03:55PM URINE Hours-RANDOM TotProt-<6
___ 03:55PM URINE U-PEP-NO PROTEIN
___ 07:15AM BLOOD HIV Ab-PND
___ 05:00AM BLOOD ANGIOTENSIN 1 - CONVERTING ___
Discharge Labs:
----------------
___ 07:15AM BLOOD WBC-8.6 RBC-5.53 Hgb-16.8 Hct-48.9 MCV-88
MCH-30.4 MCHC-34.4 RDW-13.4 RDWSD-43.8 Plt ___
___ 07:15AM BLOOD Plt Smr-NORMAL Plt ___
___ 07:15AM BLOOD Glucose-81 UreaN-13 Creat-1.1 Na-136
K-4.7 Cl-100 HCO3-27 AnGap-14
___ 07:15AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.3
Pertinent Imaging Results:
Cardiac Cath ___:
Right radial artery access. Insignificant CAD.
TEE ___:
Mild spontaneous echo contrast is present in the left atrial
appendage. A thrombus is seen in the left atrial appendage ( two
separate thrombi). No atrial septal defect is seen by 2D or
color Doppler. Overall left ventricular systolic function is
severely depressed. Right ventricle with depressed free wall
contractility. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened. No masses or vegetations are seen on the aortic
valve. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. No mass or vegetation is seen on the mitral valve.
Mild to moderate (___) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. The estimated
pulmonary artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: ___ thrombus present. Cardiomyopathy.
TTE ___:
The left atrium is mildly dilated. The right atrium is
moderately dilated. The estimated right atrial pressure is at
least 15 mmHg. Left ventricular wall thicknesses and cavity size
are normal. There is severe global left ventricular hypokinesis
(LVEF = 30%). No masses or thrombi are seen in the left
ventricle. Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size is normal with severe global free wall hypokinesis.
The aortic arch is mildly dilated. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild to moderate (___) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with severe global
biventricular hypokinesis c/w diffuse process (toxin, metabolic,
etc. - cannot fully exclude multivessel CAD, but less likely).
Mild pulmonary artery hypertension. Mild-moderate mitral
regurgitation.
Compared with the prior study (images reviewed) of ___,
global biventricular systolic function is slightly improved and
the estimated PA systolic pressure is now lower.
CXR ___:
No evidence of pneumonia or edema. Nodular structures in the
left mid lung likely prominent costochondral calcification
though difficult to exclude pulmonary nodule. If there are
elevated risk factors, consider nonemergent chest CT to further
assess.
ECG ___: Afib with RVR, rate 142, LAD, low voltage in
inferior leads, no ST elevation
Brief Hospital Course:
___ M with h/o epilepsy and recently diagnosed afib and
cardiomyopathy (EF ___ who presented with increasing
shortness of breath over the last ___ weeks.
Patient has relatively new-onset Afib of unknown etiology. TSH
normal (3.4) on ___. Cardiac cath showed no significant CAD.
TEE showed ___ thrombus, so no cardioversion attempted. For rate
control, patient was digoxin loaded with 875mcg IV over 5 doses
followed by 0.25mg PO daily. Home metoprolol succinate was
increased to 175mg daily. Patient was started on rivaroxaban
20mg qHS due to ___ thrombus. Can attempt TEE/cardioversion
again in one month.
Patient has new onset cardiomyopathy (EF ___ that is most
likely tachyarrhythmia-induced. CM is non-ischemic given clean
cardiac cath. Not due to hemochromatosis given normal ferritin.
Autoimmune cause unlikely given negative ___. No preceding viral
illness, so post-viral cardiomyopathy is unlikely. On discharge,
ACE, kappa and lambda free light chains, and HIV-1,2 antibodies
were pending to complete the non-ischemic CM workup. Lisinopril
2.5mg daily was started due to CM with low EF. Home aspirin was
reduced from 325mg daily to 81mg daily.
Patient had acute on chronic sCHF, probably ___ tachyarrhythmia.
Patient was diuresed with Lasix 20mg IV x2 and then restarted on
home Lasix 20mg PO daily. Home metoprolol succinate increased to
175mg daily. Based on lipid panel ___ (TC 195, Trig 92, HDL
56, TC/HDL 3.5, LDL 121), ___ ASCVD risk is 2.1%, so patient
was not started on a statin per guidelines.
Patient reported "burning" CP in the ___ his chest when
lying flat over the last ~4 weeks, which was most likely
GERD-related, given history and no CP with exertion, negative
troponin, and no ECG changes. He was started on omeprazole 40mg
daily.
Patient's epilepsy is well controlled. His last seizure was ___
years ago. Phenytoin sodium extended 300mg BID was continued
during his hospitalization.
Transitional Issues:
- Patient was digoxin loaded with 875mcg IV over 5 doses
followed by 0.25mg PO daily for rate control
- Home metoprolol succinate was increased to 175mg daily
- Patient was started on rivaroxaban 20mg qHS due to ___
thrombus
- Schedule TEE/cardioversion in one month
- Started on lisinopril 2.5mg daily due to CM with low EF
- Aspirin reduced from home dose of 325mg daily to 81mg daily
- F/u remaining non-ischemic CM labs: ACE, kappa and lambda free
light chains, and HIV-1,2 antibodies.
- Omeprazole 40mg daily started due to GERD symptoms
**Discharge weight was 89.6kg**
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY
2. Metoprolol Succinate XL 100 mg PO DAILY
3. Phenytoin Sodium Extended 300 mg PO BID
4. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Rivaroxaban 20 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Phenytoin Sodium Extended 300 mg PO BID
5. Digoxin 0.25 mg PO DAILY
6. Lisinopril 2.5 mg PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Metoprolol Succinate XL 175 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Atrial fibrillation with rapid ventricular response,
Non-ischemic cardiomyopathy, Acute on chronic sCHF
Secondary: GERD, Epilepsy
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 meeting and taking care of you while you were
in the hospital.
You came to the hospital with shortness of breath with exertion
that and when lying flat that had been worsening over the last
___ weeks. We gave you IV medicine called lasix (or furosemide)
to remove the extra fluid that was in your body. You should
continue to take furosemide once daily at home. Please weigh
yourself every morning at home, and call your doctor if your
weight goes up more than 3 lbs.
For your abnormal heart rhythm known as atrial fibrillation, we
could not shock your heart back into a normal rhythm, because we
found a blood clot in your heart. We will try again to shock
your heart back into a normal rhythm in one month. In the
meantime, you should take a blood thinner call rivaroxaban every
evening with dinner. You should take metoprolol succinate once
daily and digoxin once daily to help control your heart rate.
Your heart is dilated and not pumping as well as it should,
which is probably due to the fast heart rate and abnormal rhythm
that it is in. The heart catheterization that you had showed
that you do not have any blockages in the arteries in your
heart. We performed a bunch of tests for causes of an enlarged
heart, which have so far been normal.
We started you on a medicine called omeprazole for the burning
chest pain that you had been experiencing prior to admission.
Please continue to take this medication every morning.
Please continue to take phenytoin twice daily to prevent
seizures.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10675450-DS-5
| 10,675,450 | 26,032,180 |
DS
| 5 |
2125-10-09 00:00:00
|
2125-10-09 15:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back pain, leg weakness
Major Surgical or Invasive Procedure:
Lumbar puncture ___
History of Present Illness:
Ms. ___ is a ___ woman with a history of chronic back
pain, diabetes with lower extremity neuropathy, HTN, HLD, and
hypothyroidism who presents with several months of worsening
lower extremity weakness.
Over the past several months, Ms. ___ has had progressive
bilateral lower extremity weakness complicated by diabetic
neuropathy which has affected her balance. About two months ago
she suffered a fall onto her back which caused severe back pain
and bilateral leg weakness. Since then she has been able to
ambulate although slowly and with some balance issues, and she
has found it difficult to stand from a sitting position. She has
also had pain shooting down her left leg from her lower back,
which has prevented her from performing movements such as
swinging her legs into the car. About two weeks ago she was seen
at ___ where an MRI showed a bulging disc and compression
fracture of the spine, although it was unclear at what level.
Last ___ she reportedly received a cortisone shot but
this did not improve her back pain or lower extremity weakness.
The back pain has progressively worsened to a ___, though it is
relieved somewhat with tylenol and codeine.
On ___ evening, she was getting into bed (which is high off
the floor) but was unable to lift herself off the bed and slid
to the floor. She denies head strike or loss of consciousness.
She denies bowel or bladder incontinence. Due to her inability
to stand as well as her daughter's inability to help her up, she
was brought to ___ and then was transferred to ___ for
concern about a code cord.
In the ___ ER a code cord was activated. Her vitals were T
98.5 HR 92 BP 137/85 RR 18 96% RA. On physical exam she was
found to have motor weakness up to C6, a sensory deficit up to
L4, and absence of reflexes up to L4. There was no saddle
anesthesia or incontinence. Her labs were notable for a WBC of
13.8 (75% PMNs), platelet count of 247, ALT of <5, AST of 50, an
INR of 1.0, glucose of 156, and creatinine of 0.7. Opiates were
found on a urine tox screen. Neurology was consulted for the
code cord and recommended an MRI with and without contrast (no
contraindications to gadolinium), with particular concern for
possible spine mets. An MRI of the C/L/T-spine showed no spinal
cord signal abnormality, with smooth enhancement of multiple
cauda equina roots concerning for meningitis/arachnoiditis vs
demyelinating disorders vs malignancy vs sarcoidosis. Disc
protrusion was also seen at C5/C6 (with mild spinal cord
impingement) and L2-L3 (with possible contact of nerve roots).
She was then admitted to the neurology floor in stable
condition.
Past Medical History:
HTN
HLD
T2DM
GERD
Diabetic neuropathy
Hypothyroidism
Chronic back pain
Rotator cuff injury (L)
Social History:
___
Family History:
Mother died of vulvar cancer. Father unknown. She has an aunt
who had breast cancer, a sister with colon cancer in her ___ and
uncle with colon cancer in his ___. There is no family history
of colitis or ileitis, celiac disease or peptic ulcer disease.
Physical Exam:
ON ADMISSION
============
Vitals: 99.2 141 / ___
General: Obese. Awake and in some pain, but no acute distress.
Pulmonary: No tachypnea. Normal work of breathing.
Neurological exam:
Mental status: Alert and oriented to person, place, time. Able
to
state the months of the year backward. Follows appendicular
commands without difficulty. No apraxia or aphasia.
Cranial nerves:
I: not examined
II: Pupils equally round and briskly reactive to light. 4-->3mm.
Visual fields full.
III, IV, VI: Extraocular movements intact.
V: Facial sensation symmetric.
VII: Facial movements symmetric.
VIII: Hearing intact to conversation.
IX, X: Palate elevates symmetrically.
XI: SCM and trapezius with full strength.
XII: Tongue protrudes in midline, hypoglossal muscles intact
symmetrically.
Motor exam:
[Delt][Tri][ECR][FEx] [___]
L 5 5 5 5 2 2 2 4 5 4
R 5 5 5 5 2 4 2 4 5 5-
Reflexes:
Toes are downgoing b/l
Bi Tri Br Pat Ach
[C5-6] [C6-7] [C5-6] [L3-4] [S1]
L 2 2 2 0 0
R 2 2 2 0 0
Sensory exam:
Decreased sensation to light touch and pain, in length dependent
fashion, below the knee (R) and mid-shin (L). Decreased
sensation to temperature below the knees bilaterally. Full
proprioception in R foot, 1 miss in the L foot. 9 second
vibration on R toe, no vibratory sensation in L toe.
Coordination:
Able to do FNF bilaterally with a very slight action tremor. No
dysdiadochokinesia.
Gait: deferred due to profound weakness
ON DISCHARGE
============
Vitals: Temp: 97.4 PO BP: 118/78 HR: 79 RR: 20 O2 sat: 95% O2
delivery: RA
General: alert, in no apparent distress
Neurological Exam:
Mental status: Alert and oriented to person, place, time. Fluent
with no aphasia or dysarthria. Able to relate history and follow
complex appendicular commands without difficulty.
Motor: Bulk, tone normal. No adventitious movements.
[___]
L 5 5 5 5 2 5 5- ___
R 4+ 5 5 5 3- 5 5 ___
Reflexes:
Biceps 1+, BR 1+ bilaterally
No DTRs elicited in ___
Toes downgoing bilaterally
Gait: Walks with a wide base with hesitant steps with a walker
Pertinent Results:
___ 05:10AM BLOOD VitB12-246
___ 11:54PM BLOOD %HbA1c-6.7* eAG-146*
___ 05:10AM BLOOD TSH-0.65
___ 05:10AM BLOOD ___ CRP-5.9* ESR-2
___ 05:10AM BLOOD HIV Ab-NEG
___ 05:10AM BLOOD HCV Ab-NEG
___ 05:10AM BLOOD Quantiferon Gold-NEG
___ 05:10AM BLOOD HTLV Ab-NEG
___ 05:10AM BLOOD ACE- 26
___ 12:44PM CEREBROSPINAL FLUID (CSF tube 1) TNC-12*
RBC-150* Polys-1 ___ ___ 12:44PM CEREBROSPINAL FLUID (CSF tube 4) TNC-9* RBC-1
Polys-0 ___ ___ 12:44PM CEREBROSPINAL FLUID (CSF) TotProt-78*
Glucose-87 ACE-12
___ 12:44PM CEREBROSPINAL FLUID (CSF) CMV PCR-NEG VZV
PCR-NEG HSV PCR-NEG Cryptococcus-NEG
MRI SPINE W/ AND W/O CONTRAST
CERVICAL:
The craniocervical junction is unremarkable. The cervical spine
alignment is grossly normal.Vertebral body and intervertebral
disc signal intensity appear normal. Median, broad-based disc
protrusion at the C5-6 level causes moderate spinal canal
narrowing with mild impingement of the anterior spinal cord. No
spinal cord signal abnormality or enhancement. The spinal cord
appears normal in caliber and configuration elsewhere. No
abnormal enhancement after contrast administration.
Heterogeneous, mildly increased T2/STIR signal, decreased T1
signal in the
C3-6 vertebrae without erosive changes of the endplates is
suggestive ___ type 1 degenerative changes. There is
moderate hypertrophy of the posterior longitudinal ligament at
the C5-7 levels with disc osteophyte complexes at the C5-6 and
C6-7 levels. Mild left neural foraminal narrowing due to facet
hypertrophy is seen at the C3-4 level.
THORACIC:
Alignment is grossly normal. Areas of T1 and T2 hyperintensity,
predominantly within the T5 and T8 vertebrae (5:7, 7:7), likely
represent fatty marrow ___ type 2 degenerative
changes versus non expansile hemangiomas, otherwise, the
vertebral body and intervertebral disc signal intensity appears
normal with minimal degenerative changes throughout. The spinal
cord appears normal in caliber and configuration. There is no
evidence of spinal canal or neural foraminal narrowing. There is
no evidence of infection or neoplasm. There is no abnormal
enhancement after contrast administration.
LUMBAR:
Alignment is grossly normal. There are multilevel degenerative
changes
predominantly in the lower lumbar spine worst at the L2-3 and
L4-5 levels. There is moderate spinal canal narrowing at L2-L3
secondary to paramedian posterior left disc protrusion, probably
contacting the traversing nerve roots bilaterally (11:16).
There is mild bilateral articular joint facet hypertrophy.
At L4-5 level, there is irregular contour at the superior
endplate of L4
suggestive of Schmorl's node, narrowing of the intervertebral
disc space and mild spondylosis with small posterior disc bulge
causing anterior thecal sac deformity, apparently there is a
small posterior annular fissure, disc bulge is causing bilateral
neural foraminal narrowing and apparently contacting the exiting
nerve roots bilaterally.
No obvious dural enhancement.
OTHER: A 1.0 cm cyst lies within the middle pole of the right
kidney.
IMPRESSION:
1. Degenerative disc protrusion at the C5-6 level causes
moderate spinal
canal narrowing with mild impingement of the anterior spinal
cord. No local spinal cord signal abnormality or enhancement.
2. Degenerative disc protrusion the L2-3 causes moderate
spinal canal
narrowing, apparently contacting the traversing nerve roots
bilaterally.
3. Other multilevel degenerative changes throughout the lumbar
spine at
L3-L4-L4-L5 levels as described above.
Brief Hospital Course:
Ms. ___ is a ___ woman with a history of chronic back
pain, diabetes with lower extremity neuropathy, HTN, HLD, and
hypothyroidism who presents with several months of worsening
lower extremity weakness since a fall 2 months ago. On exam, she
initially had proximal > distal weakness in the lower
extremities only, with a stocking pattern sensory neuropathy to
pin prick and proprioception loss. She is arreflexic with toes
down.
MRI of the entire spine was obtained and showed some very subtle
enhancement of the cauda equina nerve roots, in addition to
chronic degenerative changes. There was no other evidence of
cord compression. However, her serum CRP was elevated (5.9). Due
to concern for an inflammatory or infectious process, lumbar
puncture was performed. This showed an elevated protein (78)
with 9 white cells (lymphocytic).
Differential diagnosis for these findings was broad and included
infectious (especially viral), inflammatory/autoimmune
(including demyelinating processes such as AIDP/CIDP), and
malignancy. Chemical meningitis was also considered given her
recent epidural steroid injection. A broad laboratory work-up
from the serum and CSF was sent. This was notable for:
low-normal B12 (264), normal TSH (0.65), Hgb A1c 6.7%, negative
Hepatitis C antibody, negative HIV, negative RPR, and negative
Quantiferon Gold. CSF was notable for 9 WBCs (lymphocytic), with
protein 78. Other CSF studies included normal ACE level,
negative CMV, VZV, and HSV viral PCR. Cytology and
immunophenotyping did not show any evidence of malignant cells.
EMG and nerve conduction studies were obtained and showed
evidence of chronic diabetic polyneuropathy, as well as possible
left sided polyradiculopathy, but no evidence of demyelination.
Overall, etiology of her presentation is thought to be mild
arachnoiditis, likely due to her recent epidural steroid
injection causing inflammation in addition to baseline diabetic
neuropathy. She will be discharged to rehab for further
strengthening.
TRANSITIONAL ISSUES:
-Follow up in Neurology as above
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 400 mg PO TID
2. Valsartan 160 mg PO DAILY
3. Tradjenta (linaGLIPtin) 5 mg oral DAILY
4. Pioglitazone 30 mg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. amLODIPine 10 mg PO DAILY
7. Levothyroxine Sodium 150 mcg PO DAILY
8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
DAILY:PRN
Discharge Medications:
1. Cyanocobalamin 250 mcg PO DAILY
2. amLODIPine 10 mg PO DAILY
3. Gabapentin 400 mg PO TID
4. Levothyroxine Sodium 150 mcg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Pioglitazone 30 mg PO DAILY
7. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
DAILY:PRN
8. Tradjenta (linaGLIPtin) 5 mg oral DAILY
9. Valsartan 160 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Arachnoiditis
Diabetic neuropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
You were in the hospital due to progressive weakness in your
legs.
In the hospital, we performed several tests. An MRI showed some
very mild inflammation in your low back. We also performed a
lumbar puncture (spinal tap), which showed a few white blood
cells, which probably reflects the epidural steroid injection
you received previously in addition to your diabetes. We also
performed an EMG, which looks at the function of nerves and
muscles in your legs. This showed evidence of the diabetes
affecting the function of your nerves, making them work less
well than they should. However, we think your symptoms should
improve some with rehab and that you should follow-up with
neurology in 3 months for further evaluation.
Best wishes,
Your ___ team
Followup Instructions:
___
|
10675450-DS-7
| 10,675,450 | 21,528,550 |
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| 7 |
2126-08-21 00:00:00
|
2126-08-21 18:35:00
|
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, malaise
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with history of DVT on
xarelto, type II diabetes complicated by neuropathy,
hypertension, hyperlipidemia, chronic back pain, and recently
diagnosed Hodgkin lymphoma on AVD who presents with fever.
Patient was recently admitted ___ to ___ where she underwent
right cervical lymph node excision biopsy by ENT and was
diagnosed with Hodgkin lymphoma. She was seen in clinic on ___
with plan to start AVD via PIV however initiation of Doxorubicin
she had reaction with skin erythema and swelling. Treatment was
stopped and she was given Dexrazoxane for 3 days. She had a port
placed on ___. She then completed C1D1 AVD on ___
She reports a fever of 101 with shaking chills and feeling
unwell. She took 2 Tylenol with improvement in fever. She called
her Oncologist who referred her to the ED.
On arrival to the ED, initial vitals were 97.7 77 101/69 18 94%
RA. Exam was unremarkable. Labs were notable for WBC 1.9 (ANC
1600), H/H 13.0/42.7, Plt 80, Na 132, K 4.1, BUN/Cr ___, AST
93, AST 159, and lactate 1.8. Blood cultures were sent. CXR was
negative for pneumonia. She was given vancomycin and cefepime.
Prior to transfer vitals were 98.7 75 134/67 18 98% RA.
On arrival to the floor, patient reports mild headache and mild
nausea. She denies vision changes, dizziness/lightheadedness,
weakness/numbness, shortness of breath, cough, hemoptysis, chest
pain, palpitations, abdominal pain, vomiting, diarrhea,
hematemesis, hematochezia/melena, dysuria, hematuria, and new
rashes.
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative unless otherwise noted in the HPI.
Past Medical History:
Left common femoral DVT - on xaroelto
Hypertension
Hyperlipidemia
Diabetes mellitus, type 2
Diabetic neuropathy- on gabapentin
Gastroesophageal reflux
Diabetic neuropathy
Hypothyroidism
Chronic back pain
vertigo
Rotator cuff injury (L)- surgery in ___
Tonsilectomy- in childhood
gallbladder removal
Social History:
___
Family History:
Mother died of vulvar cancer. Father unknown. She has an aunt
who had breast cancer, a sister with colon cancer in her ___ and
uncle with colon cancer in his ___. There is no family history
of colitis or ileitis, celiac disease or peptic ulcer disease.
Physical Exam:
ADMISSION:
===========
VS: Temp 100.6, BP 121/82, HR 92, RR 18, O2 sat 96% RA.
GENERAL: Pleasant woman, in no distress, lying in bed
comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Soft, non-tender, non-distended, positive bowel sounds.
EXT: Warm, well perfused, no lower extremity edema.
NEURO: A&Ox3, good attention and linear thought, gross strength
and sensation intact.
SKIN: No significant rashes.
ACCESS: Right chest wall port without erythema or tenderness.
DISCHARGE:
==========
24 HR Data (last updated ___ @ 742)
Temp: 98.7 (Tm 98.7), BP: 134/86 (80-137/52-86), HR: 82
(75-96), RR: 18 (___), O2 sat: 94% (94-100), O2 delivery: Ra
Otherwise notable for obese middle-aged woman sitting up in bed,
NAD. Alert/conversant, OP clear, heart RR, chest with R-sided
port with no surrounding erythema or tenderness, abd soft/NT,
legs warm without edema
Pertinent Results:
ADMISSION LABS:
===============
___ 10:06PM LACTATE-1.8 K+-4.1
___ 09:35PM GLUCOSE-160* UREA N-18 CREAT-0.6 SODIUM-132*
POTASSIUM-8.0* CHLORIDE-102 TOTAL CO2-19* ANION GAP-11
___ 09:35PM estGFR-Using this
___ 09:35PM ALT(SGPT)-93* AST(SGOT)-159* ALK PHOS-54 TOT
BILI-0.7
___ 09:35PM LIPASE-21
___ 09:35PM ALBUMIN-3.7
___ 09:35PM WBC-1.9* RBC-4.45 HGB-13.0 HCT-42.7 MCV-96
MCH-29.2 MCHC-30.4* RDW-14.3 RDWSD-50.6*
___ 09:35PM NEUTS-84* LYMPHS-14* MONOS-2* EOS-0* BASOS-0
AbsNeut-1.60 AbsLymp-0.27* AbsMono-0.04* AbsEos-0.00*
AbsBaso-0.00*
___ 09:35PM ANISOCYT-1+* MACROCYT-1+* RBCM-SLIDE REVI
___ 09:35PM PLT SMR-LOW* PLT COUNT-80*
DISCHARGE LABS:
===============
___ 12:00AM BLOOD WBC-1.9* RBC-3.92 Hgb-11.6 Hct-34.5
MCV-88 MCH-29.6 MCHC-33.6 RDW-13.2 RDWSD-42.6 Plt ___
___ 12:00AM BLOOD Neuts-50 ___ Monos-8 Eos-2 Baso-0
AbsNeut-0.95* AbsLymp-0.76* AbsMono-0.15* AbsEos-0.04
AbsBaso-0.00*
___ 12:00AM BLOOD Plt Smr-LOW* Plt ___
___ 12:00AM BLOOD Glucose-154* UreaN-14 Creat-0.4 Na-141
K-4.1 Cl-103 HCO3-23 AnGap-15
___ 12:00AM BLOOD ALT-29 AST-12 LD(LDH)-186 AlkPhos-60
TotBili-0.3
___ 12:00AM BLOOD Albumin-3.5 Calcium-8.5 Phos-2.6* Mg-1.7
MICROBIOLOGY:
=============
___ 8:30 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 9:56 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 9:38 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
RADIOLOGY:
==========
CXR
Right-sided Port-A-Cath tip terminates in the mid SVC. Heart
size is normal.
The mediastinal and hilar contours are normal. The pulmonary
vasculature is
normal. Except for linear atelectasis in the lingula, the lungs
are clear.
No pleural effusion or pneumothorax is seen. There are no acute
osseous
abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality.
Brief Hospital Course:
___ with recently diagnosed Hodgkin lymphoma on AVD who
presented with fever I/s/o mild neutropenia. No infectious
source was determined. She was treated empirically with
broad-spectrum abx for a few days until she defervesced and was
subsequently transitioned to levofloxacin for bacterial ppx at
discharge. She will follow up in ___ clinic to finish cycle
1 of AVD chemotherapy.
# Febrile neutropenia:
General malaise & fevers at home, no localizing sx, blood &
urine cultures negative, CXR wnl, She was started on
vanc/cefepime in clinic on the day of admission, and
subsequently narrowed to cefepime given absence of PNA, SSTI or
line infection. Cefepime was discontinued and switched to oral
levofloxacin ___ given she had been afebrile for 36 hours and
had ANC>1000. She was discharged on levofloxacin with an ANC of
950 (anticipating a nadir), with plan to follow up in clinic on
___ for her next chemo dose.
# Hodgkin Lymphoma: Diagnosed from neck lymph node pathology in
___, started cycle 1 of doxorubicin/vinblastine/dacarbazine
___. No chemotherapy was administered during her hospital stay;
she will follow up in clinic on ___ for her day #15
doses of the above agents. By mistake her home acyclovir was not
administered until the final day of her hospitalization, but she
was instructed to continue it upon discharge.
# Vasovagal episode: Day prior to discharge patient had episode
of lightheadedness after a hot shower and BP was confirmed to be
80/60, HR 104 in SR, SpO2 97% RA with clear lung sounds. She
felt better and BPO improved to 110s s/p 1L IVF, episode was
attributed to parasympathetic vasodilation. Given her quick
recovery her home antihypertensive meds were continued as below
# Thrombocytopenia: New, likely secondary to chemotherapy and
acute infection. Platelets remained in 80-100K range on daily
labs and did not require transfusion.
# Type II Diabetes complicated by Neuropathy
Continued home gabapentin. Held home linagliptin and
pioglitazone, instead placed on Humalog ISS.
# LLE DVT
Continued home xarelto
# Hypertension
Continued home amlodipine and valsartan
# Hypothyroidism
Continued home levothyroxine
# GERD
Continued home pantoprazole
TRANSITIONAL ISSUES:
====================
[] started levofloxacin for bacterial ppx in case ANC falls
below 500 on AVD
[] has f/u appointment scheduled for ___ to receive C1D15 AVD
dose
PPX: Rivaroxaban
ACCESS: POC
CODE: Full Code (presumed)
COMMUNICATION: Patient
EMERGENCY CONTACT HCP: ___ (daughter)
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Gabapentin 600 mg PO TID
3. Levothyroxine Sodium 150 mcg PO DAILY
4. Pantoprazole 40 mg PO Q24H
5. Valsartan 160 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of
breath/wheezing
8. linaGLIPtin 5 mg oral DAILY
9. Pioglitazone 30 mg PO DAILY
10. Rivaroxaban 20 mg PO DAILY
11. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
12. Cyanocobalamin 1000 mcg PO DAILY
13. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate
14. Ondansetron ODT 8 mg PO Q8H:PRN nausea/vomiting
15. Acyclovir 400 mg PO BID
Discharge Medications:
1. Levofloxacin 750 mg PO DAILY
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
3. Acyclovir 400 mg PO BID
4. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of
breath/wheezing
5. amLODIPine 5 mg PO DAILY
6. Cyanocobalamin 1000 mcg PO DAILY
7. Gabapentin 600 mg PO TID
8. Levothyroxine Sodium 150 mcg PO DAILY
9. linaGLIPtin 5 mg oral DAILY
10. Ondansetron ODT 8 mg PO Q8H:PRN nausea/vomiting
11. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate
12. Pantoprazole 40 mg PO Q24H
13. Pioglitazone 30 mg PO DAILY
14. Rivaroxaban 20 mg PO DAILY
15. Valsartan 160 mg PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Febrile neutropenia
Hodgkin lymphoma
Vasovagal presyncope
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 ADMITTED TO THE HOSPITAL?
- You came in because of fevers, which we take more seriously
when your immune system is suppressed by chemotherapy
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- We did many blood tests and imaging studies, which did not
show us a clear cause of infection
- We think you probably had a virus that resolved on its own
- We treated you with antibiotics for a few days, and are
sending you home on an antibiotic pill to prevent further
infections while your immune system is suppressed
- You had an episode of dizziness and low blood pressure after a
hot shower, which we think was simply a "vagal episode", where
your blood vessels dilate in response to the hot water
WHAT SHOULD I DO WHEN I GO HOME?
- Take all your medications as prescribed
- Keep all of your doctors' appointments as scheduled
We wish you the best,
Your ___ care team
Followup Instructions:
___
|
10675468-DS-19
| 10,675,468 | 26,232,270 |
DS
| 19 |
2127-10-19 00:00:00
|
2127-10-19 17:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___ CC / Nifedipine / Norvasc / Cortisone / Covera-HS /
Hydrochlorothiazide / Levaquin
Attending: ___.
Chief Complaint:
lethargy
Major Surgical or Invasive Procedure:
L midline placement ___
History of Present Illness:
___ woman w PMH dementia, mild aortic stenosis, HTN,
HLD, spinal stenosis, presenting with 3 days increasing lethargy
difficulty walking. Patient was recently admitted here for
traumatic evaluation. During the hospital course she was noted
to have a urinary tract infection. Come by daughter, states
patient has full-time care at home currently however feels
overwhelmed. Daughter does not think the patient has any fever
or cough. The patient complains of some suprapubic discomfort
recently, she says she has been using the bathroom less often
recently and is not always able to sense when she has to go. She
denies dysuria or hematuria.
The patient was recently admitted after a mechanical fall, with
resultant injuries including a L forehead laceration and
bruising of the L knee and shoulder. At the time she had a urine
culture which grew Enterococcus, which was initially treated
with nitrofurantoin, but sensitivities revealed the bug to be
pan-resistant, sensitive only to Vancomycin. The patient at that
time was asymptomatic except for mild urinary retention, and
upon discussion with the PCP it was decided to repeat the UA and
UCx before deciding to treat since the patient was mostly
asymptomatic.
In the ED, initial vitals were T 99 HR 51 BP 155/41 RR 18 O2sat
98%ra. Labs and imaging significant for CT head showing no acute
intracranial process. The patient was mildly hyponatremic. CXR
and EKG obtained, blood and urine cultures obtained. The ED
removed the forehead sutures from the patient's recent fall. The
patient was given Vancomycin, CTX, and Percocet and transfered
to the floor.
REVIEW OF SYSTEMS
The patient denies recent SOB, chest pain, fever, chills,
nausea, vomiting, diarrhea, cough, URI sx.
Past Medical History:
HTN:
Failure of multiple antiHTN medications:
-Calcium-channel blockers --> severe intractable edema.
-HCTZ --> Hyponatremia
-K-sparing --> hyperkalemia
-Clonidine --> did not tolerate
HLD
Bradycardia ___ in setting of CCB and BB
aortic stenosis
ischemic colitis in ___
Spinal stenosis
Carpal tunnel syndrome
TIA
Chronic Left ___ infarct -- on Plavix and ASA
Chronic left vertebral artery occlusion (asymptomatic)
Uteral prolapse with pessary in place
CKD, stage III - Cr stable at 1.0-1.1.
Social History:
___
Family History:
Not relevant to current presentation.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS- T=98.1 BP 136/46 HR 61 RR 18 O2sat 98%ra
Weight 131
GENERAL- NAD, alert, interactive
HEENT- EOMI, MMM. Well healing forehead laceration, diffuse
resolving ecchymoses
NECK- Supple with JVP of 14 cm, almost elevated to the angle of
the jaw at 60 degrees
CARDIAC- RRR, S1S2, + systolic ejection murmur loudest at LUSB
LUNGS- bilateral basilar crackles ___ up the lung fields
ABDOMEN- Soft, NTND. tenderness to palpation over the superpubic
region, the patient says she feels like she has to use the
bathroom.
EXTREMITIES- 1+ pitting edema b/l to the ankles. L knee
ecchymosis
DISCHARGE PHYSICAL EXAM
Notable exam changes: No JVP appreciated, no hepatojugular
reflux. Slight bibasilar crackles on pulm exam.
Pertinent Results:
ADMISSION LABS
___ 10:10PM URINE HOURS-RANDOM UREA N-259 CREAT-33
SODIUM-21 POTASSIUM-37 CHLORIDE-27
___ 10:10PM URINE OSMOLAL-226
___ 12:30PM LACTATE-1.0
___ 12:00PM GLUCOSE-98 UREA N-23* CREAT-1.1 SODIUM-127*
POTASSIUM-5.0 CHLORIDE-93* TOTAL CO2-25 ANION GAP-14
___ 12:00PM estGFR-Using this
___ 12:00PM ALBUMIN-3.8
___ 12:00PM URINE HOURS-RANDOM
___ 12:00PM URINE UHOLD-HOLD
___ 12:00PM WBC-7.7 RBC-2.97* HGB-9.1* HCT-28.3* MCV-95
MCH-30.8 MCHC-32.3 RDW-17.0*
___ 12:00PM NEUTS-56 BANDS-0 LYMPHS-16* MONOS-16* EOS-12*
BASOS-0 ___ MYELOS-0
___ 12:00PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-2+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-1+
BURR-OCCASIONAL STIPPLED-OCCASIONAL TEARDROP-OCCASIONAL
BITE-OCCASIONAL
___ 12:00PM PLT SMR-NORMAL PLT COUNT-292
___ 12:00PM ___ PTT-27.2 ___
___ 12:00PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 12:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
___ 12:00PM URINE RBC-<1 WBC-20* BACTERIA-MOD YEAST-NONE
EPI-0
DISCHARGE LABS
___ 07:50AM BLOOD WBC-7.4 RBC-2.66* Hgb-8.6* Hct-25.6*
MCV-96 MCH-32.2* MCHC-33.4 RDW-17.0* Plt ___
___ 07:50AM BLOOD Glucose-92 UreaN-23* Creat-1.1 Na-129*
K-4.8 Cl-94* HCO3-27 AnGap-13
___ 07:50AM BLOOD Calcium-8.0* Phos-3.5 Mg-2.3 Iron-PND
MICROBIOLOGY
UCx ___ (prior to admission)
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
AMPICILLIN sensitivity testing performed by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ R
NITROFURANTOIN-------- 128 R
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ <=0.5 S
___ URINE CULTURE (Preliminary):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
IMAGING
EKG (my read): 1st degree AV nodal block, unchanged from prior.
No acute ST segment changes concerning for ischemia.
CT Head w/o contrast
1. No acute intracranial process.
2. Decreased size of left frontal subgaleal hematoma.
CXR:
AP AND LATERAL VIEWS OF THE CHEST: There is no pneumothorax.
Tiny bilateral pleural effusions are seen. The cardiac
silhouette is top normal in size but unchanged from prior. There
is no focal airspace consolidation to suggest pneumonia.
Calcifications are seen within the aortic arch. Otherwise, the
mediastinal contour is normal. Degenerative changes of the right
glenohumeral joint are incompletely evaluated.
Brief Hospital Course:
___ woman w PMH dementia, mild aortic stenosis, HTN,
HLD, spinal stenosis, CKD, p/w lethargy and urinary symptoms.
# UTI: The patient was mildly symptomatic on presentation with a
report of lethargy and confusion at home per daughter, mild
suprapubic discomfort, and a dirty UA. No fever or elevated WBC
count. Recent UCx grew resistant Enterococcus, sensitive only to
Vancomycin. Began treatment with Vancomycin on ___, as this
was a complicated UTI (recent hospitalization, recent bladder
catheterization, CRF), treatment duration was decided to be 7
days, with the last dose being on ___. Midline was placed
___ for IV antibiotics at rehab.
# Lethargy: Per ED signout, the patient was reported to be
lethargic by daughter at admission. On exam, the patient seems
to be at her baseline mental status compared to last admission.
The patient's mental status may have improved with antibiotics
in the ED if AMS was ___ UTI. Vancomycin treatment as above.
# HypoNatremia: The patient was hyponatremic during her recent
admission, and improved with some fluid boluses. FeNa < 1
suggested intravascular volume depletion. Encouraged PO intake
and trended Na. The patient was asymptomatic. Sodium on
discharge was 129, but should be rechecked on ___.
# mildly fluid overloaded: ? a component of dCHF from mitral
regurgitation seen on prior echo. The patient is breathing
comfortably now in NAD. Gave IV lasix 20mg on ___, with
improvement of shortness of breath and pulmonary exam.
# s/p recent fall: the patients forehead laceration appears to
be healing well. Will continue to work on strength and balance
training at rehab.
CHRONIC MEDICAL PROBLEMS
# H/O TIA/stroke: CT head negative at this time for acute bleed
- cont asa, plavix
# HTN, HLD, CV risk factors: no acute issues
- cont carvedolil, isosorbide, ASA, lisinopril, simvastatin
# constipation: no acute issues
- cont docusate, senna, lactulose
# Dementia: no acute change in mental status
- cont memantine
- cont sertraline
# Chronic pain: ___ osteoarthritis, recent fall, and spinal
stenosis
- cont home regimin of pain medication: oxycontin 10 hs,
Percocet q8h, lyrica 50 am and 75 pm.
# GERD
- cont ranitidine
TRANSITIONAL ISSUES
- Please check Na, Creatinine, and vancomycin levels (before
vanco dose) ___:
- If Na < 125, encourage PO intake or give gentle IVF; Na was
129 on discharge.
- If Vancomycin levels > 20, hold one dose of vancomycin and
give one dose the following morning
- Please check Cr to ensure that there is no deterioration of
renal function while on vancomycin. Creatinine on discharge was
1.1.
CODE STATUS: OK to resuscitate. Do not intubate.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Aspirin 81 mg PO DAILY
2. Carvedilol 25 mg PO BID
please hold for SBP < 100, HR<60
3. Clopidogrel 75 mg PO DAILY
4. Docusate Sodium 100 mg PO HS
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
hold for sbp<100 or hr<60
6. Lactulose 60 mL PO DAILY
7. Lisinopril 20 mg PO BID
hold for sbp<100, HR<60
8. Memantine 10 mg PO BID
9. Multivitamins 1 TAB PO DAILY
10. Oxycodone SR (OxyconTIN) 10 mg PO HS
11. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain
12. Pregabalin 50 mg PO QAM
13. Pregabalin 75 mg PO HS
14. Ranitidine 150 mg PO BID
15. Senna 2 TAB PO HS
16. Sertraline 100 mg PO DAILY
17. Simvastatin 40 mg PO DAILY
Discharge Medications:
1. Outpatient Lab Work
Please check sodium, creatinine, vanc trough on ___. ___ MD
at ___ ___ follow up the results: see contingencies
attached.
2. Aspirin 81 mg PO DAILY
3. Carvedilol 25 mg PO BID
please hold for SBP < 100, HR<60
4. Clopidogrel 75 mg PO DAILY
5. Docusate Sodium 100 mg PO HS
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
hold for sbp<100
7. Lisinopril 20 mg PO BID
hold for sbp<100
8. Memantine 10 mg PO BID
9. Multivitamins 1 TAB PO DAILY
10. Oxycodone SR (OxyconTIN) 10 mg PO HS
11. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H
12. Pregabalin 50 mg PO QAM
13. Pregabalin 75 mg PO HS
14. Ranitidine 150 mg PO BID
15. Senna 2 TAB PO HS
16. Sertraline 100 mg PO DAILY
17. Simvastatin 40 mg PO DAILY
18. Vancomycin 1000 mg IV DAILY urinary tract infection
Duration: 7 Days
day 1 is ___. Last day is ___
RX *vancomycin 1 gram 1 g DAILY Disp #*3 Vial Refills:*0
19. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Mid-line, heparin dependent: Flush with 10 mL Normal Saline
followed by Heparin as above, daily and PRN per lumen.
RX *heparin lock flush (porcine) [heparin lock flush] 10 unit/mL
DAILY Disp #*1 Vial Refills:*0
20. Lactulose 30 mL PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY: Urinary tract infection
SECONDARY: Hyponatremia, Anemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted for a urinary tract infection,
and treated with antibiotics, you will complete your course of
antibiotics at ___.
It is important that you take all medications as prescribed, and
keep all follow up appointments.
TRANSITIONAL ISSUES
- Please continue vancomycin (7 day course for UTI) 1000mg
daily. Last day will be ___.
- Please check Na, Creatinine, and vancomycin levels (before
vanco dose) ___
- If Na < 125, encourage PO intake or give gentle IVF; Na was
129 on discharge.
- If Vancomycin levels > 20, hold one dose of vancomycin and
give one dose the following morning
- Please check Cr to ensure that there is no deterioration of
renal function while on vancomycin. Creatinine on discharge was
1.1.
Followup Instructions:
___
|
10675468-DS-25
| 10,675,468 | 27,460,420 |
DS
| 25 |
2130-12-25 00:00:00
|
2130-12-25 14:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___ CC / Nifedipine / Norvasc / Cortisone / Covera-HS /
Hydrochlorothiazide / Levaquin / Lyrica
Attending: ___.
Chief Complaint:
cough x3 weeks
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of afib on ___, CHF on torsemide, htn no longer on
antihypertensives, with cough x3 weeks, progressive confusion,
and temp to 99.5 at home.
History is obtained from pt's daughter, ___. She reports cough
x3 weeks. Seen by Dr. ___ on ___ - exam and CXR
reportedly clear, no treatment change. On day of presentation,
___ noted wheeze, and noted to have temp 99.9. Per ___, she
has been progressively weaker. At baseline, she is "with the
program," asks repeatedly what day it is, but generally knows
what's going on. ___ has noted progressive confusion, all
symptoms gradually progressing over the past three weeks. ___
has not heard her complain of anything in particular. They live
in a 2 family house, pt lives on first floor with 24 hour
caregiver. She walks with a walker, but hasn't been able to walk
x ___ days.
In the ___ ED:
Tmax 101, HR 66, 122/55->163/66, 20, 99% NC
Labs notable for:
BUN/Cr 48/1.8
WBC 16.7, Hb 11.4
TnT 0.06 (below last check in ___
BNP 24954 (above prior values, but always elevated >5000)
CXR with ?LLL infiltrate
BCx and UCx sent
Received Tylenol and cefepime 2 gm x1
Past Medical History:
HTN with Failure of multiple antiHTN medications:
-Calcium-channel blockers --> severe intractable edema.
-HCTZ --> Hyponatremia
-K-sparing --> hyperkalemia
-Clonidine --> did not tolerate
Most recently has come off of all BP meds given very fluctuant
BPs
HLD
Bradycardia ___ in setting of CCB and BB
minimal aortic stenosis (last TTE ___
ischemic colitis in ___
Spinal stenosis
Carpal tunnel syndrome
TIA
Chronic Left ___ infarct, on Plavix and ASA
Chronic left vertebral artery occlusion
Uterine prolapse with pessary in place
CKD, stage III (baseline Cr 1.0)
Peripheral neuropathy
PPM: Date of Implant: ___
Indication: Sick Sinus Syndrome
Device brand/name: ___ ___
Model ___: ___
Social History:
___
Family History:
Per OMR
Denies history of GI cancers, IBD, IBD. Denies family history of
early MI, arrhythmia, cardiomyopathies, or sudden cardiac death.
Physical Exam:
Admission PE
VS: 97.1, 167/52, 81, 18, 93% RA
Gen: Sleeping comfortably in bed, in NAD, easily awakens to
verbal stimuli
HEENT: PERRL, EOMI, clear oropharynx, dry MM
Neck: supple, no cervical or supraclavicular adenopathy
CV: RRR, ___ systolic murmur at apex, JVP at ankle of clavicle
at 30 degrees
Lungs: Bibasilar crackles and coarse breath sounds, no wheeze
Abd: soft, nontender, nondistended, no rebound or guarding, no
hepatomegaly, +BS
GU: No foley
Ext: WWP, trace pitting edema bilaterally
Neuro: alert and oriented to person, not to place or date
Discharge PE:
Tc: 98.5 HR 89 BP 189/90 18 97% RA
Gen: Elderly female, fatigued
Lung: CTAB no w/r/r
CV: RRR nl s1s2 no m/r/g
Abd: Soft, NT, ND +BS
Ext: Trace edema
Neuro: AOx2
Pertinent Results:
___ 06:55PM LACTATE-1.1
___ 06:45PM URINE HOURS-RANDOM
___ 06:45PM URINE UHOLD-HOLD
___ 06:45PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 06:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 06:45PM URINE RBC-0 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 06:45PM URINE HYALINE-4*
___ 06:45PM URINE MUCOUS-RARE
___ 05:36PM GLUCOSE-105* UREA N-48* CREAT-1.8* SODIUM-143
POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-29 ANION GAP-19
___ 05:36PM estGFR-Using this
___ 05:36PM CK(CPK)-38
___ 05:36PM WBC-16.7* RBC-3.65* HGB-11.4 HCT-36.4
MCV-100* MCH-31.2 MCHC-31.3* RDW-16.6* RDWSD-60.0*
___ 05:36PM WBC-16.7* RBC-3.65* HGB-11.4 HCT-36.4
MCV-100* MCH-31.2 MCHC-31.3* RDW-16.6* RDWSD-60.0*
___ 05:36PM NEUTS-72* BANDS-0 LYMPHS-15* MONOS-9 EOS-3
BASOS-0 ___ MYELOS-1* AbsNeut-12.02* AbsLymp-2.51
AbsMono-1.50* AbsEos-0.50 AbsBaso-0.00*
___ 05:36PM HYPOCHROM-NORMAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-2+ MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
___ 05:36PM PLT SMR-NORMAL PLT COUNT-314
IMPRESSION:
Streaky opacities in the lung bases may reflect worsening
atelectasis though
infection in the left lung base is not completely excluded.
Brief Hospital Course:
___ y/o woman with MMP admitted with subacute/chronic cough,
fevers, confusion. Now with leukocytosis, and anorexia. CXR
showing no evidence of consolidation. Given that she has a
pacemaker and has been having increasing symptoms for weeks of
fatigue and fevers with positive blood cultures concern for
possible blood stream infection.
#Goals of care: Despite treatment of underlying infection she
continued to report feeling terrible and then began saying she
wants to die. Discussed at length with her daughter and
palliative care. Decision made to focus only on comfort. Her
antibiotics were discontinued. Palliative care was consulted.
-Discharge on home hospice.
-standing and PRN oxycodone liquid, PRN morphine and Ativan
-Comfort measures only
-MOLST form filled with daughter, she is DNR/DNI, do not
hospitalize except for comfort, no HD, no artificial nutrition
or hydration.
# ID: fevers, coagulase negative staph bacteremia, aspiration
pneumonia. She presented with weeks of fatigue, cough, poor
appetite and fevers. CXR showed new RLL consolidation likely
due to aspiration pneumonia. She also had multiple blood
cultures initially grow coagulase negative staph which may
represent a true infection given her PPM. ID was consulted, she
was placed on Vancomycin, Zosyn and azithromycin. Antibiotics
were stopped once decision was made to focus on comfort.
# Anorexia: Likely due to infection, delirium.
# Chronic diastolic CHF: d/c torsemide
# Chronic Pain: continue oxycodone, gabapentin, lidocaine patch
# Neuro: dementia, toxic metabolic encephalopathy.
Encephalopathy secondary to infection and likely poor nutrition.
# Hypertension: Very labile blood pressures throughout
admission. Her blood pressure medications had been discontinued
recently. She was asymptomatic and her hypertension was not
treated.
# Acute renal failure: Resolved after receiving IV fluids.
# Urinary retention: foley placed for comfort.
# Diarrhea: C. diff negative, likely antibiotic induced, PRN
Imodium.
Code status: CMO, DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO QAM
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 200 mg PO QHS
4. Memantine 10 mg PO BID
5. Omeprazole 40 mg PO DAILY
6. OxyCODONE SR (OxyconTIN) 10 mg PO QHS
7. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO TID pain
8. Sertraline 100 mg PO DAILY
9. Gabapentin 400 mg PO QHS
10. Ascorbic Acid ___ mg PO QHS
11. Benefiber Clear SF (dextrin) (wheat dextrin) 3 gram/3.5 gram
oral DAILY
12. Senna with Docusate Sodium (sennosides-docusate sodium)
8.6-50 mg oral TID
13. Lactulose 30 mL PO DAILY
14. Torsemide 20 mg PO DAILY
Discharge Medications:
1. OxycoDONE Liquid 10 mg PO TID
RX *oxycodone 20 mg/mL 10 mg by mouth three times a day
Refills:*0
2. OxycoDONE Liquid ___ mg PO Q3H:PRN pain
3. Gabapentin 400 mg PO QHS
4. Memantine 10 mg PO BID
5. Sertraline 100 mg PO DAILY
6. Lorazepam ___ mg PO Q4H:PRN anxiety
RX *lorazepam 1 mg ___ tablets by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
7. Guaifenesin 10 mL PO TID
8. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidoderm] 5 % (700 mg/patch) Apply one patch to
back Daily Disp #*30 Patch Refills:*0
9. Lactulose 30 mL PO DAILY:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Aspiration pneumonia
Coagulase negative staph bacteremia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted with worsening fatigue, confusion, cough and
fevers. You were found to have a pneumonia and possible blood
infection. Despite treatment with antibiotics your symptoms did
not improve and you and your daughter decided to focus on
comfort. You are being discharged on home hospice to help
control your symptoms.
Followup Instructions:
___
|
10675858-DS-2
| 10,675,858 | 29,932,827 |
DS
| 2 |
2151-04-25 00:00:00
|
2151-04-25 12:12:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
pedestrian struck, multiple injuries
Major Surgical or Invasive Procedure:
ORIF R ulna, IMN R tibia, fasciotomies R leg
closure of fasciotomies
History of Present Illness:
This is a pleasant, ___ year old gentleman who reports being
struck by a car while en route to a football game earlier this
morning. The patient reports that he was mildly intoxicated, and
was struck by a car at approximately 30mph. He reports brief
loss
of consciousness. He was taken to ___, and
received an extensive trauma workup, including CT scan of the
head, c-spine, and torso. Plain films demonstrated a comminuted
fracture of the ulnar distal diaphysis, a displaced open
midshaft
tibial diaphysis fracture, as well as a proximal fibular
diaphyseal fracture, with evidence of a possible chronic right
medial malleolus fracture. Due to concern over the neurovascular
status, a CTA was obtained which demonstrated evidence of a
short
segment occlusion of the proximal right peroneal artery adjacent
ot the tibial fracture site with out extravasation, with distal
reconstitution of the artery.
Past Medical History:
none
Social History:
___
Family History:
non contributory
Physical Exam:
AFVSS
NAD, A&Ox3
RUE: incision c/d/i, no erythema
SILT m/r/u, +EC/IO/EPL/FDS/FDP; wwp, 2+ radial pulse
RLE: dressing c/d/i, toes wwp
SILT sp/dp/t, ___, TA, ___
LLE: buddy tape over first 2 toes, toes wwp
SILT sp/dp/t, ___, TA, ___
Pertinent Results:
___ 06:18AM BLOOD WBC-7.4 RBC-3.05* Hgb-9.6* Hct-27.0*
MCV-88 MCH-31.5 MCHC-35.7* RDW-12.5 Plt ___
___ 05:38AM BLOOD WBC-8.7 RBC-3.63* Hgb-10.9* Hct-32.4*
MCV-89 MCH-30.1 MCHC-33.8 RDW-13.0 Plt ___
___ 01:45PM BLOOD Neuts-85.2* Lymphs-7.9* Monos-6.8 Eos-0.1
Baso-0.1
___ 06:18AM BLOOD Glucose-96 UreaN-9 Creat-0.7 Na-138 K-3.7
Cl-100 HCO3-32 AnGap-10
___ 06:18AM BLOOD Calcium-8.1* Mg-1.9
Brief Hospital Course:
The patient was admitted to the orthopaedic surgery service on
___ with R open tib/fib, R ulna, L P1 fractures. Patient
was taken to the operating room and underwent IMN R tibia,
fasciotomies, ORIF R ulna. Patient tolerated the procedure
without difficulty and was transferred to the PACU, then the
floor in stable condition. Pt returned to OR 2 days later for
closure of the fasciotomies. Patient tolerated the procedure
without difficulty and was transferred to the PACU, then the
floor in stable condition. Please see operative report for full
details.
Musculoskeletal: After procedure, patient's weight-bearing
status was transitioned to RUE ___, RLE WBAT, LLE WBAT.
Throughout the hospitalization, patient worked with physical
therapy and occupational therapy.
Neuro: post-operatively, patient's pain was controlled by
Dilaudid PCA and was subsequently transitioned to oxycodone with
good effect and adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Hematology: The patient was hemodynamically stable.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A po diet was tolerated well. Patient was also started
on a bowel regimen to encourage bowel movement. Intake and
output were closely monitored.
ID: The patient received perioperative antibiotics. The
patient's temperature was closely watched for signs of
infection.
Prophylaxis: *The patient received enoxaparin during this stay,
and was encouraged to get up and ambulate as early as possible.
At the time of discharge on HD#, POD #***, the patient was doing
well, afebrile with stable vital signs, tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The incision was clean, dry, and intact without
evidence of erythema or drainage; the extremity was NVI distally
throughout. The patient was given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 2 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every 6 hours Disp #*50 Tablet Refills:*0
2. DiphenhydrAMINE 12.5-50 mg PO/IV Q6H:PRN Insomnia/Pruritis
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*40 Capsule Refills:*0
4. Enoxaparin Sodium 40 mg SC QHS
RX *enoxaparin 40 mg/0.4 mL at bedtime Disp #*14 Syringe
Refills:*0
5. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 3 hours Disp
#*100 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
R ulna fracture, R tibia/fibula fracture, L great toe proximal
phalanx 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:
******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 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
continues to be non-draining.
******WEIGHT-BEARING*******
non weight bearing right upper extremity; may bear weight
through elbow
weight bearing as tolerated bilateral lower extremity
Left lower extremity in hard soled shoe
******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
Physical Therapy:
Activity: Activity: Activity as tolerated qid
Right lower extremity: Full weight bearing
Right upper extremity: Non weight bearing
Pt can weight bear throuh R elbow
Treatments Frequency:
daily dressing changes
Followup Instructions:
___
|
10675949-DS-16
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DS
| 16 |
2179-06-30 00:00:00
|
2179-06-30 19:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
wrist fracture
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ dementia s/p unwitnessed fall w/ left wrist injury. Comes
from ___, found two days ago to have L wrist swelling.
Reported L wrist fracture on xray from rehab but no films
accompanying pt. She is a poor historian, and does not remember
falling or why she is in the hospital.
In the ED, VS T97.1 Pulse 57, RR18, BP 127/65 satting 95 on RA.
EKG showed normal rhythm non sinus, TWI in VI and flattening in
AVF. No ischemic changes. Labs were normal except for hemolyzed
K. Ortho saw patient and splinted wrist. Said non operable. CT
head and neck were negative. LEft distal ulnar fracture
confirmed on wrist xray. VSS at time of admission.
On the floor, pt. is pleasatnly demented.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
Partial deafness
___ Esophagus
Chronic ischemic heart disease
hoistory of falls
Alzheimer's Dementia
Chrnoic venous hypertension w/o complications
Social History:
___
Family History:
No history of suddenc cardiac death.
Physical Exam:
On admission:
General: NAD
HEENT: Dry MM. Corrective lenses on. Anicteric sclera.
Neck: Flat JVP
CV: RRR no MRG
Lungs: CTABL
Abdomen: Soft NT ND NBS
Ext: LEFT UE in splint. B/L with venous stasis ulcers
Neuro: AO to person. Pleasantly demented. No focal CN deficits.
MAE.
At discharge:
Vitals: T:97.2 BP:150/60 P:66 R:16 O2:95% RA, 105 lbs
General: NAD
HEENT: MMM. Corrective lenses on. Anicteric sclera.
Neck: Flat JVP
CV: RRR, ___ systolic mumur heard best over RUSB
Lungs: CTAB
Abdomen: Soft NT ND NBS
Ext: LEFT UE in splint. No peripheral edema.
Neuro: AO to person and place. Pleasantly demented. No focal CN
deficits.
Pertinent Results:
___ 06:45PM BLOOD WBC-7.7 RBC-4.27 Hgb-12.8 Hct-39.0 MCV-91
MCH-30.0 MCHC-32.9 RDW-14.2 Plt ___
___ 06:45PM BLOOD Neuts-58.8 ___ Monos-8.2 Eos-3.2
Baso-0.6
___ 06:45PM BLOOD Plt ___
___ 06:45PM BLOOD ___ PTT-30.5 ___
___ 01:55PM BLOOD Glucose-123* UreaN-37* Creat-1.2* Na-139
K-4.8 Cl-106 HCO3-24 AnGap-14
___ 06:45PM BLOOD Glucose-95 UreaN-36* Creat-1.2* Na-140
K-5.7* Cl-103 HCO3-25 AnGap-18
___ 01:55PM BLOOD Calcium-8.3* Phos-3.6 Mg-2.4
___ 08:39PM BLOOD K-4.9
Echocardiogram ___
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). There is a 1.1 x 1.2,
echogenic mass attached to the basal interventricular septum,
approximately 1.4 cm below the aortic valve. The mass is highly
mobile and exhibits echogenicity similar to the adjacent
myocardium. Differential diagnosis includes a primary cardiac
tumor (myxoma, papillary fibroelastoma, etc.), thrombus (less
likely given location and normal underlying LV function,
vegetation (much less likely). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets are
moderately thickened. There is a minimally increased gradient
consistent with minimal aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Mobile mass in the left ventricular outflow tract,
as described above. Normal underlying biventricular systolic
function. Minimal calcific aortic valve stenosis. Mild pulmonary
hypertension.
Forearm XRay AP/Lateral; wrist 3 + views; ___
1. Acute fracture involving the distal shaft of the left ulna.
2. Severe deformity of the carpus, slightly progressed from
prior exam with complete flattening of the proximal carpal row
and associated degenerative disease.
CXR ___
AP semi-upright portable chest radiograph obtained. Lung
volumes
are markedly low, which limits the evaluation with areas of
presumed
atelectasis in the lower lungs. There is no evidence of
pneumonia or CHF. No large effusion is seen. The limited
appearance of the cardiomediastinal silhouette appears stable.
Bones are demineralized. No definite fracture seen.
Negative. If strong clinical concern for fracture, dedicated
rib
series may be obtained to further assess.
CT C-spine ___
No acute fracture or malalignment.
CT Head w/o contrast ___
No acute intracranial process.
Brief Hospital Course:
___ yo female with dementia presenting with unwitnessed fall at
rehab with fractured left wrist.
# Questionable Syncope: Unwitnessed fall, patient does not
remember blacking out, falling or any other problems. Denies
any pain or discomfort. Orthostatic vitals wer checked and were
normal. EKG showed sinus rhythm no abnormalities. She was
monitored on telemetry with no abnormalities noted. CXR showed
no evidence of pneumonia, labs showed mild ___ with creatinine
1.2 (baseline 1.1), and she was given fluids. urinalysis was
not consistent with urinary tract infection. An echocardiogram
was performed, which showed a mobile mass vs. thrombus, likely
mass/myxoma in the left ventricular outflow tract. It is
posible that this mass may be intermittently occluding the left
ventricular outflow tract, causign syncopal episodes. She has
had no prior echocardiograms. The presence of the mass was
discussed with the patient's husband (also her healthcare proxy)
and also her daughter in ___ over the phone. The family
agreed that given the patient's age, fragiltiy, dementia, and
high risk of fatal bleed with anticoagulation, no further workup
or management for the mass would be pursued. The patient will
followup with her PCP, and with outpatient cardiology for likely
future TTE and any other management. Family agreed with
transfer back to ___.
# Wrist fracture: She was found to have a left distal ulna
fracture on X-ray. She was seen by nonoperable per orthopedics.
A splint was placed, pain was controlled with tylenol. she
will followup with orthopedics as an outpatient.
___: likely prerenal from dehydration. She received a 500cc
bolus overnight. UA and electrolytes were unrevealing. She was
encouraged to drink PO fluids, and she was eating and drinking
well by the time of discharge.
Transitional Issues:
-Patient was found to have mobile mass in left ventricular
outflow tract. Anticoagulation or surgery is not being pursued
at this time given fall risk and high surgical risk. This was
discussed with patient's husband.
-Please have PCP arrange follow up transthoracic echocardiogram
in the future and/or cardiology follow up
-Code Status: Full Code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D 50,000 UNIT PO Q3 WEEKS
2. Calcium Carbonate 1250 mg PO QHS
3. Salicylic Acid-Sulfur 1 Appl TP ONCE
4. Acetaminophen 650 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Calcium Carbonate 1250 mg PO QHS
3. Salicylic Acid-Sulfur 1 Appl TP ONCE
4. Vitamin D 50,000 UNIT PO Q3 WEEKS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Left distal ulna fracture
Left venticular outflow tract mass
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 ___. You were admitted
after having an unwitnessed fall at rehab. Your wrist was found
to be fractured and was splinted. The orthopedic doctor did not
think that you needed surgery.
An ultrasound of your heart was also obtained as part of
evaluation for your falls. A mass was found in one of the
chambers in your heart. This may or may not be related to your
falls. However, we felt that treatment or surgery for this mass
would likely be higher risk of harm than benefit. This was
discussed with your husband and it was decided not to pursue
treatment at this time.
Followup Instructions:
___
|
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| 10,676,001 | 29,051,030 |
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| 10 |
2177-05-01 00:00:00
|
2177-05-11 17:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
s/p cardiac cathterization ___
History of Present Illness:
___ yr ___ male with hypertension, coronary artery disease,
atrial fibrillation status post ablation and pacemaker, COPD,
skin cancers, BPH, memory impairment and renal insufficiency
w/sudden onset L-sided chest pain while at rest radiating to the
back and down left arm. He was drinking tea when the chest pain
started, of severe squeezing quality ___ on pain scale
associated with diaphoresis, radiating to L shoulder blade and
down his L arm. No nausea. He called an ambulance and EMS
administered 325mg ASA and nitro x1 with EMS w/near resolution
of CP.
In the ED, initial vitals were 96.2 60 141/84 16 100% 4L Nasal
Cannula. Labs and imaging significant for CTA negative for PE or
pna. EKG v-paced and no acute changes. Patient given SL
nitroglycerin with resoultion of his chest pain and 1L NS. Labs
notable for trop 0.03, wbc 14.5, Hct 54.3, plts 570 and creat
1.4.
Vitals on transfer were 97.4 64 153/80 24 100%/RA.
On arrival to the floor, patient is chest pain free. He feels
well and would like to go home. He confirms his usual state of
health prior to the chest pain this AM. The only deviation from
his normal routine includes drinking a bottle of beer at 2pm -
no new exertion or dietary changes.
Past Medical History:
1. CARDIAC RISK FACTORS: +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-Coronary artery disease status post anterior myocardial
infarction ___ years ago
- ppm for bradycardia after MI
- Atrial fibrillation on coumadin, follows in ___ clinic
3. OTHER PAST MEDICAL HISTORY:
R cataract surgery with Dr. ___ on ___
BPH
memory impairment
GERD
renal insufficiency baseline creat 1.3-1.6
BPH
COPD no home o2
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission Exam:
VS- 97.6 162/102 60 18 100/ra 83.8kg
GENERAL- WDWN ___ male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK- Supple with JVP of 4 cm in sitting upright position
CARDIAC- PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS- No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN- Soft, NTND. No HSM or tenderness.
EXTREMITIES- No c/c/e.
SKIN- No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES-
Right: Carotid 2+ DP 2+ ___ 2+
Left: Carotid 2+ DP 2+ ___ 2+
.
Discharge Exam:
Vitals: 97 125/81 61 18 97%RA 514/150
Gen: NAD. Well nourished. Laying in bed. ___ speaking only
HEENT: NCAT. Dry MM. EOMI. PERRL. No LAD.
NECK: Supple with JVP of 5-7cm.
CARDIAC: RRR. NS17s2. NMRG. PMI at ___ left intercostal space
LUNGS: CTAB. Good air flow. No wheeze/rhonchi/rales
ABDOMEN: BS+4. S/NT/ND. No HSM
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Pertinent Results:
Admissio Labs:
___ 07:40PM BLOOD WBC-14.5*# RBC-5.79 Hgb-18.3* Hct-54.3*
MCV-94 MCH-31.7 MCHC-33.8 RDW-14.8 Plt ___
___ 07:40PM BLOOD ___ PTT-46.2* ___
___ 07:40PM BLOOD Glucose-93 UreaN-23* Creat-1.4* Na-139
K-4.9 Cl-104 HCO3-21* AnGap-19
___ 07:40PM BLOOD CK-MB-4
___ 07:40PM BLOOD cTropnT-0.03*
___ 07:40PM BLOOD Calcium-10.0 Phos-2.4* Mg-2.2
Discharge Labs:
___ 07:48AM BLOOD WBC-9.5 RBC-5.26 Hgb-16.3 Hct-49.0 MCV-93
MCH-31.0 MCHC-33.2 RDW-14.8 Plt ___
___ 09:55AM BLOOD ___ PTT-41.1* ___
___ 07:48AM BLOOD Glucose-105* UreaN-19 Creat-1.1 Na-140
K-4.4 Cl-103 HCO3-25 AnGap-16
___ 04:55PM BLOOD CK-MB-6 cTropnT-0.15*
___ 07:48AM BLOOD Calcium-9.6 Phos-4.0 Mg-2.1
Pertinent Labs:
___ 07:40PM BLOOD CK-MB-4
___ 07:40PM BLOOD cTropnT-0.03*
___ 06:05AM BLOOD CK-MB-9 cTropnT-0.27*
___ 04:55PM BLOOD CK-MB-6 cTropnT-0.15*
___ 06:05AM BLOOD %HbA1c-5.6 eAG-114
___ 06:05AM BLOOD Triglyc-60 HDL-39 CHOL/HD-3.1 LDLcalc-70
___ 10:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
Studies:
___ CXR:
Stable exam without acute abnormalities. Please note aortic
dissection cannot be excluded on radiograph.
.
___ EKG:
Ventricular paced rhythm. Underlying atrial rhythm is probably
atrial
fibrillation. Compared to the previous tracing of ___ no
change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
60 ___
.
___ CTA:
1. Atherosclerosis.
2. Chronic obstructive pulmonary disease with mild bronchial
wall thickening.
.
___ L. heart cath:
1. Selective coronary angiography of this right dominant system
demonstrated angiographically apparent flow limiting stenosisin
single
vessel. The LMCA was normal and patent. The LAD had a 90% in
stent
restenosis (at proximal and distal edge of the distal stent)
which was
restented with 0% residual stenosis. The LCx had mild non
obstructive
disease and RCA had 50% mid level non obstructive disease.
2. Limited resting hemodynamics revealed mildly elevated LVEDP
of 19
mmHg with normal central aortic pressure.
3. Successful PTCA and stenting of the mid LAD in-stent
restenosis with
two non-overlapping 2.5 x 12 mm Promus Element DESs (see ___
comments).
FINAL DIAGNOSIS:
1. One-vessel coronary artery disease.
2. Successful PCI of the mid LAD with two nonoverlapping Promus
Element
DESs.
.
___ Echo:
The left atrium is mildly 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. There is
mild regional left ventricular systolic dysfunction with distal
septal/apical septal hypokinesis. No masses or thrombi are seen
in the left ventricle. There is no ventricular septal defect.
The right ventricular cavity is mildly dilated with normal free
wall contractility. The aortic root is mildly dilated at the
sinus level. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. The tricuspid valve leaflets are mildly thickened. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
Brief Hospital Course:
___ yo M with h/o AMI s/p DES x2 to LAD that presented with
crushing, sub-sternal chest pain at rest with elevated
troponins, and no EKG changes. Ruled in for NSTEMI. His cath was
significant for in-stent restenosis of previous DES to distal
LAD. Restented with 0% residual stenosis. Echo after NSTEMI
showed low normal EF 50-55% with no change since prior study in
___.
.
Active Issues:
#NSTEMI: Pt presented with crushing, sub-sternal pain that was
similiar in nature to his prior anterior MI. Pain was alleviated
with SLNG. In the ED he received a CTA and r/o for dissection.
His EKG showed no changes, but his troponins went from 0.03 ->
0.27->0.15. Ruled in for NSTEMI. Went to cath lab on day of
admission after loading with plavix and starting on heparin gtt.
Found to have in-stent restonis of distal stent to LAD.
Restented with DES x2 to LAD with 0% residual stenosis. Pt was
chest pain free after procedure, and no new wall motion
abnormalities on echo. Low-normal EF at 50-55%. He was
previously taking atenolol PRN. He was told to take this
medication daily. Also started on plavix 75mg qday. As his LDL
was at goal, his simvastatin was continued at current dose.
.
#A. fib: H/o paroxysmal atrial fibrillation. Rhythm since
admission was V. paced. His coumadin was initially held in
setting of upcoming catheterization, but restarted afterwards.
On admission, his INR was subtherapeutic. ___ clinic
was notified of this, and he will follow-up for INR check and
potential increase in coumadin dose. He was continued on
atenolol for rate control. No episodes of RVR.
.
___: Pt admitted with Cr of 1.4 which improved to baseline 1.1
after volume repletion. He was prehydrated prior to cath to
avoid further kidney injury.
.
Chronic Issues
#PUMP: Pt with low normal EF on repeat Echo. This is consistent
with prior study and no new wall motion abnormalities noted. No
need to switch atenolol.
.
#HTN: Controlled on lisinopril and atenolol
.
Transitional Issues:
#Will need to start taking BB standing, rather than PRN
#Will f/u with ___ clinic for likely dose increase as INR
subtherapeutic on admission
Medications on Admission:
ATENOLOL - atenolol 50 mg tablet 0.5 (One half) Tablet(s) by
mouth once a day, taken "when BP is high" per PCP instructions
HYDROCHLOROTHIAZIDE - hydrochlorothiazide 25 mg tablet
0.5 (One half) Tablet(s) by mouth daily in the morning
LISINOPRIL - lisinopril 40 mg tablet
1 Tablet(s) by mouth once a day for blood pressure
NITROGLYCERIN [NITROSTAT] - Nitrostat 0.3 mg sublingual tablet
1 (One) Tablet(s) under the tongue as needed for pain, may take
up to 3 tablets 5 minutes apart
OMEPRAZOLE - omeprazole 20 mg capsule,delayed release
1 Capsule, Delayed Release(E.C.)(s) by mouth once a day for
reflux
PENCICLOVIR [DENAVIR] - Denavir 1 % Topical Cream
apply to affected area every ___ hours while awake for 4 days as
needed for cold sores
SIMVASTATIN - simvastatin 40 mg tablet
one Tablet(s) by mouth daily for cholesterol
TAMSULOSIN [FLOMAX] - Flomax 0.4 mg capsule
one Capsule(s) by mouth nightly for prostate per Dr. ___
___ MALEATE - timolol maleate 0.5 % Eye Drops
1 drop(s) both eyes twice a day
VARDENAFIL [LEVITRA] - Levitra 10 mg tablet
one Tablet(s) by mouth daily as needed, do not take on same day
as flomax
WARFARIN - 5mg by mouth once a day or as directed by
___ clinic
Medications - OTC
ACETAMINOPHEN - acetaminophen 500 mg tablet
___ Tablet(s) by mouth twice a day as needed for pain
ASPIRIN - aspirin 81 mg tablet,delayed release
one Tablet(s) by mouth daily
Discharge Medications:
1. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Atenolol 25 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Lisinopril 40 mg PO DAILY
5. Nitroglycerin SL 0.3 mg SL PRN chest pain
6. Omeprazole 20 mg PO DAILY
7. Simvastatin 40 mg PO DAILY
8. Tamsulosin 0.4 mg PO HS
9. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
10. Warfarin 5 mg PO TUES
11. Warfarin 4 mg PO 6X/WEEK (___)
12. Outpatient Lab Work
Please check INR and have results sent to
___ Anticoagulation Management Services
Office ___
Office ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
NSTEMI
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital because you were having chest
pain which was due to a small heart attack. You had a cardiac
catheterization which showed a narrowing of one of your coronary
arteries. You had a stent placed in the area of narrowing which
resulted in improved blood flow. You had an echocardiogram which
was unchanged compared to your previous echocardiogram. You will
be contacted regarding follow up with the Cardiology department.
Your INR was noted to be below the therapeutic range at 1.8. You
will need to have your INR followed closely to get back in the
therpeutic range of 2.0-3.0. You will have your INR checked on
___ during your visit at ___.
Medication Changes
START Plavix 75mg daily
START Aspirin 325mg daily (for at least one month)
Followup Instructions:
___
|
10676001-DS-12
| 10,676,001 | 23,832,591 |
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| 12 |
2180-09-10 00:00:00
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2180-09-11 15:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
Pharmacologic stress MIBI
History of Present Illness:
Ms. ___ is a ___ ___ man with h/o htn, CAD
anterior MI, with DES to the mid LAD on ___, afib s/p AVN
ablation and PPM and on Coumadin who p/w chest pain and syncope
at home. ___ interpreter was available to aid this writer in
gathering HPI information.
Mr. ___ was reportedly not feeling well for the past 3
days. He has had fatigue, dizziness, and intermittent chest
pain. Reportedly the pain was radiating into his left scapula
but not associated with any dyspnea and not pleuritic in nature.
Today, his ___ was visiting and was obtaining some blood for an
INR check and checked his blood pressure, which was reportedly
80/50. The patient then suddenly lost consciousness for a few
seconds. He did not hit his head as he was sitting in a chair at
the time. He denied any preceding symptoms. Reportedly patient
did not have any shaking movements and did not lose bowel or
bladder function. He denies any recent illness, denies any
fevers, cough, n/v, or diarrhea. He denies any sick contacts.
In the ED, initial vital signs were: 98.9 60 119/77 16 97% RA
- Exam was notable for: Mentating, warm, no peripheral edema,
no crackles.
- Labs were notable for: plt 671, INR 2.1
- Imaging: CXR without acute cardiopulmonary process
- The patient was given: nothing
- Consults: cardiology interrogated pacer with normal function
and no arrhythmias, recommended admission given patient is very
high risk
Vitals prior to transfer were: 98 62 114/77 18 98% RA
Upon arrival to the floor, patient is feeling very well. He
feels like himself and has no complaints. He reports that his
chest pain is resolved and denies any shortness of breath.
Past Medical History:
- Hyperlipidemia
- Hypertension
- Coronary artery disease s/p anterior MI, with DES to the mid
LAD on ___
- PPM for bradycardia after MI
- Atrial fibrillation on coumadin
- BPH
- Hemorrhoids
- History of adenomatous polyps
Social History:
___
Family History:
No family history of GI malignancy.
Physical Exam:
ADMISSION
=========
VITALS: 97.5 137/75 88 18 100% RA
GENERAL: Very Pleasant elderly man, 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, JVP flat.
CARDIAC: very difficult to appreciate heart sounds but without
any murmurs
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&Ox3 (hospital, ___, but does not know month or
date), CN II-XII grossly normal, normal sensation
DISCHARGE
=========
VITALS: 97.5 PO 135/80 60 16 99 RA
GENERAL: Very pleasant elderly man, well-appearing, in no
distress.
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly, JVP flat.
CARDIAC: very difficult to appreciate heart sounds but without
any murmurs
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&Ox3 (hospital, ___, but does not know month or
date), CN II-XII grossly normal, normal sensation
Pertinent Results:
ADMISSION
=========
___ 03:58PM BLOOD WBC-9.2 RBC-5.63 Hgb-13.0* Hct-42.3
MCV-75* MCH-23.1* MCHC-30.7* RDW-23.0* RDWSD-58.1* Plt ___
___ 03:58PM BLOOD Neuts-63.8 ___ Monos-11.2 Eos-3.1
Baso-1.6* Im ___ AbsNeut-5.86 AbsLymp-1.77 AbsMono-1.03*
AbsEos-0.28 AbsBaso-0.15*
___ 03:58PM BLOOD ___ PTT-39.4* ___
___ 03:58PM BLOOD Glucose-93 UreaN-21* Creat-1.2 Na-140
K-4.7 Cl-111* HCO3-22 AnGap-12
PERTINENT
=========
___ 05:12AM BLOOD CK(CPK)-37*
___ 05:12AM BLOOD CK-MB-1 cTropnT-<0.01
___ 03:58PM BLOOD cTropnT-<0.01
DISCHARGE
=========
___ 03:58PM BLOOD WBC-9.2 RBC-5.63 Hgb-13.0* Hct-42.3
MCV-75* MCH-23.1* MCHC-30.7* RDW-23.0* RDWSD-58.1* Plt ___
___ 05:12AM BLOOD ___ PTT-38.7* ___
___ 05:12AM BLOOD Glucose-82 UreaN-22* Creat-1.1 Na-138
K-4.5 Cl-112* HCO3-19* AnGap-12
___ 05:12AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.1
IMAGING
=======
___ CXR: IMPRESSION:
No significant interval change. No acute cardiopulmonary
process.
pharm-MIBI ___:
IMPRESSION: 1. Partially reversible, moderate severity perfusion
defect in the distal anterior wall and the apex in the expected
distribution of the distal LAD.
2. Normal myocardial function with EF of 75%.
TTE ___:
Conclusions
The left atrium is mildly 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. There is
mild regional left ventricular systolic dysfunction with distal
septal/apical septal hypokinesis. No masses or thrombi are seen
in the left ventricle. There is no ventricular septal defect.
The right ventricular cavity is mildly dilated with normal free
wall contractility. The aortic root is mildly dilated at the
sinus level. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. The tricuspid valve leaflets are mildly thickened. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
Compared with the prior study (images reviewed) of ___, no
change.
EKG: V-paced at rate 60, underlying afib similar to prior
Pharm stress MIBI:
1. Partially reversible, medium sized, mild perfusion defect
involving the LAD territory.
2. Normal left ventricular cavity size. Apical akinesis with
preserved systolic function.
3. No anginal symptoms with an uninterpretable ECG for
ischemia. Appropriate blood pressure response to the vasodilator
stress.
Brief Hospital Course:
Ms. ___ is a ___ ___ man with h/o htn, CAD
anterior MI, with DES to the mid LAD on ___, afib s/p AVN
ablation and PPM and on Coumadin who p/w chest pain and syncope
at home.
#Syncope:
Patient reporting that he didn't actually experience syncope,
just felt a little lightheaded. Pacer interrogation was
unremarkable. Patient also without any localizing sign/symptoms
of infection that may be caused recent weakness. Patient without
any symptoms currently and without any complaints. Orthostatics
positive, although in setting of pacemaker, but episode occurred
when sitting. Orthostatics improved with fluids. Most likely
vaso-vagal in setting of getting blood draw.
#Chest pain:
Patient denies experiencing chest pain formerly (as reported on
admission) at this point. Reports no pain. No e/o pericarditis
on EKG and no recent viral infection. Troponins <0.01 x2. Pharm
stress MIBI negative.
# memory loss: Patient intermittently with confusion, thinking
his wife is on vacation. Continued donepezil.
CHRONIC ISSUES:
# afib: contued Coumadin, check INR daily
# CAD: Not on ASA, continued simvastatin 40
# HTN: continued lisinopril as above
# BPH: continued tasmulosin
# GERD: continued omeprazole
# glaucoma: continued timolol
TRANSITIONAL ISSUES
===================
-No medication changes during this admission
-Patient will have PCP followup with Dr. ___ on ___
-Consider discussion of code status; patient reports he has not
discussed this in the past, and it would be good to confirm his
full code status if nothing else.
-Healthcare proxy form with wife ___
___ contact: wife ___: ___
# CODE STATUS: full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
3. Warfarin 3 mg PO DAILY16
4. Simvastatin 40 mg PO QPM
5. Donepezil 10 mg PO QHS
6. Omeprazole 40 mg PO DAILY
7. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Donepezil 10 mg PO QHS
2. Lisinopril 20 mg PO DAILY
3. Omeprazole 40 mg PO DAILY
4. Simvastatin 40 mg PO QPM
5. Tamsulosin 0.4 mg PO QHS
6. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
7. Warfarin 3 mg PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
Vasovagal presyncope
Rule out Acute Coronary Syndrome
SECONDARY
Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Thank you for choosing to receive your care at ___. You were
admitted for chest pain and lightheadedness, although it appears
that this may not have been actually present now per your
report. We think your lightheadedness was a result of your
body's reaction to the blood draw. You underwent a test to see
whether there were any problems with blood flow to your heart,
which showed no concerns for a heart attack or blockage of the
blood vessels of your heaert
Moving forward, you should attend the upcoming appointments
listed below, and continue taking your meds as listed below.
We wish you the best with your ongoing recovery.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10676001-DS-13
| 10,676,001 | 21,921,338 |
DS
| 13 |
2181-08-08 00:00:00
|
2181-08-08 19:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
rigors
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with PMH of advanced dementia, CAD, A-fib on
Coumadin and complete heart block s/p PPM presenting with
rigors. History obtained from wife using ___ interpreter,
patient unable to answer most questions. Per wife he has been
more fatigued over last few days, not walking as much or eating
as much. He has difficulty expressing himself but wife reports
he has been complaining of diffuse pain. Late last night he
began having diffuse shaking chills and taken to the ED. In the
ED he was found to be febrile to 102.2, given Tylenol and IV
fluids without further fevers. Currently he reports having pain
but cannot say more about it. His wife denies any cough,
diarrhea, rash.
ROS: unable to obtain, patient not answering most questions.
Past Medical History:
- Hyperlipidemia
- Hypertension
- Coronary artery disease s/p anterior MI, with DES to the mid
LAD on ___
- PPM for complete heart block
- Atrial fibrillation on coumadin
- BPH
- Hemorrhoids
- History of adenomatous polyps
- Polycythemia requiring intermittent phlebotomy
- Thrombocytosis on hydroxyurea
Social History:
___
Family History:
No family history of malignancy.
Physical Exam:
Admission PE:
97.9 124 / 68 69 20 98 ra
Gen: NAD, resting comfortably in bed
HEENT: EOMI, PERRLA, dry mucus membranes, OP clear
Neck: supple, non-tender, normal range of motion without pain
CV: RRR nl s1s2 no m/r/g. PPM site without erythema or
tenderness
Resp: CTAB no w/r/r
Abd: Soft, mild diffuse tenderness, ND + BS
Ext: no c/c/e
MSK: mild diffuse tenderness of extremities
Neuro: CN II-XII intact, ___ strength throughout. Only oriented
to person, not answering most questions but follows basic
commands
Skin: warm, dry no rashes
Discharge PE:
97.7 135 / 84 72 18 96 RA
Gen: NAD, resting comfortably in bed
HEENT: EOMI, PERRLA, MMM, OP clear
Neck: supple, non-tender, normal range of motion without pain
CV: RRR nl s1s2 no m/r/g. PPM site without erythema or
tenderness
Resp: CTAB no w/r/r
Abd: Soft, NT, ND + BS
Ext: no c/c/e
MSK: non-tender, normal ROM
Neuro: CN II-XII intact, ___ strength throughout. Only oriented
to person, not answering most questions but follows basic
commands
Skin: warm, dry no rashes
Pertinent Results:
___ 06:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 06:00AM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 01:56AM ___ PTT-37.2* ___
___ 01:53AM LACTATE-2.2*
___ 01:45AM GLUCOSE-110* UREA N-25* CREAT-1.3* SODIUM-138
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-17* ANION GAP-20
___ 01:45AM ALT(SGPT)-10 AST(SGOT)-13 ALK PHOS-68 TOT
BILI-0.5
___ 01:45AM LIPASE-37
___ 01:45AM WBC-10.1* RBC-5.31 HGB-13.2* HCT-41.1 MCV-77*
MCH-24.9* MCHC-32.1 RDW-29.0* RDWSD-77.3*
CXR ___:
IMPRESSION:
Mild interstitial pulmonary edema. No evidence of pneumonia.
CT A/P ___:
IMPRESSION:
1. No acute abnormalities within the abdomen or pelvis.
2. Prostatomegaly.
Discharge labs:
___ 06:55AM BLOOD WBC-9.2 RBC-5.20 Hgb-13.0* Hct-40.6
MCV-78* MCH-25.0* MCHC-32.0 RDW-29.2* RDWSD-78.6* Plt ___
___ 06:55AM BLOOD ___
___ 06:55AM BLOOD Glucose-106* UreaN-20 Creat-1.1 Na-139
K-5.0 Cl-106 HCO3-18* AnGap-20
___ 06:55AM BLOOD CK(CPK)-77
___ 6:00 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
___ year old male with PMH of advanced dementia, CAD, A-fib on
Coumadin and complete heart block s/p PPM presenting with rigors
and found to be febrile in ED.
#Fever
Per wife he has been more fatigued for a few days and developed
rigors at home, having diffuse body pain but no other localizing
signs of symptoms. U/A bland, CXR without signs of pneumonia,
CT A/P without acute process, influenza negative. No menigsmus
or report of headache, low suspicion for meningitis. No further
fevers, leukocytosis resolved and diffuse aches improved.
Likely viral infection which self-resolved.
-Follow-up blood cultures.
#CV: CAD, A-fib on Coumadin, complete heart block s/p PPM, HTN
-Continue Aspirin, lisinopril, simvastatin
-Continue warfarin for goal INR ___
#Dementia: Has advanced dementia requiring complete care by wife
and home health aides. Per wife mental status slightly
worsened, possibly mild encephalopathy from underlying
infection. Close to baseline mental status on discharge per
wife.
-Continue donepezil and memantine
#CKD stage III: creatinine appears at baseline of ___
-Continue to trend, avoid nephrotoxins
#BPH: PVR checked and no signs of retention.
-Continue Flomax
#FEN/PPX: regular diet, Coumadin
Full code
HCP: ___
___: son
Phone number: ___
Proxy form in chart: No
Emergency contact: wife ___: ___
___: home with services
___ MD
___ ___
Hospitalist, Department of Medicine
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Donepezil 10 mg PO QHS
2. Lisinopril 20 mg PO DAILY
3. Omeprazole 40 mg PO DAILY
4. Simvastatin 40 mg PO QPM
5. Tamsulosin 0.4 mg PO QHS
6. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
7. Warfarin 3 mg PO 4X/WEEK (___)
8. Hydroxyurea 500 mg PO DAILY
9. Memantine 5 mg PO DAILY
10. Warfarin 4 mg PO 2X/WEEK (___)
11. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Aspirin 81 mg PO DAILY
3. Donepezil 10 mg PO QHS
4. Hydroxyurea 500 mg PO DAILY
5. Lisinopril 20 mg PO DAILY
6. Memantine 5 mg PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Simvastatin 40 mg PO QPM
9. Tamsulosin 0.4 mg PO QHS
10. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
11. Warfarin 3 mg PO 4X/WEEK (___)
12. Warfarin 4 mg PO 2X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Fever, likely viral infection
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted with shaking chills and were found to have
fevers. The fevers resolved and your symptoms improved on their
own. Most likely this was a viral infection that improved on
its own. Please follow-up with your primary care physician ___
___ weeks.
Followup Instructions:
___
|
10676060-DS-16
| 10,676,060 | 29,270,081 |
DS
| 16 |
2173-01-02 00:00:00
|
2173-01-03 22:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a ___ year old male with PMHx DM, HTN, atrial
fibrillation on coumadin, former smoker s/p resection of
lingular mass like opacity ___ (path consistent with a post
inflammatory/infectious lesion), new known RLL mass s/p
bronchoscopy on ___ presenting with hemoptysis. For the past
several weeks the patient has been experiencing dyspnea on
exertion. He first presented with some hemoptysis on ___ at
which point he had an abnormal CXR. At that time he was also
experiencing some headaches. He subsequently had a PET CT which
showed an irregular lobulated right lower lobe mass measuring
approximately 39 mm x 35 mm x 22 mm with right hilar and
mediastinal indeterminate lymph nodes. He also had an MRI head
which did not show any masses. He underwent bronchoscopy on
___ which showed fragments of alveolated lung parenchyma
with focal organization pneumonia; GMS, AFB, and Gram stains
were negative for microorganisms.
Starting on ___ at approximately 3 pm, the patient started
experiencing increased hemoptysis. Additionally, he also
endorses right sided chest pain when he coughs. He does endorse
some dyspnea on exertion which has been worsening over the past
several weeks.
In the ED, initial vitals were: 98.6 91 155/77 18 97%
- Labs were significant for
- BMP wnl
- WBC 11.3 Hgb 13.5 Hct 39.3 Plt 228; N:74.9 L:13.5 M:10.1 E:0.4
Bas:0.3
- ___: 30.0 PTT: 40.6 INR: 2.7
- Imaging revealed:
- CXR: Again seen is focal consolidation in the right lower lobe
compatible with patient's known underlying lesion. There is no
new focal consolidation, effusion, or pneumothorax.
Cardiomediastinal silhouette is stable. No acute osseous
abnormalities.
IMPRESSION:
No significant interval change. Focal right lower lobe opacity
compatible with known underlying lesion as seen on prior PET-CT.
- EKG: Rates 102, irregularly irregular rhythm, left axis
deviation, normal intervations, no ST changes
- Vitals prior to transfer were: 99.7 78 138/53 17 97% RA
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
- Gastric mucosal abnormality characterized by erythema on EGD
seen at ___ ___
- internal hemorrhoids on colonoscopy
- diverticulosis on colonoscopy
- DVT ___ years ago, in the setting of knee surgery)
- atrial fibrillation, on anticoagulation.
- DMII
- HTN
- s/p resection of ___ of L lung for a nodule, which was found
in retrospect to be non-cancerous
- varicose veins
- bilateral cataracts
- old retinal detachment
- ED
- cervical radiculopathy
Social History:
___
Family History:
Denies family history of stroke, arrythmia, premature MI,
cancers
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM:
=======================
Vitals: 98.8 153/97 89 18 96% RA
General: Alert, oriented, dyspneic on conversation
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Right lower lung with rhonchi up to middle lung, left
lung apex without breath sounds.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
======================
DISCHARGE PHYSICAL EXAM:
======================
Vitals: T 98.5 BP 117/78 HR 72 RR 18 100%RA
General: Alert, oriented, in no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, no
conjunctival pallor
Neck: Supple, JVP not elevated, no LAD
CV: Irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Right lower lung with rhonchi, dullness to percussion, no
tactile fremitus.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, venous stasis changes in bilateral lower extremities
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait normal.
Pertinent Results:
==============
ADMISSION LABS:
==============
___ WBC-11.3*# RBC-4.29* Hgb-13.5* Hct-39.3* MCV-92
MCH-31.5 MCHC-34.4 RDW-12.7 RDWSD-41.7 Plt ___
___ Neuts-74.9* Lymphs-13.5* Monos-10.1 Eos-0.4* Baso-0.3
Im ___ AbsNeut-8.43* AbsLymp-1.52 AbsMono-1.14* AbsEos-0.04
AbsBaso-0.03
___ ___ PTT-40.6* ___
___ Glucose-244* UreaN-16 Creat-0.8 Na-135 K-3.8 Cl-98
HCO3-24 AnGap-17
___ Calcium-8.9 Phos-2.7 Mg-2.1
==============
PERTINENT RESULTS:
==============
CXR (___): No significant interval change. Focal right lower
lobe opacity compatible
with known underlying lesion as seen on prior PET-CT.
==
Lower Extremity Ultrasound (___): No evidence of deep venous
thrombosis in the bilateral lower extremity veins.
==============
DISCHARGE LABS:
==============
___ WBC-15.4* RBC-4.66 Hgb-14.7 Hct-43.3 MCV-93 MCH-31.5
MCHC-33.9 RDW-12.6 RDWSD-42.5 Plt ___
___ ___
___ Glucose-154* UreaN-19 Creat-0.8 Na-134 K-4.1 Cl-95*
HCO3-27 AnGap-16
___ Calcium-9.3 Phos-3.1 Mg-2.2
Brief Hospital Course:
Mr. ___ is a ___ man with history of atrial fibrillation
on warfarin with RLL cryptogenic organizing pneumonia s/p
bronchoscopy with biopsy on ___ who presented with nonmassive
hemoptysis. He was seen by Interventional Pulmonology, who
thought that the hemoptysis was a consequence of the recent
bronchoscopy with biopsy. The patient was given antitussives,
and had no additional hemoptysis. To treat his cryptogenic
organizing pneumonia, he was discharged on prednisone 40 mg
daily for ___ weeks with Bactrim prophylaxis, calcium and
Vitamin D. Given the patient's high risk of bleeding, his
warfarin was discontinued and he was started on aspirin. The
patient is to follow up with Interventional Pulmonology.
============
ACTIVE ISSUES:
============
# Hemoptysis: Patient with subacute history of hemoptysis
presented with nonmassive hemoptysis one week s/p bronchoscopy.
Interventional pulmonology was consulted, and thought that the
hemoptysis was likely a consequence of recent instrumentation
and biopsy. The patient's warfarin was discontinued. He was
given antitussives and had no further episodes of hemoptysis.
# Cryptogenic Organizing Pneumonia: Patient with known right
lower lobe mass. Pathology from recent bronchoscopy showed focal
organizing pneumonia. GMS, AFB, and Gram stains were negative
for microorganisms. The patient was discharged on prednisone 40
mg daily for ___ weeks with Bactrim prophylaxis, calcium and
Vitamin D. The patient will follow up with Interventional
Pulmonology.
# Atrial fibrillation: Home digoxin was continued: Digoxin 0.125
mg PO 4X/WEEK ___ Digoxin 0.1875 mg PO 3X/WEEK
(___). Given the patient's high risk of bleeding, his
warfarin was discontinued and he was started on aspirin 325 mg
daily.
==============
CHRONIC ISSUES:
==============
# DMII: Continued home metformin and glimepiride.
# HTN: Continued Diltiazem Extended-Release 300 mg daily.
# HLD: Continued pravastatin 40 mg PO QPM.
# GERD: Continued omeprazole 20 mg PO DAILY.
===============
TRANSITIONAL ISSUES:
===============
- Warfarin was discontinued and aspirin was started. Plan per IP
to stop anticoagulation indefinitely. Please continue to
consider risks versus benefits.
- Patient was discharged on prednisone 40 mg daily. Appropriate
taper to be determined at next pulmonology appointment.
- Patient discharged on Bactrim and GI prophylaxis while on
steroids.
- Patient to have repeat CT chest in ___ weeks.
# CODE STATUS: Full (Confirmed)
# CONTACT: ___ (Wife) ___ ___ (Son) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 500 mg PO BID
2. Diltiazem Extended-Release 300 mg PO DAILY
3. Digoxin 0.125 mg PO 4X/WEEK (___)
4. Digoxin 0.1875 mg PO 3X/WEEK (___)
5. Warfarin 4 mg PO 4X/WEEK (___)
6. Warfarin 3 mg PO 3X/WEEK (___)
7. Pravastatin 40 mg PO QPM
8. Omeprazole 20 mg PO DAILY
9. Vitamin E 400 UNIT PO DAILY
Discharge Medications:
1. Digoxin 0.125 mg PO 4X/WEEK (___)
2. Digoxin 0.1875 mg PO 3X/WEEK (___)
3. Diltiazem Extended-Release 300 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Pravastatin 40 mg PO QPM
6. Vitamin E 400 UNIT PO DAILY
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
9. PredniSONE 40 mg PO DAILY
Take daily for 6 weeks.
RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*1
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
Take one pill daily for 6 weeks
RX *sulfamethoxazole-trimethoprim [Bactrim] 400 mg-80 mg 1
tablet(s) by mouth once a day Disp #*60 Tablet Refills:*0
11. Calcium Carbonate 1000 mg PO DAILY
RX *calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg) 2
tablet(s) by mouth once a day Disp #*60 Tablet Refills:*1
12. Vitamin D 400 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 1 tablet(s) by mouth
once a day Disp #*60 Tablet Refills:*0
13. Tessalon Perles (benzonatate) 100 mg oral TID:PRN
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
14. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H
RX *codeine-guaifenesin 100 mg-10 mg/5 mL 5 mL by mouth every
six (6) hours Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Hemoptysis
- Cryptogenic Organizing Pneumonia
Secondary Diagnosis:
- Atrial fibrillation
- Hypertension
- Hyperlipidemia
- 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 during your recent
admission to ___. You came to us because you were coughing
blood. We gave you medications to help your coughing. We also
gave you medications to treat the pneumonia in your lung. You
will follow up with the lung doctors to make sure that you
continue to get better. We wish you a fast recovery.
***Please continue to take aspirin but STOP coumadin per the
pulmonologist recommendation*** You should follow up with your
primary doctor in one week about this plan.
You will continue taking steroids (prednisone) until at this
dose until your pulmonologist tells you further instructions.
While you are on prednisone you will need to take omeprazole and
bactrim to protect you from infections and protect you from
stomach irritation.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10676247-DS-16
| 10,676,247 | 23,253,910 |
DS
| 16 |
2125-01-16 00:00:00
|
2125-01-16 13:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w PMH of pyelonephritis, ?NPH, ?glaucoma presenting with
back and abdominal pain, and headaches over the last week. Pt
reports gradual onset of lower back pain starting 6 days ago.
The pain has become increasingly severe, and is associated with
headache, and nausea/vomiting. ___ days ago the pain began
radiating to her abdomen, which is now very tender. She reports
severe pain in her lower abdomen worsen in her RLQ, radiating to
her back. She has been unable to eat or drink for ___ days
secondary to pain. Patient has also had associated nausea and
vomiting of food.
Pt endorses fevers/chills. Denies dysuria, saddle anesthesia,
incontinence, ___ weakness. She denies photophobia. Review of
systems negative for any chest pain or shortness of breath.
In the ED, initial vitals were: ___ 82 91/50 20 100% RA
- Exam was significant for:
VS: 98.2 96 105/66 16 100% RA
Uncomforable, tearful
CV, Pulm benign
Abd: Marked guarding and rebound tenderness. TTP RLQ.
- Labs were significant for leukocytosis, positive u/a, and
hypokalemia 3.0.
- Imaging revealed R sided pyelnephritis on ct a/p with contrast
- The patient was given 10mg reglan, 25mg IV benadryl, and 1 L
NS.
Vitals prior to transfer were: ___ 0 97.8 88 ___
99% RA
Upon arrival to the floor, patient reports feeling comfortable
and reports minimal if any pain.
Past Medical History:
- ? NPH vs glaucoma (unclear and patient unaware of diagnosis;
no records available in our system)
- Pyelonephritis after last pregnancy, per patient report
Social History:
___
Family History:
DM in the family
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T100.3 BP91/62 HR80 16 100%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender to deep palpation, non-distended,
bowel sounds present, no organomegaly, no rebound or guarding
Back: No CVA tenderness
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
DISCHARGE PHYSICAL EXAM:
Vitals: Tmax 98.3 114/80 70 16 98% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender to deep palpation, non-distended,
bowel sounds present, no organomegaly, no rebound or guarding
Back: No CVA tenderness
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: alert, oriented, moves all extremities antigravity
Pertinent Results:
ADMISSION LABS:
=======================
___ 02:55PM PLT COUNT-337
___ 02:55PM NEUTS-80.9* LYMPHS-10.4* MONOS-8.1 EOS-0.0*
BASOS-0.2 IM ___ AbsNeut-9.34* AbsLymp-1.20 AbsMono-0.94*
AbsEos-0.00* AbsBaso-0.02
___ 02:55PM ALBUMIN-4.1
___ 02:55PM ALT(SGPT)-25 AST(SGOT)-15 ALK PHOS-88 TOT
BILI-0.3
___ 02:55PM GLUCOSE-95 UREA N-8 CREAT-0.6 SODIUM-136
POTASSIUM-3.0* CHLORIDE-99 TOTAL CO2-21* ANION GAP-19
___ 03:02PM LACTATE-0.9
___ 04:16PM URINE MUCOUS-MANY
___ 04:16PM URINE RBC-12* WBC->182* BACTERIA-FEW
YEAST-NONE EPI-1
___ 04:16PM URINE BLOOD-SM NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-LG
___ 04:16PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 04:16PM URINE GR HOLD-HOLD
___ 04:16PM URINE UCG-NEGATIVE
___ 04:16PM URINE HOURS-RANDOM
___ 04:16PM URINE HOURS-RANDOM
___ 06:49PM LACTATE-1.0
DISCHARGE LABS:
=========================
___ 07:40AM BLOOD Glucose-91 UreaN-11 Creat-0.7 Na-137
K-4.4 Cl-105 HCO3-19* AnGap-17
___ 07:40AM BLOOD Calcium-9.8 Phos-4.9* Mg-2.2
URINE:
=========================
___ 04:16PM URINE Color-Yellow Appear-Hazy Sp ___
___ 04:16PM URINE Blood-SM Nitrite-POS Protein-30
Glucose-NEG Ketone-150 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 04:16PM URINE RBC-12* WBC->182* Bacteri-FEW Yeast-NONE
Epi-1
___ 04:16PM URINE Mucous-MANY
___ 04:16PM URINE UCG-NEGATIVE
MICRO:
=========================
IMAGING:
=========================
# CT Abd/Pelvis w/constrast (___): 1. Right-sided
pyelonephritis. No abscess or hydronephrosis. 2. Normal
appendix.
Brief Hospital Course:
___ w PMH of NPH, headaches, presenting with back and abdominal
pain, and headaches found to have right sided pyelonephritis.
# Acute Pyelonephritis: confirmed on ct a/p with findings of
positive u/a. She was initiated on Ceftriaxone and was switched
to ciprofloxain at the time of discharge based on urine
sensitivities. She should complete her course on ___ to
complete a ___nemia: Patient had an admission Hb of 10.5, consistent with
prior. No signs or symptoms of active bleeding.
# Normal Pressure Hydrocephalus: Patient apparently holds a
diagnosis of NPH and is followed by a Neurologist. She was
continued on acetazolamide.
TRANSITIONAL ISSUES:
=========================
- Patient to complete antibiotics on ___
- Needs f/u UA to document clearance of UTI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. AcetaZOLamide 500 mg PO Q12H
Discharge Medications:
1. AcetaZOLamide 500 mg PO Q12H
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Right-sided pyelonephritis
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 ___.
___ first came to the hospital because ___ were experiencing
pain in your back. Urine studies and CT scan of your abdomen
showed evidence of infection around your kidney (called
pyelonephritis). We treated ___ with IV antibiotics.
Please take all of your medications as prescribed and keep your
follow up appointments.
Please seek medical attention if ___ develop fevers, chills,
worsening abdominal pain, pain with urinating, chest pain,
shortness of breath, weakness, or any other symptom that
concerns ___.
We wish ___ all the best of health,
Your ___ healthcare team
Followup Instructions:
___
|
10677303-DS-2
| 10,677,303 | 23,917,153 |
DS
| 2 |
2159-12-19 00:00:00
|
2159-12-19 13:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
CC: facial swelling, ___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of COPD, pancreatitis and alcohol abuse with
previous history of withdrawal seizures sent from ___ for
evaulation for possible pre-septal cellulitis.
The patient initially presented on ___ after sustaining
a seizure with head trauma. He had sutures placed and was
discharged home. When he went home, he was unable to get into
his house due to a restraining order placed against the patient
and his girlfriend. The patient spent the night a shelter. Last
drink was on ___ (two days prior to admission). He
reports he was drinking for 4 days straight prior to admission.
Drinks Vodka. The patient reports he was outside the ___
___, had another seizure and was therefore sent to the
hospital. He doesn't remember much else.
In terms of alcohol use, the patient reports he drinks vodka.
Not sure when he was last sober or had a period of sobriety. He
has experienced alchol withdrawal symptoms previously, mostly
seizures, nausea, vomiting, diarrhea. He denies history of DTs
but does have hallucinations- mostly dots. Has not been in the
ICU for alcohol withdrawal.
The patient currently reports he feels horrible. He complains of
nausea, dry heaves and diarrhea. He reports he feels confused
and like he is slurring his speech. He also reports blurry
vision. He reports chronic vision difficulty in his right eye,
now with decreased vision in his left eye as well. He initially
reported pain on eye movement but now denies.
ROS: Remainder ROS negative
Past Medical History:
Alcohol abuse
History of withdrawal seizures
Pancreatitis
COPD
Arthritis
Social History:
___
Family History:
Mother- deceased Lung cancer
Father- deceased ___
Physical Exam:
Exam on admission:
Vitals: 98.0 BP: 140/92 HRL 90 R:1 8 O2: 97%RA
Laying in bed in some distress due to nausea
HEENT: Large C shaped suture line above left eye with tenderness
surrounding the sutures, no erythema. No exudate. Eyes:
Difficult to asses EOMI, patient ha difficulty following
directions.
Lungs: Clear B/L on auscultation
___: RRR S1 S2 present
Abdomen: Soft, diffusely tender, no rebound or guarding
Ext; Excoriations on arms and legs
NEURO: No tremor, Moving all extremities, AAOx3, able to relate
details of history
Exam on discharge:
Afeb VSS
Gen: NAD, lying in bed
Eyes: Eyes opening. EOMI
ENT: MMM, large laceration over left scalp.
Cardiovasc: RRR, no MRG, full pulses, no edema
Resp: normal effort, no accessory muscle use, lungs CTA ___.
GI: soft, NT, ND, BS+
Skin: multiple excoriations
Neuro: No facial droop. No tremor
Psych: Full range of affect.
Pertinent Results:
___ 09:10AM WBC-5.1 RBC-3.70* HGB-11.4* HCT-34.3* MCV-93
MCH-30.8 MCHC-33.2 RDW-18.7* RDWSD-63.3*
___ 09:10AM PLT COUNT-140*
___ 12:05AM COMMENTS-GREEN
___ 12:05AM LACTATE-1.5 K+-2.9*
___ 11:50PM GLUCOSE-89 UREA N-7 CREAT-0.9 SODIUM-136
POTASSIUM-3.0* CHLORIDE-92* TOTAL CO2-27 ANION GAP-20
___ 11:50PM ALT(SGPT)-30 AST(SGOT)-61* ALK PHOS-89 TOT
BILI-0.5
___ 11:50PM ALT(SGPT)-30 AST(SGOT)-61* ALK PHOS-89 TOT
BILI-0.5
___ 11:50PM LIPASE-25
___ 11:50PM ALBUMIN-4.1 CALCIUM-7.8* PHOSPHATE-3.4
MAGNESIUM-1.4*
___ 11:50PM WBC-5.5 RBC-4.06* HGB-12.3* HCT-37.0* MCV-91
MCH-30.3 MCHC-33.2 RDW-19.0* RDWSD-62.6*
___ 11:50PM NEUTS-62.0 LYMPHS-16.8* MONOS-16.6* EOS-2.5
BASOS-1.4* IM ___ AbsNeut-3.42 AbsLymp-0.93* AbsMono-0.92*
AbsEos-0.14 AbsBaso-0.08
___ 11:50PM PLT COUNT-145*
___ 11:50PM ___ PTT-30.1 ___
CT ___ head:
Mild cerebral atrophy and moderate periventricular cerebal with
matter chronic small vessel ischemic changes
Left Frontoparietal small to moderate extracrainal hematoma. No
skull fracture or intracranial hematoma
C-spine: No fracture or dislocation
Cervical Spondylosis with multilevel forminal stenosis
CT Sinus: Sinusitis: Minimal non-specific increase in density in
subcutaneous fat on the left. This could be related to edema,
contusion or cellulitis. No CT of facial injury.
CTA: ___
IMPRESSION:
1. No acute intracranial abnormality.
2. Normal enhancement the major cortical veins, deep veins,
dural venous
sinuses, and cavernous sinuses, without evidence of thrombosis.
3. Left scalp subgaleal hematoma with a frontal parietal
laceration and
subcutaneous emphysema.
4. Left periorbital soft tissue thickening and fat stranding
without
postseptal extension which may be posttraumatic or infectious.
5. Soft tissue stranding involving the left facial structures
which marginates
the left parotid gland which is asymmetrically enlarged.
Finding may
represent posttraumatic changes versus sialoadenitis. Recommend
clinical
correlation.
6. Numerous dental caries without associated periapical
lucencies. Recommend
follow-up dentistry.
Brief Hospital Course:
___ with history of COPD presented with seizure in setting of
alcohol withdrawal and concerns for periorbital cellulitis
#Alcohol withdrawal
The patient presented with acute alcohol withdrawal and report
of seizure prior to admission. He has no history of DTs. He was
managed on CIWA with diazepam and was no longer requiring
diazepam prior to discharge. He was seen by the social work
resource specialist and has inpatient treatment arranged for
after discharge. The patient will be discharged to Teen
Challenge. He was treated with thiamine, folate and a MVI which
were continued on discharge.
# periorbital cellulitis
# Head trauma with laceration
Presented with concern for perioribital cellulitis. The patent
was initially on broad antibiotics which were quickly
discontinued. Head CT had evidence of inflammation, likely due
to trauma. He was seen by opthalmology who preformed and exam
and found that his poor vision is likely due to cataracts.
Sutures from head laceration were removed prior to discharge.
The patient was seen by OT who performed a concussion
assessment. The patient had evidence of concussive symptoms and
OT recommended referral to cognitive neurology. The patent was
awake, alert and oriented prior to discharge.
#Hypertension
The patent had elevated blood pressure in the setting of
withdrawal. This improved once the patient was no longer scoring
on CIWA. Would continue to monitor blood pressure and consider
addition of antihypertensive if persistently elevated.
#COPD:
No igns of exacerbation, continued home Spiriva. Smoking
cessation encouraged the patent was given a nicotine patch.
Transitional issues:
- consider referral to cognitive neurology for post-concussive
testing
- consider referral to opthalmology for treatment of cataracts.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 cap
INH daily Disp #*30 Capsule 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. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tab by mouth daily Disp #*30 Tablet
Refills:*0
4. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
5. Acetaminophen 1000 mg PO Q6H:PRN pain
RX *acetaminophen 500 mg 2 tablet(s) by mouth Q6hrs as needed
for pain Disp #*48 Tablet Refills:*0
6. Walker
Rolling walker
Diagnosis: Gait unsteadiness
Prognosis: Good
Length of need: 13 months
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol withdrawal with seizures
Head Laceration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you during your recent
admission to ___. You were admitted with a seizure due to
alcohol withdrawal. You were treated with Vailum for alcohol
withdrawal and completed detox in the hospital. You will be
discharged to ___ in ___ to continue your
recovery. You also had sutures removed from your scalp from a
previous fall related to a seizure. You were seen by the
ophthalmologist for complaints of blurry vision. This is due to
cataracts and you should follow up with an eye doctor after
discharge.
We wish you luck in your recovery.
Followup Instructions:
___
|
10677400-DS-6
| 10,677,400 | 22,753,002 |
DS
| 6 |
2163-08-27 00:00:00
|
2163-08-28 16:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ HTN and HLD presenting with a few days of substernal chest
pain and dyspnea. The pain and dyspnea initially started with
running 5 days ago, and was relieved with rest. He describes the
pain as a cramping in nature that feels like someone is
"standing" on his chest and makes it hard for him to breath.
___ in intensity, and in the substernal position, no radiation
to back. Over the past two days, has been persistent with a
waxing/ waning course, not associated w/ exertion. No
association w/ lying flat or sitting forward. Did have some
associted dyspnea. Patient is a non-smoker, no ___ CAD, had good
exercise tolerance 2 weeks ago. Patient diagnosed with exercise
induced asthma over a decade ago, took an inhaler but didn't
help. Was also diagnosed with musculo-skeletal chest pain in ___
with a negative cardiac workup. At that time, the chest pain was
in bialteral lateral chest and lasted for about a week. Patient
denies any recent fevers, chills, URI like symptoms, gastric
reflux. He does have a cough, which he's unable to characterize
any more than just dry.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia +, Hypertension +
2. OTHER PAST MEDICAL HISTORY:
3. hx of umbilical hernia repair
Social History:
___
Family History:
Father: deceased ___ lung CA (age ___. Brother: DM
Physical ___:
ADMISSION:
VS- 98.3 118/73 50 18 95%RA
GENERAL- well-developed male NAD. Oriented x3. Mood, affect
appropriate.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK- Supple with JVP of 7 cm H2O.
CARDIAC- PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS- No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN- Soft, NTND. No HSM or tenderness.
EXTREMITIES- No c/c/e.
SKIN- No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES-
Right: Carotid 2+ DP 2+ ___ 2+
Left: Carotid 2+ DP 2+ ___ 2+
DISCHARGE:
VS- 98.3 100s/70s ___ 18 95%RA
GENERAL- well-developed male NAD. Oriented x3. Mood, affect
appropriate.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK- Supple with JVP of 7 cm H2O.
CARDIAC- PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS- No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN- Soft, NTND. No HSM or tenderness.
EXTREMITIES- No c/c/e.
SKIN- No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES-
Right: Carotid 2+ DP 2+ ___ 2+
Left: Carotid 2+ DP 2+ ___ 2+
Pertinent Results:
___ 06:10AM BLOOD WBC-4.7 RBC-4.29* Hgb-12.6* Hct-36.6*
MCV-85 MCH-29.4 MCHC-34.5 RDW-13.0 Plt ___
___ 06:10AM BLOOD Glucose-95 UreaN-14 Creat-0.7 Na-137
K-4.0 Cl-104 HCO3-25 AnGap-12
___ 06:43PM BLOOD D-Dimer-962*
___ 06:10AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.1
CARDIAC:
___ 04:35PM BLOOD cTropnT-<0.01
___ 11:47PM BLOOD CK-MB-1 cTropnT-<0.01
___ 11:00AM BLOOD CK-MB-1 cTropnT-<0.01
CTA:
FINDINGS: The pulmonary arterial tree is well opacified without
filling
defect to suggest pulmonary embolus. The aorta is normal in
caliber with
normal three-vessel branching arch and no evidence of dissection
or other
acute aortic pathology. The heart and pericardium are normal
without
pericardial effusion or significant atherosclerotic disease.
The esophagus is normal. There is no mediastinal, hilar, or
axillary lymphadenopathy. Though this study is not tailored for
subdiaphragmatic evaluation, imaged upper abdomen reveals
hepatic likely hemangiomata which are better assessed on the
prior CT.
The trachea and central airways are patent to the segmental
level with minimal bibasilar dependent atelectasis noted. The
lungs are well expanded without focal consolidation. No
suspicious pulmonary nodules are identified.
OSSEOUS STRUCTURES: There is no lytic or sclerotic bony lesion
to suggest osseous malignancy. Striated appearance of multiple
mid thoracic vertebral bodies is consistent with multiple
hemangiomata.
IMPRESSION: No pulmonary embolism, acute aortic process or
other explanation for the patient's dyspnea.
CXR: Low lung volumes, no pleural effusions/ ptx. No acute
process. CBC w/ a Hct 39 at baseline.
EKG: sinus brady 51, NA/ NI, TWF III/ V2.
EXERCISE STRESS: INTERPRETATION: This ___ year old man was
referred to the lab for evaluation of chest discomfort. The
patient exercised for 14 minutes of ___ protocol and stopped
for fatigue. The estimated peak MET capacity was 14.3 which
represents a good functional capacity for his
age. No progressive arm, neck, back or chest discomfort was
reported by
the patient throughout the study. He did note a fleeting ___
focal
chest discomfort on the right axilla that lasted for 1 minute
during low
level exercise. The early repolarization normalized with
exercise.
There were no significant ST segment changes during exercise or
in
recovery. The rhythm was sinus with no ectopy. Appropriate
hemodynamic
response to exercise and recovery.
IMPRESSION: Non-anginal type symptoms in the absence of ischemic
EKG
changes. Echo report sent separately. His Duke score is 14 which
has
a low CV mortality.
STRESS ECHO:
The patient exercised for 14 minutes 0 seconds according to a
___ treadmill protocol ___ METS) reaching a peak heart rate
of 157 bpm and a peak blood pressure of 184/70 mmHg. The test
was stopped because of fatigue. This level of exercise
represents an excellent exercise tolerance for age. In response
to stress, the ECG showed no ST-T wave changes (see exercise
report for details). There were normal blood pressure and heart
rate responses to stress.
Resting images were acquired at a heart rate of 50 bpm and a
blood pressure of 100/76 mmHg. These demonstrated normal
regional and global left ventricular systolic function. Right
ventricle is mildly dilated with normal free wall motion. There
is no pericardial effusion. Doppler demonstrated no aortic
stenosis, aortic regurgitation or significant mitral
regurgitation or resting LVOT gradient.
Echo images were acquired within 37 seconds after peak stress at
heart rates of 153 - 128 bpm. These demonstrated appropriate
augmentation of all left ventricular segments with slight
decrease in cavity size. There was augmentation of right
ventricular free wall motion.
IMPRESSION: Excellent functional exercise capacity. No ECG or 2D
echocardiographic evidence of inducible ischemia to achieved
workload. Normal hemodynamic response to exercise.
Brief Hospital Course:
Hospital course by problem:
#CHEST PAIN: Pt w/ no hx of catheterization in past. No known
coronary disease. Chest pain in ___: stress MIBI w no
abnormalities. Echo from ___ demonstrated normal biventricular
systolic function and no diastolic dysfunction or valvular
abnormalities. Patient given nitro, with relief of chest pain
sometime thereafter (not immediately). EKG some diffuse ST
elevations and PR depressions. Troponins negative x 3. Gave ASA
325mg x1. Pt received a CTA considering elevated DDimer and
chest pain, which demonstrated no pulmonary embolism or acute
aortic pathology. Pain was non- reproducible on exam. DDx:
angina, musculoskeletal, GERD, pericarditis. Constant nature c/w
pericarditis, pressure like nature c/w ACS. Patient remained
chest pain free. Exercise stress echo was negative for ischemic
changes. Patient went 14 minutes on ___ protocol, with high
Duke score. No abnormalities on stress ECHO (see results for
full report). Presumed pericarditis given EKG and negative
stress test. Given ibuprofen 600mg PO TID x14 days, w/
ranitidine for GI protection during that time. Has f/u with PCP
___.
# HTN: pt normotensive - SBPs 110s. Continued home felodipine
and lisinopril
# HLD: continued home simvastatin
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Lisinopril 40 mg PO DAILY
2. Felodipine 5 mg PO DAILY
3. Simvastatin Dose is Unknown PO DAILY
Discharge Medications:
1. Simvastatin 10 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. Felodipine 5 mg PO DAILY
4. Ibuprofen 600 mg PO Q8H Duration: 14 Days
RX *ibuprofen 600 mg 1 tablet(s) by mouth three times a day Disp
#*42 Tablet Refills:*0
5. Ranitidine 150 mg PO BID Duration: 14 Days
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pericarditis
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 cardiology service at ___ for chest
pain. For this, you received blood tests and an exercise stress
test, which showed no pathologic changes during exercise,
meaning there is low probability that your chest pain was due to
coronary artery disease/heart attack.
Followup Instructions:
___
|
10677515-DS-9
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| 9 |
2142-04-18 00:00:00
|
2142-04-20 13:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Dyspnea, ___ edema
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with hx notable for CAD s/p CABG, ___, pAF s/p PPM on
eloquis, ___, and recurrent aspiration PNA presenting with leg
swelling and dyspnea.
Worsening dyspnea on exertion, leg swelling and weight gain
started ___ night, patient had difficultly sleeping. Symptoms
progressed, ___ he went to his cardiologist in ___ who
investigated his pacemaker. Electrocardioversion was discussed
briefly. Given worsening shortness of breath, patient presented
to ___ ED. Of note, he shared that if cardioversion had to be
done, he preferred chemical first at ___.
No chest pain, chest pressure, cough, fevers, nigthsweats,
orthopnea, PND, calf pain. Denies dietary indiscretion, has
been
eating very healthy, keeps alcohol to a minimum.
In the ED, initial VS were:
97.8 95 132/99 16 99% RA
Exam notable for:
General: Not in acute distress
Cor: Irregularly irregular, no MRG, JVD
Pulm: Bibasilar rales
Abdomen: Soft, non-tender, non-distended
Ext: WWP, no cyanosis, 3+ edema to knees
Labs showed:
Cr 1.7, BUN 43, Trop .02, BNP 7076
Imaging showed:
CXR pending
Patient received:
40mg IV lasix once
Transfer VS were:
97.8 90 102/61 20 99% RA
Past Medical History:
CAD s/p CABG
pAF s/p PPM
___
CKD (baseline Cr of ~1.9)
hypothyroidism
dysphagia
recurrent aspiration PNA
BPH
Past Psychiatric History:
Reports being hospitalized four times at ___ for depression
(?bipolar II, as per HPI), first in ___, most recently in
___.
Underwent ECT there several times. Denies h/o SA/SIB. Per
patient, he has a therapist, ___ (?sp) in ___, but
no current psychiatrist. Per note by Dr ___, pt is
treated by psychiatrist Dr. ___.
Prior med trials:
* Abilify - No benefit
* Celexa - No benefit
* Effexor - No benefit
Social History:
___
Family History:
Denies history of seizures or mental illness in the family.
Physical Exam:
ADMISSION PHYSICAL EXAM
=============================
Todays weight 158lb (baseline weight 150lb)
VS: 97.3 ___
GENERAL: NAD , appears stated age, talkative
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, prominent external jugular vein
distention,
JVD 15cm
HEART: irregularly irregular, no MRG
LUNGS: crackels heard at RLB, mild crackles LLB, good
airmovement
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: 2+ clubbing to knees, varicose veins
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
=============================
Vitals: 97.7, 120/77, 82, 18, 95% on RA
Weight: 69.7kg
General: Healthy appearing elderly male in NAD.
HEENT: Normocephalic, atraumatic. PERRLA, EOMI.
Neck: JVP elevated
Lungs: Crackles at bases bilaterally.
CV: Irregularly irregular. No murmurs, rubs, or gallops.
Abdomen: Soft, nontender, nondistended. Normoactive bowel
sounds.
Ext: 2+ pitting edema to ankles bilaterally.
Neuro: CNII-XII grossly intact. No focal deficits.
Pertinent Results:
ADMISSION LABS
=========================
___ 04:50PM BLOOD WBC-7.6# RBC-4.47*# Hgb-12.1* Hct-38.1*
MCV-85 MCH-27.1 MCHC-31.8* RDW-16.8* RDWSD-51.8* Plt ___
___ 04:50PM BLOOD Neuts-67.7 Lymphs-18.5* Monos-10.2
Eos-2.1 Baso-0.4 Im ___ AbsNeut-5.14# AbsLymp-1.40
AbsMono-0.77 AbsEos-0.16 AbsBaso-0.03
___ 04:57PM BLOOD ___ PTT-28.5 ___
___ 04:50PM BLOOD Glucose-141* UreaN-43* Creat-1.7* Na-140
K-4.0 Cl-98 HCO3-26 AnGap-16
___ 04:50PM BLOOD cTropnT-0.02* proBNP-7076*
PERTINENT INTERVAL LABS
=========================
___ 06:50AM BLOOD Glucose-76 UreaN-40* Creat-1.6* Na-141
K-4.1 Cl-98 HCO3-31 AnGap-12
___ 06:50AM BLOOD Mg-2.0
IMAGING STUDIES
=========================
CXR ___
IMPRESSION:
Chronic changes in the lungs as seen previously noting that
interstitial edema would be difficult to exclude. Persistent
trace pleural effusions.
MICROBIOLOGY
=========================
None
Brief Hospital Course:
___ year old male with CAD s/p CABG, HFpEF, pHTN, pAF s/p PPM,
and recurrent aspiration pneumonia presented with acute
decompensated heart failure in setting of persistent atrial
fibrillation.
# Acute on chronic HFpEF
# Atrial fibrillation
Last EF was 50-55% in ___. Patient had seen his outpatient
cardiologist (Dr. ___ earlier in the week who noted that he
was in persistent atrial fibrillation for at least the last 7
days. Interrogation of the pace maker by EP in hospital showed
that he was in persistent atrial fibrillation since ___.
Therefore, it is suspected that his acute decompensation was
likely secondary to atrial fibrillation burden. He was diuresed
with IV Lasix and was responding approriately. EP started him on
amiodarone 200mg BID for 3 weeks with a plan to transition to
200mg daily for maintenance dosing. Electrical cardioversion was
deferred at this time. On ___, the patient wanted to be
discharged so he was continued on 80 mg torsemide with follow up
with cardiologist to adjust torsemide dosing as needed. He
should also continue metoprolol succinate 50 mg daily and
anticoagulation on apixaban.
CHRONIC MEDICAL CONDITIONS
============================
# Depression - extensive psychiatry history including
hospitalizations for depression and catatonia. Managed by Dr.
___ (___) with q3week ECT. Home mirtazapine
was continued.
# CAD s/p CABG - continued home atorvastatin
# Hypothyroidism - continued home levothyroxine
TRANSITIONAL ISSUES:
- New medication: 200 mg amiodarone BID x 3 weeks
- Changed medication: 40 mg torsemide increased to 80 mg
torsemide daily
- Assess volume exam and adjust torsemide. Most likely will need
to be reduced to 40 mg torsemide daily.
- Continue amiodarone 200 mg BID x 3 weeks (last day = ___. Then decrease to 200 mg amiodarone daily.
#Discharge weight: 69.7 kg
#Discharge Cr: 1.6
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 2.5 mg PO BID
2. Atorvastatin 40 mg PO HS
3. Levothyroxine Sodium 88 mcg PO DAILY
4. Mirtazapine 30 mg PO HS
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
7. Torsemide 40 mg PO DAILY
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Vitamin D 400 UNIT PO DAILY
Discharge Medications:
1. Amiodarone 200 mg PO BID Duration: 3 Weeks
RX *amiodarone 200 mg 1 tablet(s) by mouth twice a day Disp #*42
Tablet Refills:*0
2. Amiodarone 200 mg PO DAILY
Please do not take this medication until after 3 weeks of BID
dosing.
3. Torsemide 80 mg PO DAILY
4. Apixaban 2.5 mg PO BID
5. Atorvastatin 40 mg PO HS
6. Levothyroxine Sodium 88 mcg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Mirtazapine 30 mg PO HS
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Vitamin D 400 UNIT PO DAILY
11. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
1. Amiodarone 200 mg PO BID Duration: 3 Weeks
RX *amiodarone 200 mg 1 tablet(s) by mouth twice a day Disp #*42
Tablet Refills:*0
2. Amiodarone 200 mg PO DAILY
Please do not take this medication until after 3 weeks of BID
dosing.
3. Torsemide 80 mg PO DAILY
4. Apixaban 2.5 mg PO BID
5. Atorvastatin 40 mg PO HS
6. Levothyroxine Sodium 88 mcg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Mirtazapine 30 mg PO HS
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Vitamin D 400 UNIT PO DAILY
11. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Acute on chronic diastolic heart failure
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___.
Why was I here?
- You were admitted for shortness of breath.
What was done for me here?
- You were given IV Lasix to diurese you and improve your
shortness of breath.
What should I do when I leave the hospital?
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
- Take 80 mg torsemide daily.
- See your heart doctor in clinic to adjust your torsemide
medication.
- Take amiodarone 200 mg two times per day for three weeks and
then take 200 mg amiodarone daily after that.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10677587-DS-10
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2192-02-29 00:00:00
|
2192-02-29 14:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Keflex / Tetanus Vaccines & Toxoid / trazodone
Attending: ___.
Chief Complaint:
Malaise, low grade fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with history of breast
cancer s/p partial mastectomy, metastatic ampullary cancer s/p
ERCP with plastic stent placement, Zenker's divierticulum,
cardiomyopathy, bronchiectasis, recent admission for
pyelonephritis/pneumonia who presents from rehab with weakness
and abnormal labs.
Per review of records, the patient was recently admitted to
___ with confusion, and found to have Klebsiella UTI and
possible pyelonephritis, and possible pneumonia for which she
was
treated with Unasyn and narrowed to Augmentin.
The patient reports that over the last few days prior to
admission she has felt more weak. She was working with physical
therapy and felt very tired. She denies any abdominal pain, but
reported nausea. No emesis. Reports elevated temperatures and
chills at rehab. She also report a cough productive of sputum.
Noted by physician at ___ with rising AP 314->
506, WBC 9.5 -> 18. On the day of admission, she seemed more
confused so she was referred to the ___ for further care.
In the ED, vitals: 97.7 95 125/81 17 95% RA
Exam: Abd: palpable masses, nondistended, TTP in RUQ>LUQ,
negative ___ sign
Labs notable for: WBC 16, Hb 9.7, 406, INR 2.0; Na 133; AST 127,
ALT 56, AP 385, Tb 0.8; proBNP 4960; lactate 1.2; UA bland; Flu
negative
Imaging: CXR, RUQUS, CT A/P
Patient given: Ciprofloxacin 400 mg IV, Zosyn 4.5 g IV,
Vancomycin 1 g IV
On arrival to the floor, the patient reports that she feels
better. Denies any shortness of breath. No abdominal pain or
nausea at present.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
PMH: L breast cancer s/p partial mastectomy, urinary incontence
PSH: L breast partial mastectomy
Social History:
___
Family History:
heart problems
Father: Died of MI
Physical Exam:
Admission:
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur
RESP: Diffuse expiratory wheezing. Breathing is non-labored
GI: Abdomen soft, multiple palpable masses, non-distended,
tender
to palpation in RUQ. Bowel sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
Labs:
___ 05:40PM BLOOD WBC: 16.4* RBC: 3.32* Hgb: 9.7* Hct:
30.6*
MCV: 92 MCH: 29.2 MCHC: 31.7* RDW: 16.7* RDWSD: 44.___*
___ 05:40PM BLOOD Neuts: 84.0* Lymphs: 5.4* Monos: 8.1 Eos:
0.1* Baso: 0.3 NRBC: 0.4* Im ___: 2.1* AbsNeut: 13.74* AbsLymp:
0.88* AbsMono: 1.32* AbsEos: 0.01* AbsBaso: 0.05
___ 05:40PM BLOOD ___: 22.2* PTT: 36.2 ___: 2.0*
___ 05:40PM BLOOD Glucose: 82 UreaN: 14 Creat: 0.7 Na: 133*
K: 4.6 Cl: 95* HCO3: 27 AnGap: 11
___ 05:40PM BLOOD ALT: 56* AST: 127* AlkPhos: 385* TotBili:
0.8
___ 05:40PM BLOOD proBNP: 4960*
___ 05:40PM BLOOD Albumin: 2.4* Calcium: 8.3* Phos: 2.3*
Mg:
1.8
___ 05:49PM BLOOD Lactate: 1.2
Microbiology:
- Blood cultures (___): pending
- Urine culture (___): pending
Imaging:
- CT A/P with contrast (___):
1. Numerous hepatic masses with enlarged upper abdominal lymph
nodes consistent with metastatic disease.
2. A biliary stent is seen in place with debris in the distal
portion of the stent. Pneumobilia.
3. Mild wall thickening of the ascending colon which may
represent a mild colitis or sequela of fluid overload.
4. Ground-glass opacity in the lingula may be infectious or
inflammatory in etiology.
5. Small volume ascites and small bilateral pleural effusions.
6. Diffuse edema.
- CXR (___):
IMPRESSION: Left lower lobe airspace opacification may represent
atelectasis or consolidation (pneumonia). Small left and trace
right-sided pleural effusion. No pneumothorax. Pulmonary
hyperinflation with suspected pulmonary hypertension.
The right-sided Port-A-Cath terminates in the right atrium
- RUQUS (___):
1. Diffuse liver metastases. Pneumobilia. No CBD dilation.
Stent
is not identified.
2. Partially visualized right pleural effusion.
DC LABS:
___ 06:00AM BLOOD WBC-15.6* RBC-3.47* Hgb-10.2* Hct-31.3*
MCV-90 MCH-29.4 MCHC-32.6 RDW-18.2* RDWSD-44.0 Plt ___
___ 06:00AM BLOOD Glucose-75 UreaN-10 Creat-0.8 Na-137
K-3.5 Cl-97 HCO3-28 AnGap-12
___ 06:50AM BLOOD ALT-54* AST-90* AlkPhos-358* TotBili-1.1
Brief Hospital Course:
Ms. ___ is a ___ woman with history of breast
cancer s/p partial mastectomy, metastatic ampullary cancer s/p
ERCP with plastic stent placement, Zenker's divierticulum,
cardiomyopathy, bronchiectasis, recent admission for
pyelonephritis/pneumonia who presented from rehab with weakness
and abnormal labs.
# Hospital acquired bacterial pneumonia:
# Bronchiectasis:
Patient with recent admission to BID-N for concern for pneumonia
treated with Unasyn/Augmentin. CXR at that time showed left
lower lobe airspace opacities. Patient now with increased sputum
productive, and CXR with left lower lobe opacity consistent with
pneumonia. Given recent hospitalization, Decided to treat
initially for HCAP. Also with history of atypical mycobacterial
disease. Patient also noted to have wheezing on exam. She was
placed on Vanco/Zosyn then narrowed to Zosyn. MRSA, strep,
legionella negative. On discharge she was transitioned to
Levofloxacin to complete a 7 day course through ___
# Acute metabolic encephalopathy:
Patient with mild confusion and hallucination. Likely related
to hospital/infection assoc delirium. no clear medication
offenders. She improved markedly by the time of discharge.
# Metastatic ampullary cancer:
Patient with recent diagnosis of metastatic ampullary cancer,
s/p recent ERCP with plastic stent placement. Patient now with
elevated transaminases and alk phos concerning for obstruction.
Initially, there was concern for biliary obstruction, but ERCP
felt her LFT's were at baseline and CT findings were not
concerning for obstructed stone. No abdominal pain either.
Fevers are more likely related to the pneumonia. ERCP was
deferred at this time.
# Acute on chronic CHF:
# Radiation cardiomyopathy:
LVEF unknown. Patient with evidence of mild volume overload in
exam and elevated proBNP. Otherwise stable. Lasix 20mg given
which was increased to 40mg daily on DC. Will need serial
volume assessments.
CHRONIC/STABLE PROBLEMS:
# Atrial fibrillation:
- AC: restarted apixaban
- Rate: Fractionated Metoprolol
# Hypertension:
- Restarted losartan
- Continued Metoprolol
# Depression:
- Continued escitalopram
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. Escitalopram Oxalate 10 mg PO DAILY
3. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN needed for
shortness of breath, cough, wheeze
4. Metoprolol Succinate XL 100 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Losartan Potassium 25 mg PO DAILY
7. Apixaban 5 mg PO BID
8. Saccharomyces boulardii 250 mg oral DAILY
9. Calcium Carbonate 500 mg PO BID
10. Vitamin D 1000 UNIT PO DAILY
11. Cyanocobalamin 500 mcg PO DAILY
12. LOPERamide 2 mg PO DAILY
13. Amoxicillin-Clavulanic Acid Dose is Unknown PO Q12H
14. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
15. fluticasone furoate 27.5 mcg/actuation nasal DAILY:PRN
Discharge Medications:
1. LevoFLOXacin 750 mg PO DAILY Duration: 3 Days
take through ___ to complete course
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*3
Tablet Refills:*0
2. Furosemide 40 mg PO DAILY
RX *furosemide 20 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
5. Apixaban 5 mg PO BID
6. Calcium Carbonate 500 mg PO BID
7. Cyanocobalamin 500 mcg PO DAILY
8. Escitalopram Oxalate 10 mg PO DAILY
9. fluticasone furoate 27.5 mcg/actuation nasal DAILY:PRN
10. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN needed for
shortness of breath, cough, wheeze
11. LOPERamide 2 mg PO DAILY
12. Losartan Potassium 25 mg PO DAILY
13. Metoprolol Succinate XL 100 mg PO DAILY
14. Saccharomyces boulardii 250 mg oral DAILY
15. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Hospital acquired bacterial pneumonia
Secondary: Metastatic pancreatic cancer complicated by biliary
obstruction s/p ERCP w/ plastic stent, still in place. CHF/leg
swelling, delirium
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ because you had a pneumonia. We also
monitored your liver and bile ducts to make sure that your stent
was working properly, which it was. Your symptoms improved. You
will be given a pill antibiotic to complete your course.
Because of swelling in your legs, we have increased your water
pill (Lasix) dose as well.
You should follow up with your PCP and GI doctor to manage the
stent.
Followup Instructions:
___
|
10677587-DS-8
| 10,677,587 | 24,285,738 |
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| 8 |
2189-03-10 00:00:00
|
2189-03-19 05:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Keflex / Tetanus Vaccines & Toxoid
Attending: ___
Chief Complaint:
Stat trauma Motor vehicle accident vs tree
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ s/p MVC vs tree, no LOC or headstrike, +airbag, GCS 15 with
L1 2-column vert body fx w minimal retropulsion, R distal radial
nondisplaced fx, sternal fx
Past Medical History:
PMH: L breast cancer s/p partial mastectomy, urinary incontence
PSH: L breast partial mastectomy
Social History:
___
Family History:
Noncontributory
Physical Exam:
VITAL SIGNS: 98.3 71 149/85 18 94RA
GENERAL: AAOx3 NAD
HEENT: NCAT, EOMI, PERRLA, No scleral icterus, mucosa moist, no
LAD
CARDIOVASCULAR: R/R/R, S1/S2, NO M/R/G
CAROTIDS: 2+, No bruits or JVD
PULMONARY: CTA ___, No crackles or rhonchi
GASTROINTESTINAL: S/NT/ND. No guarding, rebound, or frank
peritonitis. +BSx4
EXT/MS/SKIN: No C/C/E; Feet warm. Good perfusion
PULSES (Femoral/Popliteal/Dorsalis pedis/Posterior tibial)
LLE: P/P/P/P
RLE: P/P/P/P
NEUROLOGICAL: Reflexes, strength, and sensation grossly intact;
Pt had TLSO in place for comfort
CNII-XII: WNL
Pertinent Results:
___ 11:20AM ___
___ 11:20AM ___ PTT-28.0 ___
___ 11:20AM PLT COUNT-246
___ 11:20AM WBC-8.8 RBC-4.11 HGB-11.4 HCT-36.5 MCV-89
MCH-27.7 MCHC-31.2* RDW-13.4 RDWSD-43.7
___ 11:20AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 11:20AM LIPASE-35
___ 11:20AM estGFR-Using this
___ 11:20AM UREA N-21* CREAT-1.0
___ 11:38AM freeCa-1.12
___ 11:38AM HGB-12.4 calcHCT-37 O2 SAT-93 CARBOXYHB-3 MET
HGB-0
___ 11:38AM GLUCOSE-130* LACTATE-1.9 NA+-141 K+-3.9
CL--104 TCO2-24
___ 11:38AM ___ PH-7.43 INTUBATED-NOT INTUBA
COMMENTS-GREEN TOP
___ 01:00PM URINE HYALINE-1*
___ 01:00PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 01:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 01:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 01:00PM URINE GR HOLD-HOLD
___ 01:00PM URINE UHOLD-HOLD
___ 01:00PM URINE HOURS-RANDOM
___ 01:00PM URINE HOURS-RANDOM
Brief Hospital Course:
On ___, Ms ___ ___ was involved in an MVC vs tree.
She had no loss of consciousness, and did not hit her head.
There was airbag deployment, and based on the story relayed by
EMS, ___ was 15 in the field. In the Trauma bay, this remains to
be the case as she was appropriate throughout the primary and
secondary survey, with relatively little significant findings.
Imaging reveals the following injuries: L1 2-column vert body fx
w minimal retropulsion, R distal radial nondisplaced fracture,
and a comminuted sternal fracture. Her C-collar was cleared on
HD1.
Spine was consulted regarding her L1 compression fracture. This
was determined to be ___ and Ms. ___ was
asymptomatic from it. We acquired a TLSO for her, which was to
be used for comfort. She was scheduled to follow up with spine
in 1 month.
Orthopedics was consulted for her right distal non-displaced
radial fracture. This was also determined to be non-op and she
was splinted. She will follow up with orthopedics for this in 1
month.
During HD#2, pt complained for visual changes where her vertical
fields were inverted. This occurred 5 times. Therefore,
neurology was consulted. Following the recommendation and work
up, CTA was performed as well and ruled out any vascular
dissection of the neck. Furthermore, MRI brain was obtained,
which was negative. Finally, EEG was performed and was wnl as
well. During the workup, she describes no further episodes.
Therefore, the pursuit was halted and she will follow up with
neurology in 1 month.
Patient was also found to have incidental thyroid nodules on
imaging. Upon interview, she said that this had already been
worked up and biopsied in the past and was determined to be
benign. She decline in patient work up and we were all
agreeable.
Patient continued with inhouse physical therapy who deemed her
appropriate for discharge to home, which occurred on ___
without issues.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Losartan Potassium 25 mg PO DAILY
3. Simvastatin 20 mg PO QPM
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
2. Losartan Potassium 25 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Simvastatin 20 mg PO QPM
5. TraMADol 25 mg PO Q4H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right non-displaced distal radius fracture
L1 two-column vertebral body fracture with retropulsion
Mid sternum comminuted fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the acute care surgery service at ___
after a car accident. After assessment, you are now ready to go
home.
For your vertebral column fracture, our spine doctors ___
___ management appropriate. You may wear your TLSO
brace for comfort.
For your visual changes, our neurology workup was negative.
Please call our neurologists should you have another episode.
For your arm fracture, please keep the splint on until your
follow up with the orthopedics team.
Followup Instructions:
___
|
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DS
| 2 |
2163-09-28 00:00:00
|
2163-09-28 13:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___ Aspirin / ibuprofen
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/IBS and PUD presents with abdominal pain. Pain present for
___ weeks, epigastric and RUQ. Initally thought to be due to
constipation but not relief after drinking 3 bottles of Mg
Citrate and having many bowel movement this weekend. No fevers,
chills, nausea, vomiting. Has been on lisinopril for over
___. Linzess is only new medication. Has a history of high
lipids and stopped statin due to muscle weakness.
In ED pt w/lipase 1065 lactate 2.5
ROS: +as above, otherwise reviewed and negative
Past Medical History:
IBS
PEPTIC ULCER, UNSPEC
HEMORRHOIDS, UNSPEC
Sleep Apnea
HYPERTENSION - ESSENTIAL, BENIGN
HYPERCHOLESTEROLEMIA
TOBACCO DEPENDENCE
Diabetes mellitus
Lumbar degenerative disc disease
Social History:
___
Family History:
no GI disease
Physical Exam:
ROS:
GEN: - fevers, - Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomitting, - Diarhea, + Abdominal Pain,
Improving
Constipation, - Hematochezia
PULM: - Dyspnea, - Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
PHYSICAL EXAM:
VSS: 98, 118/58, 70, 18, 96%
GEN: NAD
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: Moderate TTP RUQ/Epigastric, ND, +BS, - CVAT
EXT: - CCE
NEURO: CAOx3, Non-Focal
Pertinent Results:
___ 08:14PM GLUCOSE-231* UREA N-21* CREAT-0.9 SODIUM-138
POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-26 ANION GAP-17
___ 08:14PM ALT(SGPT)-21 AST(SGOT)-15 ALK PHOS-58 TOT
BILI-0.3
___ 08:14PM LIPASE-1064*
___ 08:14PM ALBUMIN-4.5
___ 08:17PM LACTATE-2.5*
___ 08:14PM WBC-10.3 RBC-4.19* HGB-13.7* HCT-38.6* MCV-92
MCH-32.6* MCHC-35.4* RDW-13.6
___ 08:14PM NEUTS-67.3 ___ MONOS-6.3 EOS-1.8
BASOS-0.6
___ 08:14PM PLT COUNT-339
___ 09:30PM ___ PTT-30.4 ___
RUQ US Preliminary IMPRESSION:
Unremarkable right upper quadrant ultrasound. No evidence of
cholecystitis or CBD dilation.
Brief Hospital Course:
ASSESSMENT AND PLAN:
1. Acute Pancreatitis
- Pancreas consult. Outpatient workup of idiopathic
pancreatitis. Will need MRCP at ___ with his primary
gastroenterologist
- Tolerating full diet
- Hydrated with IV fluids
- Pain control with morphine, did not require on day of
discharge, so not given as outpatient.
- antiemetics
- Nice improvement in lipase
2. Constipation
- Agressive bowel regimen. Likely opiates on top of his severe
IBS (constipation type)
- Improving
3. Type 2 Diabetes Uncontrolled without Complications
- Sliding Scale
- Glipizide, Metformin held
Full Code
Ambulation Prophylaxis
Stable for discharge, > 30 minutes spent
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 40 mg PO DAILY
2. glipiZIDE-metformin 2.5-500 mg oral TID W/MEALS
3. Zolpidem Tartrate 10 mg PO QHS
4. lisinopril-hydrochlorothiazide ___ mg oral DAILY
5. Linzess (linaclotide) 290 mcg oral DAILY
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
Discharge Medications:
1. Fluticasone Propionate NASAL 2 SPRY NU DAILY
2. Omeprazole 40 mg PO DAILY
3. Zolpidem Tartrate 10 mg PO QHS
4. glipiZIDE-metformin 2.5-500 mg oral TID W/MEALS
5. Linzess (linaclotide) 290 mcg oral DAILY
6. lisinopril-hydrochlorothiazide ___ mg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Pancreatitis
Irritable Bowel Syndrome
Type 2 Diabetes Controlled without Complications
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with acute pancreatitis. This condition will
resolve on its own, but it is very important that you eat bland
low-fat food for several days to prevent a recurrance. Also keep
yourself well hydrated. You will need to follow up with your
primary gastroenterologist for workup of why you had
pancreatitis.
Followup Instructions:
___
|
10677644-DS-7
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2166-01-09 00:00:00
|
2166-01-10 12:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___ Aspirin / ibuprofen
Attending: ___
Chief Complaint:
Severe abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with pancreatic cancer, currently C26D8 on FOLFIROX, who
presents with severe abdominal pain. The patient has had chronic
abdominal pain and chronic pancreatitis related to EtOH
consumption for ___ years. He was diagnosed with pancreatic
cancer in ___ and has had multiple episodes of acute
on chronic pancreatitis since then. He was most recently
admitted at the end of ___ of ___ for acute
pancreatitis, requiring a Dilaudid PCA for pain control. The
episode was attributed to dietary indiscretion (eating very
high-fat foods). This most recent episode started the day prior
to admission and is associated with nausea and vomiting. He
reports that he ate ___ chicken for lunch yesterday, and
his symptoms escalated shortly thereafter. He has been trying to
adhere to a low-fat diet, given repeated acute pancreatitis
flares. Last EtOH was 2 weeks ago.
In the ED, initial VS were: 96.0, 60, 168/74, 18, 100% RA
Labs were notable for: lipase 989, Mg 1.3, Phos 1.5
Imaging included: RUQ US with areas of hyperechogenicity in the
right hepatic lobe (nonspecific).
Treatments received:
HYDROmorphone (Dilaudid) 1 mg
___ 09:42 IVF NS (1000 mL)
___ 09:44 IV Ondansetron 4 mg
___ 09:49 IV HYDROmorphone (Dilaudid) 1 mg
___ 12:02 IV HYDROmorphone (Dilaudid) 2 mg
___ 13:34 IV Magnesium Sulfate (2 gm ordered)
___ 13:34 PO/NG Neutra-Phos 1 PKT
On arrival to the floor, patient reports his pain is ___. He
reports that he is nauseated, but that he is always nauseated
and this is consistent with his baseline. No vomiting. No
diarrhea, baseline constipation. Endorses sweats and chills. No
chest pain, shortness of breath.
Past Medical History:
Mr. ___ is a ___ yo gentleman with a ___ year history of
chronic abdominal pain, pancreatitis and ETOH abuse. He was
recently evaluated by Dr. ___ abdominal pain. He reports
having had this pain for the past ___ years, and that his pain
is stable. No recent changes in location, severity or quality.
He has had numerous imaging studies in the past, the last being
___ at ___. He reports that he has epigastric as well as
back pain. Pain from an injury while snowboarding and MVA. He
has chronic bloating and poor appetite. His weight is recently
down 15 pounds. His energy has been "OK", but fluctuates with
pain and mood. He was recently out rising his bike and injured
himself.
- He underwent EUS with Dr. ___ ___. Biopsy of a
portahepatis node was + for acinar cell carcinoma. Biopsies of
the pancreas and hepatic lesions where highly suspicious for CA.
- ___: CTA abd/pelv - Hypoenhancing pancreatic lesion
worrisome for primary malignancy with adjacent adenopathy and
metastases in the liver as detailed above. No prior available to
evaluate for interval change. No other acute intra-abdominal
process to explain patient's symptoms.
- ___: MRCP 1. Pancreatic head/uncinate process mass
concerning for malignancy, possible neuroendocrine tumor, as
described above. 2. Multiple RIGHT lobe hepatic lesions
concerning for metastatic disease. 3. Few subcentimeter nodes
adjacent to the pancreatic mass, better visualized on recent CT
- ___: FOLFIRINOX #1
- ___: CTs show stable disease.
- ___: Scans show stable diease.
- ___: FOLIFIRINOX #12 (oxaliplatin ommited due to
neuropathy)
- ___: Treatment break due to fatigue.
- ___: Restarted FOLFIRINOX (oxaliplatin ommited)
- ___: Admission to ___ for worsened abdominal pain and
nausea
consistent with pancreatitis.
- ___: Admission to ___ for worsened abdominal pain
Discussed appropriate diet/avoidance of fatty foods given
pancreatitis.
- ___: Cycle: 26 Day: ___ FOLFIRINOX
PAST MEDICAL HISTORY:
- Metastatic pancreatic cancer (liver mets)
- Chronic pancreatitis
- h/o EtOH use disorder
- Type II Diabetes
- Peptic Ulcer
- Hemorrhoids
- Sleep Apnea
- Hypertension
- Hypercholesterolemia
- Tobacco Dependence
- Colonic Adenoma
- Obesity
- Lumbar Degenerative Disc Disease
- L3-L4 Herniated Disc s/p L3-L4 microdiskectomy in ___
- Ganglion of Wrist
- s/p left femur fracture s/p repair in ___
Social History:
___
Family History:
DM and HTN. GM with pancreatic cancer in her ___. Aunt with
breast cancer in her ___.
Physical Exam:
ADMISSION EXAM
=============================
VS: T 98.5, BP 196/82, HR 61, RR 18, SpO2 100/RA
GENERAL: sleepy, arousable to voice but dozes off after 5 sec.
Appears comfortable.
HEENT: Pupils 2mm, minimally reactive to light. Sclera
anicteric. MMM. No oral lesions or thrush.
CARDIAC: RRR, S1+S2, I/VI systolic murmur at RUSB
LUNG: CTAB, no W/R/C
ABD: mildly distended, soft, exquisitely TTP in epigastrium and
RUQ + guarding in these areas. No rebound. +BS.
EXT: WWP, no edema
NEURO: sleepy, as above, oriented to self, ___,
SKIN: No significant rashes
DISCHARGE EXAM
=============================
VS: T 97.8, BP 125/70, HR 84, RR 18, SpO2 98/RA
GENERAL: alert and interactive, sitting on edge of bed, NAD
HEENT: sclera anicteric, MMM
CARDIAC: RRR, S1+S2, I/VI systolic murmur at RUSB
LUNG: CTAB, no adventitious breath sounds
ABD: soft, non-distended, tender to palpation in the
epigastrium/upper quadrants, normoactive bowel sounds
EXT: WWP, no edema
NEURO: A/Ox3, ambulating steadily
SKIN: No significant rashes
Pertinent Results:
ADMISSION LABS
========================
___ 11:55AM BLOOD WBC-5.4 RBC-3.47* Hgb-11.1* Hct-33.2*
MCV-96 MCH-32.0 MCHC-33.4 RDW-14.6 RDWSD-50.4* Plt ___
___ 11:55AM BLOOD Neuts-73.5* Lymphs-16.0* Monos-8.7
Eos-0.6* Baso-0.6 Im ___ AbsNeut-4.00# AbsLymp-0.87*
AbsMono-0.47 AbsEos-0.03* AbsBaso-0.03
___ 11:55AM BLOOD ___ PTT-30.6 ___
___ 09:20AM BLOOD Glucose-261* UreaN-15 Creat-1.1 Na-139
K-4.5 Cl-94* HCO3-22 AnGap-23*
___ 09:20AM BLOOD ALT-131* AST-80* AlkPhos-284*
TotBili-1.6*
___ 09:20AM BLOOD Lipase-989*
___ 09:20AM BLOOD Albumin-4.7 Calcium-10.4* Phos-1.5*
Mg-1.3*
___ 09:35AM BLOOD Lactate-2.6*
DISCHARGE LABS
========================
___ 05:21AM BLOOD WBC-5.7 RBC-3.12* Hgb-9.9* Hct-29.6*
MCV-95 MCH-31.7 MCHC-33.4 RDW-14.9 RDWSD-51.5* Plt ___
___ 05:21AM BLOOD Glucose-112* UreaN-7 Creat-0.8 Na-140
K-3.5 Cl-100 HCO3-27 AnGap-13
___ 05:21AM BLOOD ALT-159* AST-101* AlkPhos-175*
TotBili-3.2*
___ 05:21AM BLOOD Calcium-8.0* Phos-3.4 Mg-1.7
RELEVANT STUDIES
========================
___ Imaging LIVER OR GALLBLADDER US
1. No evidence of gallstones, gallbladder distention, or wall
thickening.
2. No intrahepatic or extrahepatic biliary dilatation.
3. Previously described hepatic masses are not visualized on the
current study. Areas of hyperechogenicity in the right hepatic
lobe are nonspecific, but could reflect the sequelae from
previously treated hepatic metastases. If clinically indicated,
these could be better assessed with MRI.
MICROBIOLOGY
========================
__________________________________________________________
___ 12:54 pm Swab R/O Yeast Screen Site: SKIN
Source: axilla swab ( pt refused groin).
**FINAL REPORT ___
SWAB- R/O YEAST (Final ___: NO YEAST ISOLATED.
__________________________________________________________
___ 10:30 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 9:30 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 5:45 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
Brief Hospital Course:
Mr. ___ is a ___ gentleman with chronic abdominal
pain, chronic pancreatitis, pancreatic cancer, currently on
FOLFIROX, who presents with severe abdominal pain. Presentation
consistent with acute on chronic pancreatitis.
#ACUTE ON CHRONIC PANCREATITIS: acute worsening of abdominal
pain in the setting of eating a spicy/likely high-fat meal prior
to admission. Lipase 989 on admission - most recently 653 on
___. Also with nausea. He is high risk for acute
pancreatitis, given prior EtOH abuse with chronic pancreatitis
in the setting of active pancreatic cancer. He denies any
current EtOH abuse.
With significant pain medication requirements at baseline due to
chronic pain - he was initially managed with a dilaudid PCA
(first at 0.12mg q6min and then at 0.2mg q6min), and eventually
transitioned to dilaudid IV 1mg q2h PRN -> dilaudid PO ___ q4h
PRN as he began to tolerate PO. Fentanyl patch was continued. He
was started at ___ and gradually increased to a regular, low-fat
diet. Received teaching with nutrition regarding a low-fat diet
going forward. Of note, pt reported that he was taking dilaudid
___ q4h PRN at home (only prescribed ___ q4h). Encouraged
him to discuss pain control with outpatient provider if his pain
wasn't adequately controlled. He was stable on his discharge
regimen of fentanyl 75mcg patch.
#ELEVATED TRANSAMINASES: newly elevated transaminases on
admission (compared to ___ AST/ALT 43/39, T bil 1.2, Alk phos
217), as well as elevated bilirubin and alk phos, consistent
with
mixed hepatocellular and cholestatic pictures. RUQ US on
admission without evidence of biliary obstruction/ductal
dilation, no new liver lesions noted. No new medications.
Transaminases not elevated enough to suggest viral infection.
___ be related to acute pancreatic inflammation, effecting
biliary/hepatic drainage. Fluctuated and ultimately uptrended
slightly during admission. No evidence of biliary obstruction on
RUQ US. Consider MRI liver to better assess liver mets as an
outpatient.
#TYPE 2 DIABETES: on metformin, glipizide, and ___ glargine at
home. Relatively well-controlled (A1c 8 in ___. Continued
25U glargine at bedtime, held metformin, glipizide while
inpatient. Will resume upon discharge.
#METASTATIC PANCREATIC CANCER: followed by ___, MD at
___. Currently on FOLFIROX in 14 day cycles, last treatment on
___. Most recent CA ___ on ___ 149.1 (rising). Continued
LORazepam 0.5 mg PO Q6H:PRN nausea/vomiting/anxiety/insomnia,
Omeprazole 40 mg PO BID, Fluconazole 200 mg PO Q24H for thrush
PPX, Ondansetron 8 mg IV Q8H:PRN nausea.
#HYPERTENSION: Continued lisinopril 10, HCTZ 12.5mg
#COPD: Respiratory status stable. Continued
Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID.
#TOBACCO DEPENDENCE: Continued BuPROPion (Sustained Release) 150
mg PO QAM
TRANSITIONAL ISSUES
===================
[] On discharge: AST/ALT 101/159, Alk phos 174, T bili 3.2
(increase from prior labs). Continue to follow as outpatient -
no evidence of impending biliary obstruction on RUQ US.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone Propionate NASAL 2 SPRY NU DAILY
2. Nystatin Oral Suspension 5 mL PO QID thrush
3. Omeprazole 40 mg PO BID
4. Zolpidem Tartrate 10 mg PO QHS
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
shortness of breath/wheezing
7. glipiZIDE-metformin 5mg/1000mg oral BID
8. Linzess (linaclotide) 290 mcg oral DAILY
9. lisinopril-hydrochlorothiazide ___ mg oral DAILY
10. LORazepam 0.5 mg PO Q6H:PRN nausea/vomiting/anxiety/insomnia
11. Multivitamins 1 TAB PO DAILY
12. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
13. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
14. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN Pain - Moderate
15. Potassium Chloride (Powder) 20 mEq PO BID
16. Glargine 25 Units Bedtime
17. BuPROPion (Sustained Release) 150 mg PO BID
18. Fentanyl Patch 75 mcg/h TD Q72H
19. Clotrimazole 1 TROC PO QID
20. Fluconazole 200 mg PO Q24H
21. Docusate Sodium 200-300 mg PO BID
22. Polyethylene Glycol 17 g PO DAILY:PRN constipation
23. Senna 17.2-25.8 mg PO BID
Discharge Medications:
1. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
2. Glargine 25 Units Bedtime
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. BuPROPion (Sustained Release) 150 mg PO BID
5. Clotrimazole 1 TROC PO QID
6. Docusate Sodium 200-300 mg PO BID
7. Fentanyl Patch 75 mcg/h TD Q72H
8. Fluconazole 200 mg PO Q24H
9. Fluticasone Propionate NASAL 2 SPRY NU DAILY
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
shortness of breath/wheezing
11. glipiZIDE-metformin 5mg/1000mg oral BID
12. Linzess (linaclotide) 290 mcg oral DAILY
13. lisinopril-hydrochlorothiazide ___ mg oral DAILY
14. LORazepam 0.5 mg PO Q6H:PRN
nausea/vomiting/anxiety/insomnia
15. Multivitamins 1 TAB PO DAILY
16. Nystatin Oral Suspension 5 mL PO QID thrush
17. Omeprazole 40 mg PO BID
18. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
19. Polyethylene Glycol 17 g PO DAILY:PRN constipation
20. Potassium Chloride (Powder) 20 mEq PO BID
Hold for K >
21. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
22. Senna 17.2-25.8 mg PO BID
23. Zolpidem Tartrate 10 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on chronic pancreatitis
Pancreatic adenocarcinoma
Type 2 diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were having severe abdominal pain and your labs showed you
were having pancreatitis.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You had an ultrasound of your abdomen, which appeared similar
to prior ultrasound she had done.
- You were treated with IV pain medications for your abdominal
pain. As you started to feel better, we transitioned you back
to oral medications.
- We slowly advanced your diet as you tolerated it.
WHAT WILL HAPPEN WHEN YOU LEAVE THE HOSPITAL?
- Continue to take all of your medicines as prescribed.
- It is very important that you communicate with your doctors if
___ are taking your pain medications more than what is
prescribed. They can work with you to make sure that your pain
is well controlled.
- You will follow-up with your cancer doctor in the office.
Followup Instructions:
___
|
10677644-DS-8
| 10,677,644 | 26,784,145 |
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| 8 |
2166-01-16 00:00:00
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2166-01-17 14:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___ Aspirin / ibuprofen
Attending: ___
Chief Complaint:
Jaundice
Major Surgical or Invasive Procedure:
ERCP, bile duct stent placement - ___
History of Present Illness:
___ yo male with a history of pancreatic cancer who is admitted
with a biliary obstruction. The patient was recently admitted
from ___ with pancreatitis and was noted to have
increasing LFTs and bilirubin. A RUQ ultrasound was done then
which did not show obstruction. The patient went to this
outpatient oncologists office today and was found to have even
further increasing bilirubin so was refereed to the ED. The
patient has noted dark urine but he denies any fevers or
abdominal pain. He denies any shortness of breath, diarrhea,
dysuria, or rashes.
In the ED labwork was notable from transaminitis and
hyperbilirubinemia. A RUQ ultrasound showed a mass causing
biliary dilation. GI was consulted and plan to perform ERCP
tomorrow.
Past Medical History:
Mr. ___ is a ___ yo gentleman with a ___ year history of
chronic abdominal pain, pancreatitis and ETOH abuse. He was
recently evaluated by Dr. ___ abdominal pain. He reports
having had this pain for the past ___ years, and that his pain
is stable. No recent changes in location, severity or quality.
He has had numerous imaging studies in the past, the last being
___ at ___. He reports that he has epigastric as well as
back pain. Pain from an injury while snowboarding and MVA. He
has chronic bloating and poor appetite. His weight is recently
down 15 pounds. His energy has been "OK", but fluctuates with
pain and mood. He was recently out rising his bike and injured
himself.
- He underwent EUS with Dr. ___ ___. Biopsy of a
portahepatis node was + for acinar cell carcinoma. Biopsies of
the pancreas and hepatic lesions where highly suspicious for CA.
- ___: CTA abd/pelv - Hypoenhancing pancreatic lesion
worrisome for primary malignancy with adjacent adenopathy and
metastases in the liver as detailed above. No prior available to
evaluate for interval change. No other acute intra-abdominal
process to explain patient's symptoms.
- ___: MRCP 1. Pancreatic head/uncinate process mass
concerning for malignancy, possible neuroendocrine tumor, as
described above. 2. Multiple RIGHT lobe hepatic lesions
concerning for metastatic disease. 3. Few subcentimeter nodes
adjacent to the pancreatic mass, better visualized on recent CT
- ___: FOLFIRINOX #1
- ___: CTs show stable disease.
- ___: Scans show stable diease.
- ___: FOLIFIRINOX #12 (oxaliplatin ommited due to
neuropathy)
- ___: Treatment break due to fatigue.
- ___: Restarted FOLFIRINOX (oxaliplatin ommited)
- ___: Admission to ___ for worsened abdominal pain and
nausea
consistent with pancreatitis.
- ___: Admission to ___ for worsened abdominal pain
Discussed appropriate diet/avoidance of fatty foods given
pancreatitis.
- ___: Cycle: 26 Day: ___ FOLFIRINOX
PAST MEDICAL HISTORY:
- Metastatic pancreatic cancer (liver mets)
- Chronic pancreatitis
- h/o EtOH use disorder
- Type II Diabetes
- Peptic Ulcer
- Hemorrhoids
- Sleep Apnea
- Hypertension
- Hypercholesterolemia
- Tobacco Dependence
- Colonic Adenoma
- Obesity
- Lumbar Degenerative Disc Disease
- L3-L4 Herniated Disc s/p L3-L4 microdiskectomy in ___
- Ganglion of Wrist
- s/p left femur fracture s/p repair in ___
Social History:
___
Family History:
DM and HTN. GM with pancreatic cancer in her ___. Aunt with
breast cancer in her ___.
Physical Exam:
ADMISSION EXAM
=======================
General: NAD
VITAL SIGNS: T 98.6 BP 120/60 HR 89 RR 18 O2 100%RA
HEENT: MMM, no OP lesions
CV: RR, NL S1S2
PULM: CTAB
ABD: Soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis
SKIN: No rashes or skin breakdown
NEURO: Alert and oriented, no focal deficits.
DISCHARGE EXAM
=======================
VS: 98.1 PO 116 / 66 80 18 97
GEN: lying in bed, comfortable, NAD
HEENT: EOMI, sclera anicteric, PERRL, MMM, no OP lesions
Cards: RRR, no murmurs, rubs, or gallops
Pulm: CTAB, no adventitious breath sounds, unlabored
respirations
Abd: soft, non-distended, ttp in RUQ, nontender elsewhere
Extremities: warm, well-perfused, no lower extremity edema
Skin: no rashes or bruising
Neuro: A/Ox3, CN II-XII grossly intact, moving all four
extremities with purpose
Pertinent Results:
ADMISSION LABS
=========================
___ 09:40PM BLOOD WBC-6.2 RBC-3.21* Hgb-10.3* Hct-31.1*
MCV-97 MCH-32.1* MCHC-33.1 RDW-15.6* RDWSD-54.9* Plt ___
___ 09:40PM BLOOD Neuts-45.3 ___ Monos-16.1*
Eos-2.6 Baso-1.0 Im ___ AbsNeut-2.82 AbsLymp-2.16
AbsMono-1.00* AbsEos-0.16 AbsBaso-0.06
___ 09:40PM BLOOD ___ PTT-31.9 ___
___ 09:40PM BLOOD Glucose-200* UreaN-9 Creat-0.9 Na-137
K-4.2 Cl-97 HCO3-26 AnGap-14
___ 09:40PM BLOOD ALT-259* AST-134* AlkPhos-266*
TotBili-4.6* DirBili-3.3* IndBili-1.3
___ 09:40PM BLOOD Lipase-119*
___ 09:40PM BLOOD Albumin-4.0
___ 09:46PM BLOOD Lactate-1.7
RELEVANT STUDIES
========================
___ RUQ U/S:
1. Increased 4.5 cm uncinate process pancreatic mass compatible
with known
pancreatic cancer which likely causes new mild intrahepatic and
extrahepatic
biliary dilation.
2. Distended gallbladder contains sludge. No wall thickening.
3. Re-demonstration of ill-defined hepatic masses suggestive of
metastatic
disease.
4. Patent portal vein.
___ ERCP:
Impression:
The scout film was normal.
The major papilla appeared normal.
The bile duct was successfully cannulated using a Clevercut
sphincterotome preloaded with a 0.025in guidewire. Contrast was
injected and there was brisk flow through the ducts. Contrast
extended to the entire biliary tree.
Contrast injection showed a single 3 cm long tight stricture at
the level of the higher and middle third CBD. There was mild
post-obstructive dilation of the CBD, CHD and right and left
main hepatic ducts.
A biliary sphincterotomy was successfully performed with the
sphincterotome. There was no post-sphincterotomy bleeding.
A 10mm x 60mm Wallflex biliary Rx fully covered metal stent
(ref ___, ___ was placed across the stricture.
Excellent bile and contrast drainage was seen endoscopically
and fluoroscopically.
DISCHARGE LABS
=========================
___ 06:26AM BLOOD WBC-6.0 RBC-3.13* Hgb-10.1* Hct-30.4*
MCV-97 MCH-32.3* MCHC-33.2 RDW-15.8* RDWSD-55.6* Plt ___
___ 06:26AM BLOOD Glucose-269* UreaN-6 Creat-0.8 Na-138
K-4.8 Cl-97 HCO3-30 AnGap-11
Brief Hospital Course:
Mr. ___ is a ___ gentleman with history of
metastatic pancreatic cancer who presented from clinic with
increasing hyperbilirubinemia and was found to have new biliary
obstruction.
#Biliary Obstruction: Bilirubin uptrending since prior admission
from ___ RUQUS showed evidence of new biliary
dilatation. Underwent ERCP on ___, which showed 3 cm CHD
stricture which was successfully stented with a metal stent.
Bilirubin downtrended s/p ERCP. Slowly advanced diet until
patient was able to tolerate regular, low fat diet.
#Pancreatic Adenocarcinoma: Metastatic to liver. Last received
FOLFIRINOX on ___. Disease continues to progress as evidenced
by biliary obstruction. Continued home meds - BuPROPion
(Sustained Release) 150 mg PO BID, Prochlorperazine 10 mg PO
Q6H:PRN nausea/vomiting, Ondansetron 8 mg PO/NG Q8H:PRN
nausea/vomiting, LORazepam 0.5 mg PO/NG Q6H:PRN nausea/
vomiting/ anxiety/ insomnia.
#Cancer-related pain: Fentanyl patch 75 mcg/hr discontinued on
___ (day prior to admission) because patient was complaining of
diaphoresis with this. This was replaced with MS ___ 15 mg PO
BID. Increased to 45 mg q8h during admission with adequate pain
control achieved. Continued Morphine Sulfate ___ 30 mg PO/NG
Q4H:PRN.
#Hypertension: Continued Lisinopril 10 mg PO/NG DAILY,
Hydrochlorothiazide 12.5 mg PO/NG DAILY.
#Diabetes Mellitus: Held home glipizide and metformin while
admitted/NPO/on limited diet. Managed with Humalog sliding scale
and home Lantus. Will resume glipizide and metformin on
discharge.
#GERD: Continued home omeprazole
#OSA: Continued home CPAP.
TRANSITIONAL ISSUES
===================
[ ] MS ___ increased to 45mg q8h with adequate pain control.
[ ] PO dilaudid was discontinued and morphine ___ was started -
30mg q3h PRN.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion (Sustained Release) 150 mg PO BID
2. Clotrimazole 1 TROC PO QID
3. Docusate Sodium 200-300 mg PO BID
4. Fluconazole 200 mg PO Q24H
5. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
6. Linzess (linaclotide) 290 mcg oral DAILY
7. LORazepam 0.5 mg PO Q6H:PRN nausea/vomiting/anxiety/insomnia
8. Omeprazole 40 mg PO BID
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 17.2-25.8 mg PO BID
11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
shortness of breath/wheezing
12. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
13. glipiZIDE-metformin 5mg/1000mg oral BID
14. lisinopril-hydrochlorothiazide ___ mg oral DAILY
15. Multivitamins 1 TAB PO DAILY
16. Nystatin Oral Suspension 5 mL PO QID thrush
17. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
18. Potassium Chloride (Powder) 20 mEq PO BID
19. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
20. Zolpidem Tartrate 10 mg PO QHS
21. Fluticasone Propionate NASAL 2 SPRY NU DAILY
22. Glargine 25 Units Bedtime
23. Morphine SR (MS ___ 15 mg PO Q12H
Discharge Medications:
1. Morphine Sulfate ___ 30 mg PO Q3H:PRN Pain - Moderate
RX *morphine 30 mg One tablet(s) by mouth Once every 3 hours
Disp #*56 Tablet Refills:*0
2. Morphine SR (MS ___ 45 mg PO Q8H
RX *morphine 45 mg One capsule(s) by mouth Once every 8 hours
Disp #*21 Capsule Refills:*0
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. BuPROPion (Sustained Release) 150 mg PO BID
5. Clotrimazole 1 TROC PO QID
6. Docusate Sodium 200-300 mg PO BID
7. Fluconazole 200 mg PO Q24H
8. Fluticasone Propionate NASAL 2 SPRY NU DAILY
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
shortness of breath/wheezing
10. glipiZIDE-metformin 5mg/1000mg oral BID
11. Glargine 25 Units Bedtime
12. Linzess (linaclotide) 290 mcg oral DAILY
13. lisinopril-hydrochlorothiazide ___ mg oral DAILY
14. LORazepam 0.5 mg PO Q6H:PRN
nausea/vomiting/anxiety/insomnia
15. Multivitamins 1 TAB PO DAILY
16. Nystatin Oral Suspension 5 mL PO QID thrush
17. Omeprazole 40 mg PO BID
18. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
19. Polyethylene Glycol 17 g PO DAILY:PRN constipation
20. Potassium Chloride (Powder) 20 mEq PO BID
21. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
22. Senna 17.2-25.8 mg PO BID
23. Zolpidem Tartrate 10 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Biliary obstruction
Metastatic pancreatic cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
WHY WERE YOU ADMITTED TO THE HOSPITAL?
You had an abnormal lab value related to your gallbladder (your
bilirubin was high).
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You had a procedure, called an ERCP, to place a stent in your
bile duct. This relieved the blockage and allowed your bilirubin
to come down.
- We increased your pain medications, which seemed to control
your pain well.
WHAT WILL HAPPEN WHEN YOU LEAVE THE HOSPITAL?
- Continue to take all of your medicines as prescribed.
- Please keep all of your follow-up appointments, listed below.
Followup Instructions:
___
|
10677688-DS-19
| 10,677,688 | 22,354,009 |
DS
| 19 |
2184-01-14 00:00:00
|
2184-01-14 21:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Leg swelling
Major Surgical or Invasive Procedure:
Large volume paracentesis
History of Present Illness:
___ female with new diagnosis of hypothyroidism and
cirrhosis presenting for evaluation of abdominal swelling, leg
swelling and back pain. Patient states that for the past couple
months, she has had worsening swelling of bilateral lower
extremities as well as recurrence of a ventral hernia which was
repaired with mesh in ___ and a new hernia. She also states
that
the weekend after ___, she was picking up a basket of
laundry and had sharp shooting pains radiating down bilateral
legs. She states this pain has persisted and is limiting her
ambulation now.
For the combination of these symptoms, she presented to ___ in ___ on ___ at which point she was diagnosed
with cirrhosis and hypothyroidism. Patient was unaware of
cirrhosis diagnosis, despite taking the prescribed medications
and having a handout from ___ about cirrhosis and varices.
Patient presents today because she states that she had
difficulty
setting up follow-up appointments and she remembered somebody
saying something about presenting to the hospital in ___ for
further studies. She is unaware of any other diagnosis that she
currently carries.
With regards to back pain, patient states she has bilateral
electric radiating pains down the back of her thighs, worse with
ambulation. She states that she has no loss of bowel or bladder
control, no numbness, weakness, or tingling of the legs. She
states that she has no fevers or chills, no oncologic history.
With regards to her abdominal swelling, she noticed swelling
increase over months and that a new hernia arose today. Denies
pain in area.
No headache, no visual changes, no chest pain, difficulty
breathing, no cough, no palpitations, no nausea, no vomiting, no
diarrhea, hematochezia, no melena, no dysuria, no hematuria no
arthralgias.
During demonstration of ambulation, patient developed acute
abdominal pain with umbilical hernia, now unable to reduce
ventral hernia. CT abd/pelvis was obtained to rule out
strangulation.
Patient states that ___ was her last drink on admission to
___. She left ___ on ___ and has not had a drink
since.
Past Medical History:
PMH:
1. Likely hypertension.
2. Incisional hernia.
3. Obesity, (body mass index ___ kg/m2).
4. History of recurrent pneumonias.
PSH:
1. Excision of "enormous tumor" along with a total abdominal
hysterectomy, bilateral salpingo-oophorectomy at ___
___ in ___.
2. Left knee skin graft following trauma.
Social History:
___
Family History:
Notable for colon cancer in bother her father and brother. Both
passed away from cancer at age ___ and in their ___ respectively.
Her mother has pre-hypertension and she has an aunt with
diabetes.
Physical Exam:
ADMISSION EXAM:
===============
VS: 97. PO 105 / 68 79 18 91 RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, mild icteric sclera, pink
conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: soft but mild distension, nontender in all quadrants,
no
rebound/guarding, volleyball size ventral hernia, erythema along
suprapubic area/lower abdominal skin fold. edema noted up to the
flanks.
EXTREMITIES: ___ bilateral pitting edema of the lower
extremities. venous stasis changes with bullae.
NEURO: A&Ox3, moving all 4 extremities with purpose, no
asterixis
DISCHARGE EXAM:
===============
VITALS: ___ 0019 Temp: 97.9 PO BP: 94/54 HR: 56 RR: 18 O2
sat: 93% O2 delivery: Ra
GENERAL: Sitting on the bed, comfortable and speaking in full
sentences
HEENT: AT/NC, EOMI, PERRL, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: soft some abdominal distension, nontender in all
quadrants, no rebound/guarding, volleyball size ventral hernia,
erythema along suprapubic area/lower abdominal skin fold.
EXTREMITIES: ___ bilateral pitting edema of the lower extending
to knee with trace edema to hips bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, no
asterixis
Pertinent Results:
ADMISSION LABS:
==============
___ 01:15PM BLOOD WBC-8.4 RBC-3.85* Hgb-15.0 Hct-43.4
MCV-113*# MCH-39.0*# MCHC-34.6 RDW-15.1 RDWSD-63.7* Plt ___
___ 01:15PM BLOOD Neuts-67.9 ___ Monos-9.7 Eos-1.6
Baso-0.7 Im ___ AbsNeut-5.69 AbsLymp-1.65 AbsMono-0.81*
AbsEos-0.13 AbsBaso-0.06
___ 01:15PM BLOOD ___ PTT-34.8 ___
___ 01:15PM BLOOD Glucose-73 UreaN-10 Creat-0.7 Na-141
K-4.2 Cl-106 HCO3-23 AnGap-12
___ 01:15PM BLOOD ALT-36 AST-65* AlkPhos-102 TotBili-3.6*
___ 01:15PM BLOOD Albumin-2.4* Calcium-8.5 Phos-3.6 Mg-1.6
DISCHARGE LABS:
==============
___ 05:10AM BLOOD WBC-6.7 RBC-3.70* Hgb-13.5 Hct-41.1
MCV-111* MCH-36.5* MCHC-32.8 RDW-15.0 RDWSD-62.2* Plt ___
___ 05:10AM BLOOD ___ PTT-41.6* ___
___ 05:10AM BLOOD Glucose-73 UreaN-13 Creat-0.8 Na-145
K-3.7 Cl-105 HCO3-27 AnGap-13
___ 05:10AM BLOOD ALT-25 AST-53* LD(LDH)-280* AlkPhos-95
TotBili-2.1*
___ 05:10AM BLOOD Albumin-3.9 Calcium-9.4 Phos-3.3 Mg-1.7
PERTINENT IMAGING:
=================
RUQ US
1. Patent hepatic vasculature.
2. Coarse and nodular hepatic parenchyma consistent with the
patient's known
cirrhosis. No concerning liver lesion identified.
3. Scant trace ascites.
4. Minimal sludge noted in the gallbladder.
__________________________________________________________
___ 1:17 pm PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ 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.
__________________________________________________________
___ 5:27 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- <=2 S <=2 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S 128 R
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
__________________________________________________________
___ 1:15 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 1:48 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
The patient is a ___ year old female with history of cirrhosis,
likely secondary to alcohol and hepatitis C, ventral hernia,
hypothyroidism with anasarca, presenting with an acute
decompensation of her cirrhosis.
ACUTE/ACTIVE PROBLEMS:
======================
#Decompensated cirrhosis
#Ascites
#Varices
#Lower extremity swelling:
The patient was admitted to ___ in mid ___ for
increasing abdominal distention and lower extremity edema, and
received a diagnosis of cirrhosis at that time, likely due to
ETOH/HCV. She was treated with diuretics, but ultimately left
that hospitalization against medical advice. She presented to
the ___ with continued severe lower extremity edema and
abdominal distention, as well as the inability to ambulate. At
the ___, she was found to be in acute decompensated cirrhosis.
Her upper quadrant ultrasound showed a cirrhotic liver, but no
thrombosis. She had an ___ guided large volume paracentesis with
the removal of 2.75L of peritoneal fluid which was negative for
SBP. Finally, her CT scan showed a large ventral hernia which
was also noted on exam (discussed below) which did not show any
signs of incarceration. The patient was diuresed with large
boluses of IV lasix and PO spironolactone daily, and on the day
of discharge her volume status was net negative 7 liters for
length of stay. Ultimately, she was discharged on 60mg PO lasix
BID and 150mg Spironolactone PO BID.
# Urinary tract infection: She had urine cultures, blood
cultures, a chest X-ray, a right upper quadrant ultrasound, and
a CT of her abdomen and pelvis. Her urine cultures grew pan
sensitive E. Coli, and she was treated with three days of
ceftriaxone. Her blood cultures were negative, her chest X-ray
did not show any abnormality
# ___: During active diuresis, the patient was noted to have a
slight bump in her creatinine thought to be related to
intravascular depletion. She was given two boluses of 100g
albumin on subsequent days with improvement in her Cr. Her
discharge creatinine was 0.8.
Chronic:
========
#Ventral hernia: Exam and imaging both consistent with a large
ventral hernia with no concern for incarceration. Given the high
morbidity related to surgery in cirrhosis, a surgical consult
was not pursued. The patient was given an abdominal binder which
helped with her symptoms.
#Low back pain: The patient has chronic lower back pain which
was treater with Gabapetin and Tylenol with good relief of
symptoms.
#Macrocytosis: Likely secondary to alcohol and liver disease.
B12 and Folate normal.
#Alcohol use disorder: Patient stated that she drank 5 glasses
of wine a night x ___ years, and before that, drank mostly every
day but fewer drinks. States her last drink was ___, when
she was admitted to ___. We continued to encourage
abstinence while she was in the hospital, stressing that if she
drinks again she will likely die.
#Hypothyroidism: Continued on Levothyroxine Sodium 75 mcg PO
DAILY
#GERD: Continued on Pantoprazole 40 mg PO Q24H
#Smoking: Nicotine Patch 14 mg TD DAILY
TRANSITIONAL ISSUES:
==================
- MELD on discharge: 14
- Gabapentin 200 BID: Consider uptitrating as outpatient as
needed for back pain
- Back pain: Can consider MRI as outpatient as pain consistent
with radiculopathy
- follow up at cancer genetics clinic for possible Lynch
syndrome, has DNK'ed in the past
- discharge Cr: 0.8, discharge weight 86.4 kg
- diuretic doses: 60 mg PO Lasix BID, 150 mg spironolactone BID
- needs hepatitis B vaccine series
- Discuss hepatitis C treatment in the outpatient setting,
patient found to have genotype 3A
- Discuss EGD/colonoscopy for variceal and colon cancer
screening
- liver MRI for hypodensity seen on CT A/P, patient will require
___ screening going forward
>30 minutes were spent of discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 75 mcg PO DAILY
2. Pantoprazole 40 mg PO Q24H
3. Spironolactone 50 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Thiamine 100 mg PO DAILY
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
7. ALPRAZolam 0.5 mg PO BID:PRN anxiety
8. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Mild
9. Nicotine Patch 14 mg TD DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Furosemide 60 mg PO BID
RX *furosemide 20 mg 3 tablet(s) by mouth twice daily Disp #*180
Tablet Refills:*0
3. Gabapentin 200 mg PO BID
RX *gabapentin 100 mg 2 capsule(s) by mouth twice daily as
needed Disp #*20 Capsule Refills:*0
4. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Spironolactone 150 mg PO BID
RX *spironolactone 50 mg 3 tablet(s) by mouth twice daily Disp
#*180 Tablet Refills:*0
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
7. FoLIC Acid 1 mg PO DAILY
8. Levothyroxine Sodium 75 mcg PO DAILY
9. Nicotine Patch 14 mg TD DAILY
10. Pantoprazole 40 mg PO Q24H
11. Thiamine 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Acute decompensated cirrhosis
- Active hepatitis C
- Uncomplicated urinary tract infection
- Ascites
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
WHY WAS I ADMITTED?
- You had significant leg swelling and abdominal distension
- This was because of your cirrhosis
- You needed IV medications to remove some of the fluid as well
as a needle drainage of the fluid in your belly
WHAT WAS DONE WHILE I WAS HERE?
- You were given medications to help you urinate off the extra
fluid
- You had a needle inserted into your belly to drain the fluid
- You had an infection in your urine which was treated with
antibiotics
- Your electrolytes and kidney function was monitored closely
while we removed fluid
WHAT SHOULD I DO NOW?
-You should take your medications as instructed
-You should go to your doctor's appointments as below
-Keep a low sodium diet
-You should weigh yourself daily and call the liver clinic if
your weight increases by 3 pounds.
We wish you the best!
-Your ___ Care Team
Followup Instructions:
___
|
10677740-DS-11
| 10,677,740 | 22,023,845 |
DS
| 11 |
2188-08-18 00:00:00
|
2188-08-20 13:35:00
|
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Chlorpromazine
Attending: ___
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
Electrophysiology study and LinQ placement
History of Present Illness:
Accept note
Mr. ___ is a ___ man with a history of bipolar
disorder, hyperlipidemia and left anterior fascicular block, who
presents after a syncopal episode.
Over the prior few days before presentation, Mr. ___ noted
increased stress with worsening symptoms of depression/anxiety
due to his work and his family situation. He also noted that he
had to walk slower on his daily commute to/from work. Over the
past month, he has also had a sore throat at night. On ___
in the afternoon, he was sitting at a table going through notes
for a lesion plan for the class he was going to teach that day,
for which he was "more nervous than usual," when he suddenly
lost consciousness. The next thing he remembers is waking up a
___ feet away, near the door.
He does not recall what happened when he passed out or how he
moved. He does not recall any prodromal symptoms such as
lightheadedness, dizziness, chest pain, shortness of breath, or
palpitations. He noted some a feeling that he had hit the back
of his head, but denies any frank head pain. Until this point he
generally was feeling well, with ___ recent fevers, chills,
nausea, vomiting, or diarrhea.
His fall was unwitnessed but his coworker heard him and called
for an ambulance. His coworker thought that he had fallen
backwards out of the chair, or that he had walked out of the
chair and tripped over an uneven patch on the floor near the
door. After the fall, he states he was groggy and "woozy" but
had ___ memory defects. He denies any focal weakness, numbness,
or pain/paresthesias either before or after the episode.
However, his coworker did note that his eyes were "fluttering"
or blinking rapidly after his fall, which resolved.
He states he has had normal PO food and water intake, but that
over the hour or two prior to his fall he was much more thirsty
than usual. He has never had symptoms of lightheadedness on
exertion or on standing in the past. He denies any calf pain.
He notes he has had a fall in the past in ___, when he tripped
on a stage and fell, injuring his face. He was not able to
remember the beginning of this fall but does remember falling
and injuring himself, with ___ loss of consciousness. He was seen
by Dr. ___ at ___ at this time for suspicion of syncope
but echocardiogram and cardiac MRI were unremarkable, Holter
monitor showed ___ arrhythmia, and EKG showed left anterior
fascicular block.
He also notes he has had symptoms of fainting without memory of
the incident in his late ___ and early ___, when he was
hospitalized for treatment of bipolar disorder. He states this
was always in association with chlorpromazine treatment and
resolved when he stopped taking the medication.
He was brought to the ___ ED. At the ED, he had an
unremarkable Chem7, UA, CBC, with normal CK-MB and troponins.
His C- CT head showed ___ evidence of injury. His EKG showed left
anterior fascicular block (LAFB) but also right bundle branch
block (RBBB).
Admission note
Mr. ___ is a ___ gentleman with a PMH notable for
hyperlipidemia, who presents after syncope.
The patient had been feel well and in good health up until
___ when he suddenly lost consciousness while working. He
had been preparing for a lesson plan for a class when the next
thing he remembers is waking up a few steps away near the door.
He does not recall what immediately happened when he passed out
or how he moved himself. He did feel pain in the back of his
head. He did not have any prodromal symptoms, such as
lightheadedness, dizziness, chest pain, shortness of breath, or
palpitations. He had been feeling well with ___ recent fevers,
chills, nausea, vomiting, or diarrhea.
In the ___ ED, he had normal routine labs and an EKG that
showed RBBB and LAFB. Given the abnormal EKG, he was admitted
for further work up.
On arrival to the floor, patient reports feeling fine other than
a slight headache in the back of his head. He reports ___ recent
travel, leg or calf pain, or surgeries. He had previously been
seen by Dr. ___ at ___ for a history of falls that were
suspicious for syncope. At that time, he had an echocardiogram
and cardiac MRI that did not show any significant abnormalities.
Holter monitor did not show any arrhythmia. At that time, his
EKG was noted to have left anterior hemi-block but ___ right
bundle branch block.
Past Medical History:
- Hyperlipidemia
- Bipolar disorder
- Psoriasis
- Allergic rhinitis
- Benign prostatic hyperplasia
- Osteoarthritis of knee
- s/p cataract surgery
Social History:
___
Family History:
Mother died of a heart attack in her ___. Father lived to be in
his ___. ___ other significant history of heart disease or early
death.
Physical Exam:
Admission physical exam:
Vital Signs: T 97.8, BP 144/78, HR 61, RR 18, SAT 99% RA
General: Alert, oriented, ___ acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, ___ carotid bruits
CV: Regular rate and rhythm, normal S1 + S2, soft systolic
murmur heard in the precordium, ___ rubs or gallops
Lungs: Clear to auscultation bilaterally, ___ wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
___ rebound or guarding
Ext: Warm, well perfused, 2+ pulses, ___ clubbing, cyanosis or
edema
Neuro: Grossly nonfocal
Discharge physical exam:
Vitals- Tm 98.1 Tc 97.8 HR 62(58-72) BP 115/75 (115-134/69-75)
[134/72 lying, 129/75 sitting, 102/66 standing] RR 18 SaO2
95-99% RA
General- Alert, oriented, ___ acute distress
HEENT- Sclera anicteric, MMM,
Neck- supple, JVP not elevated, ___ cervical/supraclavicular LAD
Lungs- CTAB, ___ wheezes, rales, rhonchi
CV- RRR, normal S1 + S2, ___ M/R/G
Abdomen- soft, non-tender, non-distended, normoactive bowel
sounds, ___ rebound tenderness or guarding, ___ organomegaly
GU- ___ foley catheter present
Ext- warm, well perfused, 2+ pulses, ___ clubbing, cyanosis or
edema. Negative ___ sign. ___ pain on deep palpation of
popliteal fossa and posterior leg. ___ palpable cords.
Neuro- PERRLA, motor function grossly normal
Pertinent Results:
Admission labs:
===============
___ 07:30PM BLOOD WBC-7.2 RBC-5.00 Hgb-15.1 Hct-46.5 MCV-93
MCH-30.2 MCHC-32.5 RDW-12.7 RDWSD-43.6 Plt ___
___ 07:30PM BLOOD Neuts-79.7* Lymphs-13.7* Monos-5.4
Eos-0.8* Baso-0.3 Im ___ AbsNeut-5.77 AbsLymp-0.99*
AbsMono-0.39 AbsEos-0.06 AbsBaso-0.02
___ 07:30PM BLOOD Plt ___
___ 09:14PM BLOOD ___ PTT-20.4* ___
___ 07:30PM BLOOD Glucose-106* UreaN-28* Creat-0.9 Na-136
K-4.7 Cl-100 HCO3-26 AnGap-15
___ 07:30PM BLOOD CK(CPK)-172
___ 04:06PM BLOOD CK(CPK)-200
___ 06:15AM BLOOD Lipase-20
___ 07:30PM BLOOD CK-MB-3 cTropnT-<0.01
___ 04:06PM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:30AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.9
___ 06:15AM BLOOD Triglyc-69 HDL-46 CHOL/HD-3.5 LDLcalc-101
___ 06:15AM BLOOD TSH-1.6
___ 06:15AM BLOOD Free T4-1.1
Discharge labs:
===============
___ 06:15AM BLOOD WBC-4.0 RBC-4.57* Hgb-13.9 Hct-42.0
MCV-92 MCH-30.4 MCHC-33.1 RDW-12.9 RDWSD-43.0 Plt ___
___ 06:15AM BLOOD Plt ___
___ 06:15AM BLOOD ___ PTT-27.4 ___
___ 06:15AM BLOOD Glucose-91 UreaN-19 Creat-0.7 Na-139
K-4.3 Cl-105 HCO3-24 AnGap-14
Micro:
=====
Urine culture ___ growth
Radiology:
=========
___ ECHO
The right atrium is moderately dilated. Mild symmetric left
ventricular hypertrophy with normal cavity size, and
regional/global systolic function (biplane LVEF = 63 %). Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). Doppler parameters are most consistent
with Grade I (mild) left ventricular diastolic dysfunction.
There is ___ left ventricular outflow obstruction at rest or with
Valsalva. 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 ___ aortic
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are structurally normal. There is ___ mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is ___
pericardial effusion.
IMPRESSION: Mild left ventricular hypertrophy with normal
biventricular regional/global systolic function. Mild aortic and
mitral regurgitation.
Compared with the prior study (images reviewed) of ___,
the degree of mitral regurgitation has decreased whereas the
degree of aortic regurgitation has increased slightly.
___ CT HEAD W/O contrast
FINDINGS:
There is ___ evidence of acute large territorial infarction,
hemorrhage, edema, or mass. There is prominence of the
ventricles and sulci suggestive of involutional changes. There
is ___ evidence of fracture. The visualized portion of the
paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. The visualized portion of the orbits are
unremarkable.
IMPRESSION: ___ acute intracranial process.
___ CXR
FINDINGS:
Cardiac silhouette size is mildly enlarged. The aorta is
tortuous. The mediastinal and hilar contours are unremarkable.
The pulmonary vasculature is not engorged. Calcified granuloma
is seen within the lateral aspect of the left mid lung field.
Lungs are mildly hyperinflated but clear. ___ focal
consolidation, pleural effusion or pneumothorax is seen.
Moderate degenerative changes are noted in the thoracic spine.
IMPRESSION: ___ acute cardiopulmonary abnormality.
___ EP Brief Procedure Report
Findings ___ quad to ra and his AH 130, HV 60 post atropine
with pacing HV maximal 67 ms ___ AVN pathways ___ SVT linq
placed subcutaneously
Brief Hospital Course:
Mr. ___ is a ___ yo M with past medical history of bipolar
disorder and dyslipidemia who presented with unexplained syncope
and fall. Head CT was negative for acute intracranial process.
Lack of prodrome to his syncope raised concerning for possible
cardiogenic origin. ECG with inter-atrial conduction delay,
RBBB, and LAFB. TTE without explanatory structural
abnormalities. The electrophysiology service was consulted, with
electrophysiology study performed and ___ inducible arrhythmia
identified. A linq device was placed prior to discharge for
ongoing surveillance.
ACTIVE ISSUES:
# SYNCOPE
Patient presents with loss of consciousness and unwitnessed
fall, without prodrome, with ___ focal neurologic deficits, with
mild "woozy" feeling after the episode. Lack of prodrome raised
concern for possible cardiac etiology; low suspicion for
neurologic etiology in the absence of aura, postictal state, or
neurologic deficits. ___ clearly accompanying symptoms to suggest
vasovagal syncope, though has had increased life stressors as
below; low suspicion for PE in the absence of shortness of
breath, hypoxia, pleuritic chest pain, tachycardia, or
suggestive risk factors. Cardiac enzymes reassuring against ACS,
and TSH within normal limits. Imaging notable for head CT
without acute intracranial abnormality, and CXR without evidence
of infiltrate or rib fractures. EKG with newly recognized RBBB
with known LAFB. TTE with mild LVH and mild AR and MR, but ___
clear explanatory structural abnormalities. The
electrophysiology service was consulted, with electrophysiology
study performed and ___ inducible arrhythmia identified. Ling
device was placed prior to discharge for ongoing surveillance,
with device clinic follow-up scheduled.
CHRONIC ISSUES:
# BIPOLAR DISORDER:
Patient with history of BPD with depression/anxiety. Emotional
stressors could have contributed to or exacerbated presentation.
Patient off medication for ___ years.
# HYPERLIPIDEMIA:
He had self-discontinued simvastatin prior to discharge due to
concern for associated gingival bleeding.
# ERECTILE DYSFUNCTION:
He had self-discontinued sildenafil prior to discharge due to
concern for associated gingival bleeding.
TRANSITIONAL ISSUES:
- Follow up Linq device; follow up in device clinic within one
week.
- Address depression/anxiety management given increased life
stressors.
- Given that his syncopal episode remains unexplained, ___ state
law requires that he refrain from driving for 6 months.
- Readdress statin and sildenafil; he self-discontinued
simvastatin and sildenafil because of concern of association
with gingival bleeding.
- Recheck urinalysis to ensure resolution of microscopic
hematuria; he was found to have 7 RBC on admission UA.
- Lungs were found to be mildly hyperinflated on admission CXR
in the absence of known COPD or respiratory symptoms; consider
PFTs if develops symptoms. He also was found incidentally to
have calcified granuloma on admission CXR.
#Code: full code
#Communication: ___, HCP, son: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 40 mg PO QPM
2. Cialis (tadalafil) 20 mg oral PRN
Discharge Medications:
1. Cialis (tadalafil) 20 mg oral PRN
2. Simvastatin 40 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Syncope
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. You came to the
hospital because you had an episode of loss of consciousness and
fall.
What happened to you during your hospital stay?
- We did a head CT because you fell, and it showed ___ fracture
or bleed in the head
- We monitored your heart rhythm closely and consulted the
cardiology heart rhythm specialist for further evaluation
- A heart echo was performed and showed ___ abnormalities
- The heart rhythm doctor did not identify any abnormal rhythm,
that's why a Linq device was placed in order to monitor your
heart rhythm for up to ___ years in hopes of correlating any
future events with possible arrhythmias
What should you do when you leave the hospital?
- Make sure to follow up with the heart device clinic in 1 week,
and your other doctors as ___
- ___ taking all your previous medications as previously
prescribed
- You should not drive for 6 months (or until syncope is
explained); given that your syncopal episode remains
unexplained, ___ state law requires that you refrain from driving
for 6 months
We wish you all the best.
Your ___ team
Followup Instructions:
___
|
10677866-DS-6
| 10,677,866 | 22,244,117 |
DS
| 6 |
2158-06-17 00:00:00
|
2158-06-18 21:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo woman with a recent history of stroke
and a PFO, who presented to the ED with headache and chest pain.
She initially presented ___ with symptoms of right hand
numbness, blurriness in the right eye, and word finding
difficulty lasting 1 hour, as well as a headache. An MRI, MRA,
and MRV revealed a left parietal stroke. On stroke workup she
was
found to have a PFO on her TTE, though her leg ultrasound and
MRV
pelvis were negative for DVT.
Two days ago developed a headache that is similar to the
headache
she had during the stroke. She denies sx of vision changes,
weakness, numbness, or speech problems. She called her
outpatient
doctor who recommended she come to the ED for evaluation. She
initially came to last night but left before being evaluated
because the wait was too long. The headache has improved since
then and is ___. Subsequently last night, she developed chest
pain and now presents to the ED again for evaluation of both the
headache and chest pain. Neurology was consulted for concern the
headache may represent another stroke.
The headache is left sided and throbbing. It radiates to the
vertex. It comes and goes. There is no associated neck
stiffness.
She denies nausea and vomiting. Overall the headache is
improving. She endorses right arm achiness and dysuria but
denies
any other symptoms.
Past Medical History:
- small ischemic stroke earlier this month, found to have a PFO
Possible single lifetime migraine in ___
Possible ocular migraine in ___
Brain cyst (?prolactinoma)
Spontaneous miscarriage at 10 weeks x1
PCOS with irregular periods (last period 2 weeks ago)
**Of note, pt describes an episode when she was ___ where she
developed right arm tingling lasting seconds followed by whole
body paralysis. Pt states she was bedbound and her mother helped
her with all her ADLs at this time. She then spontaneously
recovered 2 weeks later. She lived in ___ at the time and
she did not see a doctor due to financial reasons.
Social History:
___
Family History:
Mother: ___ (no history of complex migraines)
Father: Possible seizures
Physical Exam:
Admission
Vitals: 97.8 67 118/84 15
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple.
Pulmonary: clear to auscultation bilaterally
Cardiac: RRR, no murmurs
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 on the stroke card. She described the cookie
jar picture with detail and accuracy. 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
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. No orbiting. Finger tapping was
quick symmetric.
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 1 1 1 1 2
R 1 1 1 1 2
- Toes were downgoing bilaterally.
-Sensory: No deficits to light touch, pinprick, cold sensation,
proprioception throughout. No extinction to DSS visually.
Graphesthesia intact bilaterally.
-Coordination: No dysmetria on FNF or HKS bilaterally. Rapid
alternating movements with normal cadence and speed; no
dysdiadochokinesia bilaterally. No ataxia.
-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
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple.
Pulmonary: clear to auscultation bilaterally
Cardiac: RRR, no murmurs
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 on the stroke card. She described the cookie
jar picture with detail and accuracy. 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
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. No orbiting. Finger tapping was
quick symmetric.
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 1 1 1 1 2
R 1 1 1 1 2
- Toes were downgoing bilaterally.
-Sensory: No deficits to light touch, pinprick, cold sensation,
proprioception throughout. No extinction to DSS visually.
Graphesthesia intact bilaterally.
-Coordination: No dysmetria on FNF or HKS bilaterally. Rapid
alternating movements with normal cadence and speed; no
dysdiadochokinesia bilaterally. No ataxia.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem, on toes, and on heels without
difficulty. Romberg absent.
Pertinent Results:
___ 10:50AM BLOOD WBC-6.5 RBC-4.05# Hgb-12.0# Hct-37.6#
MCV-93# MCH-29.6 MCHC-31.9* RDW-13.0 RDWSD-44.0 Plt ___
___ 12:20AM BLOOD WBC-8.1 RBC-4.16 Hgb-12.5 Hct-38.6 MCV-93
MCH-30.0 MCHC-32.4 RDW-13.0 RDWSD-43.6 Plt ___
___ 12:20AM BLOOD Neuts-45.8 ___ Monos-7.9 Eos-1.0
Baso-0.6 Im ___ AbsNeut-3.73 AbsLymp-3.63 AbsMono-0.64
AbsEos-0.08 AbsBaso-0.05
___ 12:20AM BLOOD ___ PTT-27.9 ___
___ 07:55AM BLOOD Glucose-110* UreaN-62* Creat-5.9*# Na-139
K-3.6 Cl-102 HCO3-27 AnGap-14
___ 10:21PM BLOOD Glucose-139* UreaN-13 Creat-0.8 Na-139
K-3.7 Cl-103 HCO3-25 AnGap-15
___ 10:50AM BLOOD cTropnT-<0.01
___ 07:55AM BLOOD cTropnT-0.01
___ 07:55AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.6
___ 10:21PM BLOOD D-Dimer-263
___ 07:55AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:41AM URINE Blood-NEG Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM
___ 09:39PM URINE Blood-NEG Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
___ 08:41AM URINE Color-Yellow Appear-Hazy Sp ___
___ 09:39PM URINE Color-Straw Appear-Hazy Sp ___
___ 08:41AM URINE RBC-4* WBC-14* Bacteri-MOD Yeast-NONE
Epi-6
___ 09:39PM URINE RBC-<1 WBC-6* Bacteri-FEW Yeast-NONE
Epi-2
___ 09:39PM URINE UCG-NEGATIVE
___ 08:41AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
MR head
unctate hyperintensity in the posterior left insular cortex on
the diffusion
tracer, which is too small to characterize on the ADC map, is in
the same
location as the small acute infarcts seen on ___, with new
punctate
corresponding T2 hyperintensity. This could represent either T2
shine through
from the prior infarction, or a new punctate infarction at the
same site. The
latter possibility would suggest a persistent embolic source.
CTA (wet read):
No acute intracranial process. No acute vascular abnormalities.
Brief Hospital Course:
___ is a ___ F with a PMHx of recent small
left parietal and insular strokes in the setting of PFO who
presents with HA similar to the one she experienced prior to her
stroke and perhaps some right forearm tingling. The headache
subsequently resolved, and she was headache-free for three days
on the day of discharge. A CTA head/neck did not show evidence
of RCVS and an MRI brain did not show evidence of new stroke
(just T2 shine-through in the left insula from old stroke). She
was diagnosed with a migraine (with her recent stroke
potentially serving as a nidus in the setting of stress/poor
sleep and a cervicogenic component). She was advised to take
NSAIDs as soon as headache symptoms start but to return to the
ED if she experiences any aphasia, sensory/motor sxs, etc. She
was also told to apply hot compresses and seek help from a
physical therapist if her headaches persist to help with the
cervicogenic component of her headaches.
Her CXR was negative for a cardiopulmonary process. Her two UAs
showed ___ WBCs with few bacteria, but they also had multiple
epithelial cells. She denied frequency, dysuria, and
fevers/chills, and these samples were felt to be a contaminant.
Her troponins were neg x 2. D-dimer neg.
She already has neurology follow-up scheduled after her prior
recent admission.
Transitional issues:
-UCx; s/sx of UTI
-If HA occurring more often than once every three weeks, she
should follow up with neurology
Medications on Admission:
ASA 81mg daily
Tylenol prn HA
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN headache
2. Aspirin 81 mg PO DAILY
3. ___ (norethindrone (contraceptive)) 0.35 mg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Migraine
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 headache which seems to have been a
migraine. Your recent stroke has left a small bit of brain which
is irritable and we suspect that this was a nidus for migraine
formation. If it occurs again without any weakness, numbness,
changes in speech, or changes in vision, take ibuprofen as soon
as possible. If you are taking ibuprofen for headache more than
once every three weeks, please let your neurologist know. If you
have any of the danger symptoms listed below, please return to
the emergency department. Please continue to take your aspirin
daily without missing doses, and please continue to avoid
estrogen-containing oral contraceptives or Mirena devices.
It was a pleasure seeing you again!
Your ___ Neurology Team
Followup Instructions:
___
|
10677907-DS-19
| 10,677,907 | 26,280,341 |
DS
| 19 |
2166-07-13 00:00:00
|
2166-07-13 19:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Amoxicillin
Attending: ___
Chief Complaint:
___, diarrhea, weakness
Major Surgical or Invasive Procedure:
Renal biopsy ___
History of Present Illness:
Ms. ___ is a ___ y.o. perimenopausal F with ESRD ___
T1DM s/p simultaneous pancreas-kidney ___,
HTN,
with a recent hospitalization from ___ for provoked LLE
DVT(not currently on anticoag), and ___ for
vaginal
bleeding. She is being admitted to the ET service for ___ in the
setting of diarrhea.
She presented to the ED for ___ days of diarrhea and weakness.
Patient states that she has had ___ small volume loose
stools/day
for the past ___ days. Denies any unusual travel, or food
intake.
She says that this has made her weak and she feels dehydrated.
She denies any nausea or vomiting. Furthermore, she endorses
taking all of her medications. The diarrhea is described as
frothy, mucous like, green to light brown without blood. She
states the stool is usually small volume and sometimes leaves
mucous like streaks on the side of the commode. Feels that the
overall severity of the diarrhea is improving. Denies any fevers
or chills. Denies abdominal pain. Endorses a poor appetite, but
has been drinking Gatorade.
Recently, there have been NO changes to her immunosuppressive
regimen and she endorses taking all of her doses. Recently
changed BP meds from amlodipine to lisinopril.
In the ED
Vitals: T 96.3, HR 108 (in room 80), BP 140/78, RR 16, 100% RA
Exam: In NAD, RRR, CTAB, abd soft NTND, no tenderness over L
transplanted kidney, several laparotomy scars,no CVA tenderness,
no ___ edema
- Labs notable for:
10.1
12.4>------<217
32.6
N:79.7 L:10.5 M:8.6 E:0.7 Bas:0.2 ___: 0.3 Absneut: 9.84
Abslymp: 1.30 Absmono: 1.06 Abseos: 0.09 Absbaso: 0.03
137 110 50
--------------< 98 gap 17
4.1 10 3.2
Urine with 45 WBC, LG leuks, Mod bacteria, negative nitr
See OMRfor further labs.
Imaging notable for:
-Radiology Report RENAL TRANSPLANT U.S. Study Date of ___
3:00 ___
IMPRESSION:
Unremarkable renal transplant ultrasound.
Consults: Transplant Renal
Patient was given:
-1L NS
-IV magnesium
-CMV PCR, tacro, c.diff, noro ag were drawn
-started on 1L D5w + 150 mEq naco3 @ 100 cc/h
REVIEW OF SYSTEMS: Positive per HPI, remaining 10 point ROS
reviewed and negative.
Past Medical History:
ESRD ___ T1DM s/p SPK (___)
HTN
Prior h/o squamous cell skin cancer (s/p excision from lip
___, nose ___
Provoked LLE DVT
s/p multiple abd hernia repairs
s/p ovarian cyst removal
s/p appendix removal
Social History:
___
Family History:
Mother bladder cancer.
Father colon cancer (dx age ___, skin cancer.
Two brothers, sister healthy.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
===============================
VS: ___ 1816 Temp: 97.9 PO BP: 105/66 L Sitting HR: 104
RR:
18 O2 sat: 100% O2 delivery: Ra
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
Dry mucous membranes, no evidence of mucosal cracking or
lesions.
No thrush.
NECK: supple, no LAD, no JVD
HEART: RRR, blowing holosystolic murmur radiating to the
carotids
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAMINATION:
===============================
24 HR Data (last updated ___ @ 738)
Temp: 98.0 (Tm 99.1), BP: 118/50 (118-176/50-90), HR: 91
(71-91), RR: 18, O2 sat: 94% (90-95), O2 delivery: Ra, Wt: 126.2
lb/57.24 kg
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
Dry mucous membranes
NECK: supple
HEART: RRR, ___ systolic murmur
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly, lower midline abdominal
biopsy site without tenderness, dressing c/d/i
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Admit Labs
================
___ 12:45PM BLOOD WBC-12.4* RBC-3.51* Hgb-10.1* Hct-32.6*
MCV-93 MCH-28.8 MCHC-31.0* RDW-13.9 RDWSD-46.8* Plt ___
___ 12:45PM BLOOD Neuts-79.7* Lymphs-10.5* Monos-8.6
Eos-0.7* Baso-0.2 Im ___ AbsNeut-9.84* AbsLymp-1.30
AbsMono-1.06* AbsEos-0.09 AbsBaso-0.03
___ 12:45PM BLOOD Plt ___
___ 12:45PM BLOOD Glucose-98 UreaN-50* Creat-3.2*# Na-137
K-4.1 Cl-110* HCO3-10* AnGap-17
___ 12:45PM BLOOD ALT-5 AST-14 AlkPhos-57 Amylase-76
TotBili-0.2
___ 12:45PM BLOOD Lipase-33
___ 12:45PM BLOOD Albumin-4.3 Calcium-9.0 Phos-4.0 Mg-1.3*
___ 05:40AM BLOOD tacroFK-13.6 rapmycn-9.1
___ 12:45PM BLOOD GreenHd-HOLD
___ 07:24PM BLOOD CMV VL-NOT DETECT
Discharge Labs
================
___ 06:18AM BLOOD ___ PTT-25.8 ___
___ 06:18AM BLOOD Glucose-89 UreaN-18 Creat-2.5* Na-136
K-4.3 Cl-95* HCO3-25 AnGap-16
___ 06:18AM BLOOD ALT-5 AST-14 AlkPhos-49 TotBili-0.4
___ 06:18AM BLOOD Albumin-3.7 Calcium-9.0 Phos-2.7 Mg-1.5*
___ 06:18AM BLOOD tacroFK-3.2* rapmycn-6.6
Imaging
-Radiology Report RENAL TRANSPLANT U.S. Study Date of ___
3:00 ___
IMPRESSION:
Unremarkable renal transplant ultrasound.
Micro
================
___ 3:06 am STOOL CONSISTENCY: WATERY Source:
Stool.
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Pending):
FECAL CULTURE - R/O VIBRIO (Pending):
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
No E. coli O157:H7 found.
___ 11:07 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with past medical history of
T1DM, HTN, diabetic nephropathy s/p SPK ___, chronic renal
allograft dysfunction (Cr 1.6-2.0), LLE DVT ___ - completed
3 months of AC), recent admission in ___ for vaginal
bleeding and ___, who was admitted for ___ iso diarrheal
illness.
Active Issues
============
___
#Metabolic Acidosis
Baseline Cr 1.6-2.0 found to be 3.2 on admission labs. Bicarb on
presentation found to be 10. Transplant renal U/S unremarkable
for obstruction. Urine sediment bland. Urine electrolytes
revealed sodium avid urine. Treated with aggressive hydration
and NaHCO3 repletion. ___ likely prerenal iso marked
hypovolemia and diarrhea, with contribution from high tacro iso
diarrhea. Metabolic acidosis is also likely due to
diarrhea in addition to chronic low bicarb levels. Spun urine
___ without abnormalities. Given persistent ___ despite IVF,
underwent renal biopsy ___. Prelim renal biopsy pathology
showed that she did not have rejection. Creatinine began to
slowly improve before discharge.
#Hypertension
SBP as high as 170-180s during admission. Asymptomatic without
HA, CP/SOB. Home lisinopril was held during this admission for
___, so pt was started on amlodipine 5mg qd which she had been
recently taking
outpt. Transitional issue to consider restarting her lisinopril
pending renal function stabilization.
#Diarrhea:
Presented w/ ___ day history of >6BMs/day. Non-dysenteric. No
abdominal pain. Diarrheal illness and poor appetite contributed
to her ___ and metabolic acidosis discussed below. Treated as
infectious colitis with ciprofloxacin. Symptoms improved
following treatment. Infectious workup including O&P, c.diff,
noro, stool cultures negative. CMV VL undetectable.
#Chronic anemia
Hgb stable ___ likely ___ iron deficiency from ongoing vaginal
bleeding but possibly contributing chronic kidney disease .
Ordered anemia labs with unremarkable folate/B12, hemolysis
labs. Given
borderline low transferrin sats in ___, prescribed PO iron
supplementation
# ESRD ___ diabetic nephropathy (T1DM) s/p SPK ___ Baseline Cr
1.6-2.0
#Immunosuppression
On home pred 2.5, tacrolimus and sirolimus. Tacrolimus 2mg bid
was decreased to 0.5mg qam, 1mg qpm with a goal of ___.
Rapamycin 2mg daily was decreased to 1.5mg with a goal ___.
Continued prednisone 2.5mg daily.
Transitional Issues
===================
Discharge Cr: 2.5
Discharge Tacro dose: 0.5 mg PO QAM, 1 mg PO QpM
Discharge Tacro ___: 3.2
Discharge ___ dose: 1.5mg PO daily
Discharge ___: 6.6
[] Please f/u labs recheck (chem 10, cbc, ___ level),
ordered for ___
[] Please restart lisinopril once Cr stable
[] Please f/u blood pressure control and titrate
antihypertensives. Pt hypertensive this admission, started on
amlodipine. home lisinopril held this admission and on discharge
given pt's ___.
[] On prior admission a transvaginal U/S revealed the following
findings with recommendations: Heterogeneous, avascular
endometrium with both echogenic and cystic portions, measuring
up to 7 mm. These findings may represent blood products due to
stage of menstrual cycle, although underlying polyp or
additional lesion is not excluded and may be present. Recommend
gynecologic follow-up and follow-up ultrasound ___ days after
termination of bleeding. If finding persists, possible
sonohysterogram.
#CODE: Full Code (confirmed with patient on ___
#HCP: ___, ___
#Alternate HCP: ___, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LOPERamide 2 mg PO BID
2. PredniSONE 2.5 mg PO DAILY
3. Sirolimus 2 mg oral DAILY
4. Sodium Bicarbonate 1300 mg PO BID
5. Tacrolimus 2 mg PO Q12H
6. Magnesium Oxide 400 mg PO BID
7. Fish Oil (Omega 3) 1000 mg PO DAILY
8. Lisinopril 5 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. norethindrone acetate 5 mg oral DAILY
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. 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
3. Sirolimus 1.5 mg PO DAILY
Daily dose to be administered at 6am
RX *sirolimus 1 mg 1 tab by mouth daily Disp #*30 Tablet
Refills:*0
RX *sirolimus 0.5 mg 1 tab by mouth daily Disp #*30 Tablet
Refills:*0
4. Tacrolimus 0.5 mg PO QAM
RX *tacrolimus 0.5 mg 1 capsule(s) by mouth daily in the morning
Disp #*30 Capsule Refills:*0
5. Tacrolimus 1 mg PO QPM
RX *tacrolimus 1 mg 1 capsule(s) by mouth daily in the evening
Disp #*30 Capsule Refills:*0
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. LOPERamide 2 mg PO BID
8. Magnesium Oxide 400 mg PO BID
9. norethindrone acetate 5 mg oral DAILY
10. PredniSONE 2.5 mg PO DAILY
11. Sodium Bicarbonate 1300 mg PO BID
12. Vitamin D 1000 UNIT PO DAILY
13. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do
not restart Lisinopril until your doctor tells you it is OK to.
14.Outpatient Lab Work
ICD: N17.9. DATE: ___. LABS: chem 10, cbc, tacrolimus,
rapamycin. FAX TO: ___ MD. ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
acute kidney injury
diarrhea
SECONDARY DIAGNOSIS
s/p renal transplant
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because of diarrhea and
because your kidneys were not working as well as usual.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- We gave you IV fluids and your kidney function slowly
improved.
- We treated your diarrhea with antibiotics
- You underwent a kidney biopsy which showed that you did not
have rejection of your transplanted kidney.
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Please take all of your medications as prescribed and go to
your follow up appointments with your doctors ___ below)
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team
Followup Instructions:
___
|
10677907-DS-20
| 10,677,907 | 21,921,951 |
DS
| 20 |
2167-07-20 00:00:00
|
2167-07-21 14:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Amoxicillin / labetalol
Attending: ___.
Major Surgical or Invasive Procedure:
- Tunneled line in right internal jugular vein placed ___
- Dialysis initiated ___
attach
Pertinent Results:
ADMISSION LABS:
===============
___ 04:35PM BLOOD WBC-9.2 RBC-2.51* Hgb-7.5* Hct-23.3*
MCV-93 MCH-29.9 MCHC-32.2 RDW-14.4 RDWSD-48.8* Plt ___
___ 04:35PM BLOOD Neuts-86.3* Lymphs-6.0* Monos-6.6
Eos-0.2* Baso-0.1 Im ___ AbsNeut-7.97* AbsLymp-0.55*
AbsMono-0.61 AbsEos-0.02* AbsBaso-0.01
___ 06:21AM BLOOD ___ PTT-24.5* ___
___ 04:35PM BLOOD Glucose-102* UreaN-80* Creat-9.0*#
Na-133* K-3.9 Cl-102 HCO3-8* AnGap-23*
___ 08:48AM BLOOD tacroFK-5.0
___ 06:09PM BLOOD ___ pO2-129* pCO2-20* pH-7.23*
calTCO2-9* Base XS--17 Comment-GREEN TOP
PERTINENT LABS:
===============
___ 05:49AM BLOOD Amylase-122*
___ 06:35AM BLOOD Amylase-81
___ 07:00AM BLOOD Amylase-81
___ 05:49AM BLOOD Lipase-160*
___ 06:35AM BLOOD Lipase-72*
___ 07:00AM BLOOD Lipase-62*
___ 05:49AM BLOOD %HbA1c-5.4 eAG-108
___ 06:21AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 06:35AM BLOOD FreeKap-115* FreeLam-641* Fr K/L-0.18*
___ 06:21AM BLOOD HCV Ab-NEG
___ 05:03PM BLOOD ___ pO2-167* pCO2-35 pH-7.47*
calTCO2-26 Base XS-2 Comment-GREEN TOP
___ 01:56PM URINE Hours-RANDOM Creat-75 TotProt-227
Prot/Cr-3.0*
___ 06:50AM URINE Hours-RANDOM Na-31 K-16
___ 01:56PM URINE U-PEP-MULTIPLE P IFE-MONOCLONAL
MICROBIOLOGY:
=============
___ 06:50AM URINE Mucous-RARE*
___ 06:50AM URINE RBC-4* WBC-4 Bacteri-FEW* Yeast-NONE
Epi-2
___ 06:50AM URINE Blood-SM* Nitrite-NEG Protein-200*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NORMAL pH-6.0
Leuks-TR*
___ 06:50AM URINE Color-Straw Appear-HAZY* Sp ___
IMAGING:
========
Renal transplant US, ___:
1. Resistive index of the intrarenal arteries ranging from
0.69-0.78,
increased from the prior exam (previously measuring 0.51-0.63).
2. No other renal transplant abnormalities noted.
DISCHARGE LABS:
===============
___ 07:00AM BLOOD WBC-8.7 RBC-2.77* Hgb-8.2* Hct-25.6*
MCV-92 MCH-29.6 MCHC-32.0 RDW-14.7 RDWSD-49.7* Plt ___
___ 07:00AM BLOOD Glucose-98 UreaN-27* Creat-4.9* Na-134*
K-3.8 Cl-95* HCO3-28 AnGap-11
___ 07:00AM BLOOD Calcium-8.1* Phos-3.4 Mg-3.1*
Brief Hospital Course:
TRANSITIONAL ISSUES:
====================
[] Hepatitis B vaccination
[] Follow up with hematology for MGUS management, including
follow up of serum free light chains and UPEP
[] Follow up mild hyponatremia, suspected to be related to her
underlying kidney disease
BRIEF HOSPITAL SUMMARY:
=======================
Ms. ___ is a ___ woman with a past medical history
of ESRD secondary to T1DM s/p SPK (___) complicated by
progressive renal allograft failure and MGUS who presented with
signs and symptoms of uremia including fatigue, anorexia,
dysgeusia, weight loss and nausea. On admission, patient was
found to significantly acidotic with mixed AGMA/NAGMA with
appropriate respiratory compensation which was felt to due to
underlying uremia as well as antecedent diarrhea. Initially the
patient was managed with IVF and a bicarb gtt with resolution of
acidemia, but complicated by hypokalemia for which bicarb was
discontinued. Ultimately, the patient's potassium was carefully
replaced and she was initiated on HD with improvement in her
uremia and presenting symptoms.
ACUTE/ACTIVE ISSUES:
====================
# Acute on chronic renal failure
# ESRD s/p simultaneous kidney-pancreas transplant with
allograft failure
Patient presented with a Cr of 9 (from baseline 3.5-4) on
admission labs with clinical evidence of worsening uremic
symptoms, including severe nausea, fatigue, anorexia, and weight
loss. Acute worsening was felt to be due to progression of
underlying graft rejection as initially suggested from biopsy on
___, as well as also with a prerenal component due to poor
oral intake. Tunneled line placed and dialysis initiated on
___, with subsequent HD sessions on ___ and ___. Tolerated
dialysis well, though experienced some vertigo and nausea on
___, which resolved with meclizine. She is planned to continue
HD on ___ schedule as outpatient. She will continue sevelamer
800 tid with meals and daily nephrocaps. Of note, during
admission it was found that she is non-immune to HBV. She also
had a PPD placed which revealed 0 mm of induration.
# Metabolic acidosis
# Hypokalemia
Patient presented with mixed anion gap/non-anion gap metabolic
acidosis (pH 7.23, bicarbonate 8, pCO2 20, anion gap 23) with
appropriate respiratory compensation in the setting of
progressive graft dysfunction and possible sub-therapeutic
dosing of home sodium bicarbonate. Acidosis improved with
intravenous bicarbonate. The bicarb gtt was ultimately
discontinued given resolution of acidosis and development of
severe hypokalemia. Her potassium was carefully replaced, but
initially resistant to appropriate repletion. This was felt to
be due to poor PO intake. Her potassium improved as dialysis was
initiated and patient's PO intake improved.
# Normocytic anemia
Hemoglobin 7.5 on admission from baseline 10.3. Likely
multifactorial marrow suppression in the setting of CKD with
superimposed gingival/vaginal bleeding related to likely
underlying platelet dysfunction in the setting of uremia.
Received 1 unit pRBCs on ___. Throughout admission, patient
demonstrated no signs of overt bleeding and remained
hemodynamically stable. She received erythropoietin during HD
sessions as above and continued her home ferrous sulfate. On
discharge, hemoglobin was 8.2.
# MGUS
Patient was previously found to have IgG lambda MGUS during
transplant evaluation. Outpatient bone imaging was negative and
bone marrow biopsy showed <10% plasma cells. SPEP from ___ with
monoclonal IgG lambda representing roughly 13.5% of total
protein, up from 7.5% in ___. MGUS unlikely to be driving
acute on chronic renal failure. Kappa and lambda light chains
pending.
# Chest pain
Reported positional chest pain on admission, relieved with
leaning forward. Stated similar in quality to prior reflux. EKG
was inconsistent with uremic pericarditis or ischemia otherwise.
Symptoms relieved with omeprazole and tums as needed, so
discontinued on discharge.
# Type I DM s/p simultaneous kidney-pancreas transplant
# Pancreatic Exocrine Insufficiency
From admission, HbA1C 5.4, without the need for insulin. Patient
was continued on her home immunosuppressive regimen of
prednisone 2.5mg qd, mycophenolate 360 qd, tacrolimus 0.5mg
AM/1.0mg ___. Patient did endorse a history of diarrhea prior to
admission, going to the bathroom ~5 times per day. She was
empirically started on Creon, 1 tablet with meals, with
reduction in frequency of bowel movements, likely representing
exocrine pancreatic insufficiency.
# Vertigo
Patient experienced positional dizziness that improved with
meclizine, consistent with vertigo. Likely ___ fluid shifts from
new HD.
CHRONIC/RESOLVED ISSUES:
========================
# History of provoked DVT, not on home anticoagulation.
# Contact: ___ (Fiancé/HCP), ___
# Full code (confirmed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 2.5 mg PO DAILY
2. amLODIPine 5 mg PO BID
3. Tacrolimus 1 mg PO QAM
4. Tacrolimus 0.5 mg PO QPM
5. CARVedilol 6.25 mg PO BID
6. Vitamin D 1000 UNIT PO DAILY
7. ergocalciferol (vitamin D2) 50,000 unit oral 1X/WEEK
8. norethindrone acetate 5 mg oral DAILY vaginal bleeding
9. mycophenolate sodium 360 mg oral BID
Discharge Medications:
1. Creon 12 1 CAP PO QIDWMHS
2. Meclizine 12.5 mg PO Q8H:PRN vertigo
3. Nephrocaps 1 CAP PO DAILY
4. sevelamer CARBONATE 800 mg PO TID W/MEALS
5. amLODIPine 5 mg PO BID
6. CARVedilol 6.25 mg PO BID
7. ergocalciferol (vitamin D2) ___ unit oral 1X/WEEK (MO)
8. mycophenolate sodium 360 mg oral BID
9. norethindrone acetate 5 mg oral DAILY vaginal bleeding
10. PredniSONE 2.5 mg PO DAILY
11. Tacrolimus 1 mg PO QAM
12. Tacrolimus 0.5 mg PO QPM
13. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
- Acute on chronic renal failure secondary to renal allograft
failure
- ESRD
- Anemia
SECONDARY DIAGNOSIS:
====================
- MGUS
- HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted to the hospital because of fatigue, nausea,
shortness of breath, and decreased appetite.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- Your symptoms were felt to be due to progressive renal
failure, for which you started on dialysis
- In addition, you received IV fluids and medications as well as
a blood transfusion to improve your symptoms
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Please continue to take all of your medications as directed
- Please follow up with all the appointments scheduled with your
doctor ___ below)
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
10677944-DS-7
| 10,677,944 | 21,828,824 |
DS
| 7 |
2186-11-17 00:00:00
|
2186-11-21 11:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
s/p fall, failure to thrive, confusion
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ y/o male with a past medical history of dementia, ADHD,
depression and anxiety who presented from his ALF with FTT and
s/p fall. History is extremely limited as patient is unable to
provide a detailed history and ALF was unable to provide a
history overnight (called, however person covering did not know
the patient and did not provide collateral history). Per the ED,
patient has had a rapid decline over the past several months. He
currently lives at an assisted living facility ___
___) and he has been difficult to care for. There
is concern that his decompensation could be psychiatric related
and in the past he has had issues with polypharmacy. Patient
reportedly has had multiple falls and recently had a fall today.
In the ED, initial VS were T 97.8, HR 94, BP 154/82, RR 18, 92%
RA. Labs were notable for a normal WBC, normal Hb, PLT 134,
normal electrolytes and renal function. Lactate 1.2. UA was
negative for UTI. BCx obtained. CT C-spine with no fracture but
degenerative changes. CT head w/o acute process. CXR showed no
acute process.
On arrival to the floor, T 97.7, BP 135/94, HR 95, RR 20, 95%
RA, weight 67.1 kg. Patient was resting in bed and in no acute
distress, but withdrawn and slow to respond. Patient stated he
was brought to the hospital but does not know why. Complained of
feeling confused for quite some time now. Denied hallucinations.
Denied HI. Stated that he "would like to go to sleep and never
wake up" and would like to die in a "passive way". Reports that
years ago he overdosed on aspirin.
Past Medical History:
PAST PSYCHIATRIC HISTORY:
Hospitalizations: Pt reports several past hospitalizations but
was unable to provide definitive details
Current treaters and treatment: Dr. ___, psychiatrist,
and
___, therapist, at ___
(___)
Medication and ECT trials: Currently takes fluoxetine 40mg PO
daily, seroquel 25mg PO BID prn, and bupropion 300mg PO
Self-injury: pt vaguely mentioned a past aspirin overdose
Harm to others: unknown
Access to weapons: unknown
PAST MEDICAL HISTORY, per ___ note written by PCP, ___, on ___, confirmed with pt and updated today:
HTN
HLD
DM
CAD
AF
Paroxysmal SVT
Low-tension glaucoma
___: Admitted for confusion and gait disturbance. Was
discharged on same day to ___.
Social History:
___
Family History:
FAMILY PSYCHIATRIC HISTORY:
Father had dementia and depression
Mother had depression
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - T 97.7, BP 135/94, HR 95, RR 20, 95% RA, weight 67.1 kg
GENERAL: alert, withdrawn, oriented to self, place (hospital).
Patient did not know the year initially but when provided
multiple choice options he said "it may be ___, but I don't
know"
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, ___ ___ strength, sensation intact to
soft touch, normal FNF, no pronator drift, no asterixis, +
essential tremor, toes down b/l, impaired proprioception
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Vital Signs: 98.1, 156/84, 95, 20, 95% on RA
General: Oriented to person, knows he is in hospital, but not
sure which
HEENT: sclera anicteric, MMM
Lungs: clear to auscultation b/l, no wheezes/rales/rhonchi
CV: RRR, nl S1, S2, no murmurs, rubs, gallops
Abdomen: soft, NT, ND, NABS, no HSM
Ext: WWP, no ___ edema
Skin: no rash
Neuro: CN ___ intact, normal strength and sensation in upper
and lower extremities, (+) intention tremor, (+) pronator drift
R > L, no dysdiadochokinesis, gait deferred
Pertinent Results:
ADMISSION LABS:
___ 08:50PM BLOOD WBC-8.1 RBC-4.93 Hgb-14.7 Hct-43.1 MCV-87
MCH-29.8 MCHC-34.1 RDW-12.5 RDWSD-39.7 Plt ___
___ 08:50PM BLOOD Neuts-62.6 ___ Monos-7.7 Eos-1.1
Baso-0.7 Im ___ AbsNeut-5.09 AbsLymp-2.24 AbsMono-0.63
AbsEos-0.09 AbsBaso-0.06
___ 08:50PM BLOOD Plt ___
___ 08:50PM BLOOD Glucose-159* UreaN-13 Creat-0.6 Na-138
K-3.8 Cl-99 HCO3-26 AnGap-17
___ 08:55PM BLOOD Lactate-1.2
DISCHARGE LABS:
___ 07:30AM BLOOD WBC-6.8 RBC-4.77 Hgb-14.3 Hct-41.8 MCV-88
MCH-30.0 MCHC-34.2 RDW-12.6 RDWSD-39.8 Plt ___
___ 07:30AM BLOOD Glucose-132* UreaN-10 Creat-0.5 Na-134
K-3.1* Cl-97 HCO3-25 AnGap-15
___ 07:30AM BLOOD ALT-20 AST-24 AlkPhos-49 TotBili-1.1
___ 07:30AM BLOOD Calcium-9.5 Phos-2.7 Mg-1.6
___ 07:30AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG
___ 12:55PM BLOOD Ethanol-NEG
___ 07:30AM BLOOD ___ PTT-27.7 ___
IMAGING/STUDIES:
___ CT HEAD W/O CONTRAST
No intra-axial or extra-axial hemorrhage, edema, shift of
normally midline
structures, or evidence of acute major vascular territorial
infarction. There is mild periventricular white matter
hypodensity which is consistent with chronic microvascular
ischemic disease. There is global involution likely age
related. Basilar cisterns are widely patent. The paranasal
sinuses appear well aerated as do the mastoid air cells and
middle ear cavities. The bony calvarium is intact. Carotid
siphon calcification is notable.
IMPRESSION:
No acute intracranial process.
___ CT C-SPINE
No fracture or malalignment. Extensive multilevel degenerative
disease
appears unchanged.
___ CXR
PA and lateral views of the chest provided. There is no focal
consolidation, effusion, or pneumothorax. The cardiomediastinal
silhouette is normal. Imaged osseous structures are intact. No
free air below the right hemidiaphragm is seen. Partially
imaged fusion hardware at the thoracolumbar junction noted.
IMPRESSION:
No acute intrathoracic process.
MICROBIOLOGY:
___ URINE CULTURE Pending
___ BLOOD CULTURE Pending
Brief Hospital Course:
___ y/o male with a past medical history of dementia, ADHD,
depression and anxiety who presented from his ALF with
confusion, failure to thrive, and s/p fall.
# Depression with SI: The patient has a long standing history of
depression, requiring inpatient hospitalization and ECT. On
presentation, the patient reported sadness and desire to go to
sleep and not wake up. The patient was found to have flat affect
with psychomotor slowing. The patient was evaluated by
psychiatry who recommended 1:1 sitter and placed patient under
___. It was thought that the patient's depression may be
contributing to his worsening confusion. The patient's
psychiatric medication regimen was adjusted as below. The
patient was discharged to an inpatient psychiatric facility and
should follow up with these psychiatric providers for further
titration of medication regimen and further management.
# Confusion: The patient reported progressively worsening
confusion, which was corroborated by his sister whom he speaks
to on the phone nearly daily. The patient was evaluated with a
CT head which showed no acute changes. Similarly, electrolytes,
UA, Utox and serum tox were found to be within normal limits.
TSH, B12 and urine culture remained pending at the time of
discharge. The patient's confusion was thought to be due to his
worsening neurocognitive condition (Alzheimer's disease versus
vascular dementia versus mixed) vs. worsening depression vs.
polypharmacy. The patient was evaluated by psychiatry who
recommended discontinuation of buspar, and mirtazapine as well
as reduction in duloxetine dosing. They recommended discharge to
inpatient psychiatric facility at ___. The patient
should f/u with psychiatric providers for further evaluation and
management.
# s/p fall: The patient reportedly had a fall prior to
admission, in which he fell onto his lower back. Though the
patient did not recall the exact circumstances of his fall, it
was suspected to be mechanical in origin given his history of
unsteady gait and possible peripheral neuropathy. The patient's
ECG showed sinus arrhythmia and the patient reported no history
of chest pain, lightheadedness or dizziness. The patient was
evaluated as above and his medications were adjusted as above.
CT Head, CT C-Spine and CXR did not show any acute changes or
injury. The patient was evaluated by physical therapy who felt
that intermittent gait disturbance was likely secondary to his
underlying medical and psychiatric conditions.
# DM: the patient was restarted on his home metformin and
glipizide at discharge (he was managed on ISS while in the
hospital)
# HLD: continued home statin
# CAD: continued aspirin, metoprolol
# h/o EtOH use: The patient reported his last drink was years
prior. He was continued on thiamine, folate, MVI
Transitional Issues:
- f/u with psychiatry for further management of confusion and
management of medications
- consider evaluation of Alzheimers as well as ___
Disease as an outpatient.
- Please consider MRI as outpatient if confusion/falls persist.
- Consider down titration of lorazepam as tolerated as this
medication may not be ideal in the geriatric population
- Contact: ___ HCP ___ ___ (sister)
___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. RISperidone 1 mg PO QHS
2. Simvastatin 40 mg PO QPM
3. Thiamine 100 mg PO DAILY
4. Cyanocobalamin 50 mcg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Lorazepam 0.5 mg PO BID:PRN anxiety
7. Mirtazapine 7.5-15 mg PO DAILY:PRN acute anxiety or agitation
8. Aspirin 81 mg PO DAILY
9. BusPIRone 10 mg PO TID
10. Duloxetine 90 mg PO DAILY
11. FoLIC Acid 1 mg PO DAILY
12. GlipiZIDE XL 2.5 mg PO DAILY
13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
14. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
15. Metoprolol Succinate XL 25 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Cyanocobalamin 50 mcg PO DAILY
3. Duloxetine 60 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. RISperidone 1 mg PO QHS
9. Simvastatin 40 mg PO QPM
10. Thiamine 100 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
13. Lorazepam 0.5 mg PO BID:PRN anxiety
14. GlipiZIDE XL 2.5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Depression, Confusion/Altered Mental Status, s/p
mechanical fall
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Thank you for allowing us to participate in your care at ___.
You were admitted to the hospital because of your fall and
because of confusion. We evaluated you with a CT scan of your
head and xrays of your chest and spine which showed no acute
changes. We also evaluated your electrolytes and your blood
counts which were normal. We also checked your B12 level and
your thyroid function. The results of these tests are still
pending. We also evaluated you with urine culture. These results
are still pending as well. We believe your fall and your
confusion may have happened because of the medications you are
taking. We stopped your mirtazapine and your busiprone and we
decreased your duloxetine.
After discharge, you should follow up with your primary care
physician for further management of your medical conditions. You
should follow up with your psychiatrist for further management
of your psychiatric medications and for further management of
your confusion.
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
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2121-10-10 18:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Admitted for hypotension and Influenza.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo man with stage 4 non-small cell CA under treatment
presents
to ER with cough and fever. He's had issues with chronic cough
but on ___ was taking pills and aspirated with prolonged
coughing spell. Since then has been coughing up greenish/yellow
sputum. Denies hemoptysis. Feeling chills and temps to 100.5
In ER, his Tmax was 102.1, lowest BP was 96/60, lactate 3.9, Flu
A PCR was POSITIVE. He was treated with PO Oseltamivir 75mg Q 12
hour and Zosyn 4.5 g IV once.
On floor, patient's son acts as a ___ with the help of
patient's wife. Patient reports he is doing well. His only
complaint is L sided mouth 'foreign body' sensation/discomfort.
He denies dizziness or chest pain. Feels like he is able to
breathe well. No SOB. No cough at this time, No sputum
production. He felt like he had a fever earlier today.
Per family patient had trouble swallowing pills yesterday and
he
ended up coughing as he tried to swallow it. His PCP who saw him
was of the opinion (this is per son's understanding) that the
pill may have gone inside the trachea.
Patient's son feels his father may have caught the flu from an
event he attended at a ___ community a few weeks ago
Past Medical History:
- HTN
- HLD
- BPH
- CAD s/p PCI with stent x2 placement in ___
- osteoporosis
- hearing loss
- h/o prostatitis
- back surgery
- s/p appy
- PPD negative
Social History:
___
Family History:
His sister has gastric cancer. No other malignancies in family
Physical Exam:
General: NAD
VITAL SIGNS:98.1 PO 113 / 67 90 18 97 2L NC
HEENT: MMM, Small 2mm oral ulcer seen in L buccal mucosa. No
lymphadenopathy, pt with no respiratory distress, seen coughing.
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB. No crackles or wheezes.
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis;
SKIN: No rashes or skin breakdown
NEURO: able to ambulate independently. No focal deficits seen.
CN ___ wnl.
DiSCHARGE PHYSICAL ON ___
Pt seen and examined with help of bedside translator.
He feels well and cough is getting better. No new sx or
complaints.
VS- 97.9 PO 104/61 / 77 16 94 RA
Heart- RRR S1 and S2 heard. No MRG
Lungs- CTAB. No crackles or wheezes. No stridor, No JVD. Skin
normal
Abd- soft NT ND
Extremities- No edema.
Ambulates independently to bathroom and back.
skin normal
When patient ambulates on room Air, his spo2 drops to 89%
Pertinent Results:
___ 07:47AM BLOOD WBC-3.2* RBC-3.74* Hgb-9.7* Hct-31.3*
MCV-84 MCH-25.9* MCHC-31.0* RDW-16.9* RDWSD-51.8* Plt ___
___ 07:47AM BLOOD Plt ___
___ 07:47AM BLOOD Glucose-99 UreaN-10 Creat-0.8 Na-139
K-3.7 Cl-104 HCO3-22 AnGap-17
___ 07:25AM BLOOD ALT-11 AST-19 AlkPhos-90 TotBili-0.6
___ 07:55AM BLOOD CK-MB-1 cTropnT-<0.01
___ 06:13PM BLOOD ___ 8:04 pm SPUTUM
Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora. e-1.6
___ 4:40 am URINE Source: ___.
**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.
Brief Hospital Course:
Mr. ___ is an ___ male with stage IV
non-small-cell lung adenocarcinoma, currently on pembrolizumab
who presents to ER with cough and fevers, diagnosed of influenza
A virus.
# Septic Shock with lactic acidosis
# Influenza
# Aspiration risk
# Health care associated pneumonia
Septic shock resolved. Lactate normal. FLU A PCR positive-
respi isolation.
Rx with Oseltamivir 75mg BID - 5 days completed while
inpatient on ___.
Sputum stain shows no microbes, culture-commensals.
Started on IV Vanc and Cefepime with IV cipro. Receivedd
for 3 days, Transitioned of D4 to PO levofloxacin since pt
afebrile and pneumococcal Ag and legionella Ag negative. Sputum
cultures showed commensal respi flora.
He also Underwent Swallow eval, which he passed and is safe
to eat regular diet
When we ambulated the pt prior to Dc, he desaturated to 89%
onRA with ambulation. Home oxygen was setup while inpatient and
he was discharged with home oxygen.
# Interstitial lung disease of unclear etiology
Previously on PO steroids as concern for possible
immunotherapy-induced pneumonitis. Steroids stopped by outpt
pulmonologist since no evide\nceof active pneumonitis. No
steroids given as inpatient.
# ___ esophagus
Repeat EGD needed in ___.
Continue PPI
# Stage 4 ___.[Left upper love with hx of malignant effusion]
on Pembrolizumab Cycle 6
had pleurx in the past which was removed in ___
since the effusions dried up.
# Hx CAD
Continue aspirin 81mg Resumed Metoprolol and IMDUR today
(some chest pain this
AM, likely musculoskeletal but could be anginal as well. I
amconsidering the language barrier here and patients reduced
ability to express himself even with translators ,plus he has
some hearing impairment)
He was able to tolerate Imdur 30mg without hypotension.
# Medication reconciliation
Family not able to report patient's current medications.
Unsure if he is actually taking calcitonin spray
(?Indication and potential to cause malignancy if used > ___ m ).
Unsure why is he on both calcitonin + calcitriol at the same
time. No response from PCP (for email) re : need for Above
meds,
will stop permanently for now.
# Frozen shoulder syndrome
Could be the reason for his shoulder pain bilaterally
degenrative shoulder joints noted on CXR bilaterally.
# Apthous ulcer
Lidocaine jelly to affected area.
Pain resolved per pt.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Finasteride 5 mg PO DAILY
2. Terazosin 5 mg PO QHS
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Ipratropium Bromide MDI 2 PUFF IH QID
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Simvastatin 10 mg PO QPM
7. Isosorbide Mononitrate 60 mg PO Q24H
8. Omeprazole 40 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Senna 8.6 mg PO BID
Discharge Medications:
1. Guaifenesin-Dextromethorphan ___ mL PO Q6H:PRN cough
RX *dextromethorphan-guaifenesin [Guaifenesin-DM] 100 mg-10 mg/5
mL ___ ml by mouth 4 times daily as needed for cough Refills:*3
2. Levofloxacin 750 mg PO DAILY Duration: 4 Days
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth daily
Disp #*2 Tablet Refills:*0
3. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Finasteride 5 mg PO DAILY
7. Ipratropium Bromide MDI 2 PUFF IH QID
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Omeprazole 40 mg PO DAILY
10. Senna 8.6 mg PO BID
11. Simvastatin 10 mg PO QPM
12. Terazosin 5 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# Influenza A infection
# HCAP
# Septic Shock
# Lactic Acidosis
# Barretts esophagus
# Hx CAD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
dear ___,
You were admitted for influenza with pneumonia. You received
antibiotics as treatment for your influenza. You had some cough
but felt better at the end of your stay here.
It was a pleasure taking care of you.
Sincerely,
___ MD
Followup Instructions:
___
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2131-12-19 00:00:00
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2131-12-29 20:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Keflex / aspirin
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
G-tube removal
History of Present Illness:
___ with a history of stage IV ovarian cancer currently
undergoing chemotherapy who previously had a decompressive
G-tube placed by interventional radiology at ___ for a malignant
SBO. The majority of her care has been at ___ the history has
been verbally obtained from the patient as we do not yet have
the records. Per the patient the G-tube was placed approximately
three months ago and has been painful since that time. The pain
has become more excruciating recently and associated with
purulent drainage. She has undergone four outpatient antibiotic
treatments, which have only been marginally effective. She
denies
fevers or chills.
Past Medical History:
Past Medical History: Stage IV ovarian cancer on chemotherapy.
She reports a history of mitral valve prolapse and hypertension.
She reports being up-to-date with mammograms, colonoscopies and
bone density evaluations.
Past Surgical History: appendectomy, a cesarean section and a
ruptured ectopic surgery in ___. She had a vertical incision
for the cesarean section and the ectopic. The ectopic was on
the right side she believes, but she was also told that both
ovaries were left in place. Tonsillectomy. Laparotomy for
ovarian cancer.
Social History:
___
Family History:
Noncontributory
Physical Exam:
Physical Exam:
Vital signs within normal limits
General: awake, alert, NAD
HEENT: NCAT, EOMI, anicteric
Heart: RRR, NMRG
Lungs: CTAB, normal excursion, no respiratory distress
Abdomen: soft, non-tender, prior G-tube site clean, no
cellulitis or drainage
Neuro: strength intact/symmetric, sensation intact/symmetric
Extremities: WWP, no CCE, no tenderness, 2+ B ___
Skin: no rashes/lesions/ulcers
Pertinent Results:
___ 12:15PM GLUCOSE-96 UREA N-21* CREAT-0.6 SODIUM-141
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-29 ANION GAP-12
___ 12:15PM WBC-16.1* RBC-2.68* HGB-9.1* HCT-27.4*
MCV-102* MCH-34.0* MCHC-33.2 RDW-17.2* RDWSD-64.6*
___ 12:15PM NEUTS-76* BANDS-8* LYMPHS-13* MONOS-2* EOS-0
BASOS-0 ___ METAS-1* MYELOS-0 AbsNeut-13.52* AbsLymp-2.09
AbsMono-0.32 AbsEos-0.00* AbsBaso-0.00*
Brief Hospital Course:
___ year old female with stage IV ovarian cancer who is s/p prior
G tube at ___ for venting. The patient has had pain at that
site since it was placed and has required multiple courses of
antibiotics for small fluid collections at the site and
intermittent cellulitis. The patient was admitted to ___ and
had her G-tube removed by ___ at bedside with symptomatic
improvement. She was continued on TPN for nutrition and
continued to take PO as desired for comfort. She continued on
her lovenox for a known PICC associated DVT. The patient had
been on once daily ertapenem infusions for known prior fluid
collections at the G-tube site. On discharge, we sent her with a
prescription for cipro and flagyl to help transition her back to
her home infusions with ___ services. The patient will follow up
as an outpatient with her primary care provider and continue her
private and ___ services at home. We prepared a page 1
and worked with case management to reinstate her services the
day after discharge.
Medications on Admission:
lovenox 60 mg SC q12
ertapenem 1g IV q24
loratadine 10mg PO daily
Colace 100mg PO BID
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*3
2. Enoxaparin Sodium 60 mg SC Q12H
3. Loratadine 10 mg PO DAILY
4. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
5. Ciprofloxacin HCl 500 mg PO Q12H
Take twice daily on ___, and ___ and then stop
RX *ciprofloxacin HCl 500 mg 500 tablet(s) by mouth q12 Disp #*6
Tablet Refills:*0
6. MetroNIDAZOLE 500 mg PO TID
Take three times a day ___ and ___ and then stop
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*9 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal Fluid Collection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-Take 3 days of cipro and flagyl ___, and ___
and then stop your antibiotics
-Continue your diet as tolerated
-Continue your TPN with the help of your home nursing
-Continue on lovenox for your DVT
Followup Instructions:
___
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|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Tetracycline / Erythromycin Base / Sulfa (Sulfonamide
Antibiotics) / Augmentin / doxycycline / nitrofurantoin
Attending: ___.
Chief Complaint:
Septic shock
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with a history of ESBL ___
transferred from nursing home to ___ for septic shock NOS,
and transferred to ___ due to recurrent episodes of septic
shock presumed urinary source, currently on levophed.
Since a lap hysterectomy and bilateral SPO and cystoscopy on
___, she has had recurrent episodes of sepsis from
infections (UTIs, diverticulitis, duodenitis). Urine cultures
have grown ESBL E.Coli multiple times, and she has mostly been
treated with meropenem. She recently also had an episode of
shingles treated with valacyclovir and prednisone. Her ID course
is reviewed in excellent detail by Dr. ___ on his
___ note in OMR.
Most recently, she presented with left-sided abdominal pain and
suprapubic pain on ___ and was felt to have a UTI. She was
initially treated with ertapenem/metronidazole and then
transitioned to cipro/metronidazole on ___ to finish an
extended course ending on ___. On ___, she developed
acute onset fever to 101.2, tachycardia to 140s, and WBC of 1.0
with 30% bands. Her lactate was elevated to 2.7 at this time and
procalcitonin was elevated. Infectious workup at this time was
mostly unremarkable, but she was again treated with ertapenem
via her left arm PICC and discharged to ___. The urine culture
from that hospitalization on ___ ___ had
NGTD as of ___ (___). Her last day of ertapenem
was on ___, at which time she was switched to macrobid for
suppressive antibiotics.
On ___ (the day after stopping ertapenem), she developed
increased urinary frequency, fever to 102 and hypotension to SBP
___, and was taken to ___ where lactate was 2.8.
She received 3L of fluid with good BP response and started on
levophed. She was then transferred to ___ due to recurrent
episodes of septic shock.
Past Medical History:
PAST MEDICAL HISTORY: The patient has a history of IBS of the
colon, Htn and hypercholesterolemia. Her last colonosopy was in
___ and was reportedly normal. SHe is upto date on MMG's her
last was ___. She denies history of asthma, mitral valve
prolapse,thromboembolic disorder.
PAST SURGICAL HISTORY: Tonsils ___, Appendectomy ___, GB
___, Radical resection of left thigh melanoma ___.
OB/GYN HISTORY: She is a gravida 0, para 0 woman. She denies
history of fibroids, cysts, pelvic infections, or abnormal Pap
smears beyond the one noted above. She has been Post-menapausal
'for years.'
Social History:
___
Family History:
She reports that her mother had breast cancer at ___ cancer. Her
father had glioblastoma ___ and bladder cancer.
Physical Exam:
ADMISSION EXAM:
Vitals: HR 76, T 98.4, BP 148/87, RR 18.
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: Supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: Tender to mild palpation RLQ and LLQ. Otherwise soft,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
EXT: Slightly delayed capillary refill in the upper extremities.
___ warm and well perfused, 2+ pulses, no clubbing, cyanosis or
edema.
SKIN: Unremarkable.
NEURO: A&Ox3. Strength grossly intact. Sensation preserved.
ACCESS: ___
DISCHARGE EXAM:
Vital Signs: 98.3PO 116 / 71 83 18 97 RA
Glucose: 119-182
GEN: Alert, NAD
HEENT: NC/AT
CV: RRR, no m/r/g
PULM: CTA B
GI: S/NT/ND, BS present
EXT: no ___ edema or calf tenderness
NEURO: Non-focal
Pertinent Results:
Admission Labs:
___ 11:00PM BLOOD WBC-10.0 RBC-4.05 Hgb-11.9 Hct-37.1
MCV-92 MCH-29.4 MCHC-32.1 RDW-13.3 RDWSD-43.7 Plt ___
___ 11:00PM BLOOD Neuts-91* Bands-6* ___ Monos-2*
Eos-0 Baso-0 ___ Metas-1* Myelos-0 AbsNeut-9.70*
AbsLymp-0.00* AbsMono-0.20 AbsEos-0.00* AbsBaso-0.00*
___ 11:00PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 11:00PM BLOOD ___ PTT-24.4* ___
___ 11:00PM BLOOD Glucose-163* UreaN-29* Creat-1.2* Na-143
K-4.0 Cl-103 HCO3-21* AnGap-19*
___ 05:01AM BLOOD ALT-228* AST-36 AlkPhos-125* TotBili-0.6
___ 05:28AM BLOOD ALT-39 AST-20 AlkPhos-99 TotBili-0.5
___ 06:07AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 06:07AM BLOOD HCV Ab-NEG
___ 11:03PM BLOOD Lactate-2.6*
___ 05:00PM BLOOD Lactate-1.8
___ 06:04AM BLOOD ANTI-DNASE-Negative
___ 12:50AM URINE Color-DkAmb* Appear-Hazy* Sp ___
___ 12:50AM URINE Blood-NEG Nitrite-POS* Protein-30*
Glucose-NEG Ketone-NEG Bilirub-MOD* Urobiln-4* pH-6.0 Leuks-LG*
___ 12:50AM URINE RBC-0 WBC-63* Bacteri-MOD* Yeast-NONE
Epi-<1
___ 12:50AM URINE CastHy-3*
ASO Screen (Final ___:
< 200 IU/ml PERFORMED BY LATEX AGGLUTINATION.
Urine culture NEGATIVE
Blood culture x 4 NEGATIVE
Discharge Labs:
___ 06:00AM BLOOD WBC-3.0* RBC-3.42* Hgb-10.3* Hct-31.6*
MCV-92 MCH-30.1 MCHC-32.6 RDW-14.4 RDWSD-47.6* Plt ___
___ 06:00AM BLOOD Neuts-45.1 ___ Monos-11.4 Eos-2.8
Baso-0.7 AbsNeut-1.31* AbsLymp-1.16* AbsMono-0.33 AbsEos-0.08
AbsBaso-0.02
___ 08:30AM BLOOD Glucose-157* UreaN-16 Creat-0.6 Na-142
K-4.1 Cl-102 HCO3-28 AnGap-12
___ 08:30AM BLOOD Calcium-9.4 Phos-4.0 Mg-1.7
CXR - IMPRESSION:
Distal aspect of the left-sided PICC is not optimally seen, but
likely
terminates in the low SVC. No evidence of pneumothorax.
CT A/P - IMPRESSION:
1. No perinephric abscess. No acute abdominopelvic process.
2. Foley catheter coiled in the bladder, consider slight
retraction.
CT Cystogram - IMPRESSION:
1. No evidence of enterovesicular fistula.
2. Renal hypodensities, likely renal cysts.
Tagged WBC Scan - IMPRESSION: No evidence of occult infection.
Brief Hospital Course:
Ms. ___ is a ___ year old female with a history of ESBL ___
___ transferred from nursing home to ___ for septic shock
NOS, and transferred to ___ due to recurrent episodes of
septic shock from a presumed urinary source, initially requiring
levophed.
# Sepsis - Initally presented with fever, tachycardia, and
hypotension requiring pressors with presumed urinary source
given history of ESBL E.Coli UTIs, positive UA on admission, and
increased urinary frequency. She was eventually weaned of off of
levophed and is s/p hydrocortisone course x 2 days. CT
abd/pelvis without clear source of infection. CT cystogram
showed no evidence of a fistulae. Leukocytosis and lactate
continued to downtrend. Tagged WBC scan also did not reveal
evidence of occult infection. Patient was treated with IV
meropenem for a total 10d course. Thereafter, she was observed
in the hospital to see whether the infection would declare
itself and whether it could be captured with multiple cultures
and imaging. Of note, ID has raised concern whether current
presentation could have represented nitrofurantoin
hypersensivity, as patient has developed similar symptoms while
on nitrofurantoin several times now. She remained stable after
stopping antibiotics and was discharged home. She will f/u
closely with ID.
# Transaminitis: noted to have an ALT in the 300s on admission
that downtrended. The patient reported no abdominal pain. She
had elevated LFTs during previous hospitalizations as high as
___ in the setting of septic shock. Hepatitis serologies were
negative. LFTs continued to downtrend during admission.
# Pancytopenia: This was thought to be reactive in the setting
of her infection, or possibly a drug reaction. There may have
also been a component of frequent blood draws contributing to
her anemia as well. Of note, WBC downtrended slightly to 3.0 on
the day of discharge (45% neutrophils). She should have repeat
CBC drawn at f/u appt to ensure stability.
# Hypertension: held lisinopril 10 mg daily, pt remained
normotensive so this was not restarted
# CAD: continued atorvastatin 10 mg daily
# Anxiety: continued home ativan
# Diabetes: held home metformin while inpatient, restarted at
discharge
# GERD: continued home omeprazole
TRANSITIONAL ISSUES
===================
- Patient had negative hepatitis B Ab serology, should be
immunized for hepatitis B. Hepatitis C negative.
- Repeat CBC should be drawn at f/u appointment as above
FULL CODE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. LORazepam 0.5 mg PO DAILY:PRN anxiety
4. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. LORazepam 0.5 mg PO DAILY:PRN anxiety
4. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. HELD- Lisinopril 10 mg PO DAILY This medication was held. Do
not restart Lisinopril until you discuss with your primary care
physician.
Discharge Disposition:
Home
Discharge Diagnosis:
Hypotension
Transaminitis
Pancytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were initially admitted to the ICU out of concern for sepsis
in the setting of a recurrent urinary tract infection. You had a
broad infectious workup performed while you were here, which was
negative for any clear infection. You were treated with
antibiotics for a total of 10 days and then observed when the
antibiotic was discontinued. Ultimately, it was felt that your
more recent episodes of low blood pressures could have been
related to hypersensitivity reactions to nitrofurantoin. You
should avoid this medication in the future, and it has been
added to your allergy list.
Of note, your blood cell counts were slightly low while you were
here. You should follow up with your primary care physician as
scheduled to have these repeated.
Followup Instructions:
___
|
10678884-DS-8
| 10,678,884 | 24,537,731 |
DS
| 8 |
2123-03-26 00:00:00
|
2123-03-26 09:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
pt has celiac disease- no gluten / gluten
Attending: ___.
Chief Complaint:
left leg pain
Major Surgical or Invasive Procedure:
L L45 microdiscectomy
History of Present Illness:
___ yo M who had a L4-5 Discectomy in ___ by Dr. ___
subsequently did well since that last surgery, but has always
had
persistent back pain and went to a chi___ who ordered an
MRI prior to ___ because he was having some bilateral leg
pain, but it wasn't that severe, he was able to walk, and do his
normal activities, however today he reports he was lying on ___
ground doing some back exercises when he had severe bilateral
leg
pain. He reports the left is worse than the right and since he
has been in the ED the right has dissipated quite a bit but the
left is posteriorly traveling down his left lateral thigh into
his calf and lateral aspectof his foot. He also notes some
sensory changes where th eleft foot has felt for awhile that it
does not sense temperature as well.
No bowel or bladder incontinence.
Past Medical History:
Non-contributory
Social History:
___
Family History:
Non-contributory
Physical Exam:
NTTP at T and L spine
L2 L3 L4 L5 S1
R 5 5 5 5 5
L 5 5 5 5 5
sensation intact in above dermatomes though has some troulb ein
L4 distribution on right and left distinguing pinprick rom light
touch
no clonus
downgoing toes
Rectal sensation intact to pinprickand tone intact
Reflexes
R/L
Patella ___
Achilles ___
Brief Hospital Course:
Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. Patient was
transferred to the PACU in a stable condition. He was
maintained flat for 24 hours. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Initial postop pain was
controlled with a PCA. Diet was advanced as tolerated. The
patient was transitioned to oral pain medication when tolerating
PO diet. 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.
Discharge Medications:
1. Diazepam ___ mg PO Q8H:PRN spasm
RX *diazepam 2 mg ___ tablet(s) by mouth every eight (8) hours
Disp #*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*120 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
lumbar radiculopathy
recurrent L L45 disc herniation
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 have undergone the following operation: Minimally Invasive
Microdiscectomy
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 moving 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.
-Brace: You do not need a brace.
-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.
-You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
___. We are not allowed to call in narcotic prescriptions
(oxycontin, oxycodone, percocet) to the pharmacy. In addition,
we are only allowed to write for pain medications for 90 days
from the date of surgery.
-Follow up:
oPlease Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
oAt the 2-week visit we will check your incision, take baseline
X-rays and answer any questions. We may at that time start
physical therapy.
oWe will then see you at 6 weeks from the day of the operation
and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound
Followup Instructions:
___
|
10679138-DS-10
| 10,679,138 | 20,430,343 |
DS
| 10 |
2193-05-26 00:00:00
|
2193-05-26 17:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex / atorvastatin / Beta-Blockers (Beta-Adrenergic Blocking
Agts) / IV contrast / methyldopa / adhesive tape / torsemide
Attending: ___.
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with a past medical history of CHF who was
recently discharged from ___ on ___ after presenting for
dyspnea and chronic cough. She originally noted increased
dyspnea after being started on TMP/SMX for urinary symptoms and
a cough. Her dyspnea was believed to be secondary to volume
overload with superimposed influenza, for which she was diuresed
and treated with oseltamivir. proBNP at that time was elevated
to 848. Due to ___, her irbesartan was held at time of
discharge.
She now returns to ___ with complaints of worsening DOE. She
endorses orthoopnea, a 4 lb weight gain and ___ edema. She denies
any fevers. She has had some chest pain but only with coughing.
Her cough is overall improving. Denies abdominal pain. Mild
nausea, without emesis. No black or bloody stools, no fever. She
does endorse some dysuria which began today.
In the ED intial vitals were: 98.1 HR 57 BP 189/61 24 SpO2:
98%/RA Patient was given: 0.4mg sublingual nitroglycerin. On
arrival to the floor, patient was restarted on irbesartan and
given 20mg IV lasix. Her nifedipine was held in the setting of a
suspected CHF exacerbation. This morning, patient continues to
complain of a cough, producing white mucous. She also reports
some difficulty breathing. She has some chest pain only with
coughing, but none at rest.
Past Medical History:
- H/O PNA ___ ago c/b R-sided effusion requiring chest tube then
thoracotomy
- Hypertension
- LVH
- Renal artery stenosis s/p stent
- Stage I infiltrating ductal carcinoma breast CA, ER+, PR-,
___- s/p XRT/ lumpectomy
- Osteopenia, dx on a BMD of ___
- Dysfunctional uterine bleeding s/p D&C
- H/O Gangrenous appendicitis ___
- H/O C. Diff colitis
- hx of Hernia repair
- GERD
- Left elbow fracture ___ years ago
- Chest pain NOS, clean cardiac cath prior to ___ at ___
- h/o anxiety
- CHF
Social History:
___
Family History:
Mother with breast cancer
Physical Exam:
On Admission:
Vitals: 98.2/97.9; 167-176/65-73; 59-64; 18; 95-97% RA
GENERAL: Oriented x3. resting comfortably
HEENT: NCAT. Sclera anicteric. MMM
NECK: Supple with JVP of 6cm
CARDIAC: RRR no MRG
LUNGS: few inspiratory wheezes bilaterally
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation.
EXTREMITIES: 1+ pitting edema bilaterally
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
On Discharge:
Vitals: 98.4/97.7; 135-182/47-77; 51-60; 18; 95-98% RA
GENERAL: Oriented x3. resting comfortably
HEENT: NCAT. Sclera anicteric. MMM
NECK: Supple with JVP to lower ear with bed at 60 degrees
CARDIAC: RRR no MRG
LUNGS: Faint expiratory wheezes, equal bilaterally. Much
improved from yesterday.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 1+ pitting edema bilaterally, improved from prior
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
LABS: Reviewed in OMR, please see below.
Pertinent Results:
On Admission:
___ 04:05PM BLOOD WBC-4.0 RBC-4.23 Hgb-12.6 Hct-35.9*
MCV-85 MCH-29.8 MCHC-35.2* RDW-14.3 Plt ___
___ 04:05PM BLOOD Plt ___
___ 04:05PM BLOOD Glucose-120* UreaN-16 Creat-1.0 Na-123*
K-4.5 Cl-88* HCO3-22 AnGap-18
___ 04:40AM BLOOD Calcium-8.7 Phos-3.8 Mg-1.7
___ 04:40AM BLOOD Osmolal-261*
On Discharge:
___ 05:59AM BLOOD WBC-4.1 RBC-4.12* Hgb-12.1 Hct-35.3*
MCV-86 MCH-29.4 MCHC-34.3 RDW-14.5 Plt ___
___ 05:59AM BLOOD Glucose-140* UreaN-24* Creat-1.3* Na-132*
K-4.7 Cl-94* HCO3-25 AnGap-18
___ 05:59AM BLOOD Calcium-9.2 Phos-3.7 Mg-3.2*
Imaging:
___:
IMPRESSION: Mild pulmonary vascular congestion, perhaps
minimally improved in the interval.
___:
TTE: IMPRESSION: Mild symmetric left ventricular hypertrophy
with preserved regional and global biventricular systolic
function. Aortic valve sclerosis. Trace aortic regurgitation.
Compared with the prior study (images reviewed) of ___,
the findings are similar
Brief Hospital Course:
#Shortness of breath: Mrs. ___ was admitted to ___ for
evaluation of shortness of breath. Her initial chest x-ray
showed some vascular congestion. She was diuresed with lasix,
and was approximately 2.5-3L net negative. In this setting, her
respiratory symptoms improved significantly. A TTE on ___
showed mild LVH, trace AR diastolic dysfunction with an LVEF of
60%. Ultimately, it was felt that her CHF exacerbation was
related to her hypertension and recent influenza.
#Hypertension: Patient's blood pressure varied considerably
during her hospitalization. Given her recent ___, we opted to
continue holding her irbesartan.
#Hyponatremia: On presentation, patient was found to be
hyponatremic to 123. This was felt to be in the setting of
volume overload. Patient was diuresed as above and placed on a
2L fluid restriction. Her sodium improved to 132 on the day of
discharge.
#Influenza: Patient completed Tamiflu on the day of admission.
She had no further flu-like symptoms.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Lorazepam 0.25 mg PO BID
3. NIFEdipine 60 mg PO QAM
4. NIFEdipine 30 mg PO QPM
5. Paroxetine 25 mg PO DAILY
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Spironolactone 12.5 mg PO EVERY OTHER DAY
8. Acetaminophen 325-650 mg PO Q6H:PRN pain, fevers
9. Autologus 20% Diluted Serum tears 1 % BOTH EYES Q1H
10. OSELTAMivir 75 mg PO Q12H
11. Aciphex (RABEprazole) 20 mg oral daily
12. Calcium Carbonate 600 mg PO QPM
13. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES EVERY
HOUR
14. GenTeal Mild to Moderate (artificial tears(hypromellose))
0.3 % ophthalmic daily
15. Restasis (cycloSPORINE) 0.05 % ophthalmic BID
16. Travatan Z (travoprost) 0.004 % ophthalmic BID R eye
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain, fevers
2. Aspirin 81 mg PO DAILY
3. Calcium Carbonate 600 mg PO QPM
4. Lorazepam 0.25 mg PO BID
5. NIFEdipine 60 mg PO QAM
6. NIFEdipine 30 mg PO QPM
7. Paroxetine 25 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Spironolactone 12.5 mg PO EVERY OTHER DAY
10. Aciphex (RABEprazole) 20 mg oral daily
11. Autologus 20% Diluted Serum tears 1 % BOTH EYES Q1H
12. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES EVERY
HOUR
13. GenTeal Mild to Moderate (artificial tears(hypromellose))
0.3 % ophthalmic daily
14. Restasis (cycloSPORINE) 0.05 % ophthalmic BID
15. Travatan Z (travoprost) 0.004 % ophthalmic BID R eye
16. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: CHF exacerbation
Secondary: Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___ were admitted to ___ for
difficulty breathing. We found that ___ had too much fluid in
your lungs. This was probably related to your high blood
pressure and your recent flu infection. We also used an
ultrasound to look at your heart, and it has not changed
significantly since ___, which is reassuring. On discharge, ___
will need to take a new medication, furosemide, to help keep
fluid off your lungs. ___ will follow up next week with Dr.
___. Please call his office for an appointment. It was a
pleasure to help care for ___ during this hospitalization, and
we wish ___ all the best in the future.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10679138-DS-11
| 10,679,138 | 21,372,980 |
DS
| 11 |
2196-09-02 00:00:00
|
2196-09-02 15:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex / atorvastatin / Beta-Blockers (Beta-Adrenergic Blocking
Agts) / IV contrast / methyldopa / adhesive tape / torsemide
Attending: ___.
Chief Complaint:
CHEST PAIN
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ female with a past medical history of CHF, GERD who
presented to the ED with chest pain.
The patient was hospitalized at ___ from ___. She
presented with cough and fevers, and was found to have the flu.
She was treated with 5 days of tamiflu 75mg once daily (dose
reduced due to renal function). She received frequent nebulizers
and an initial dose of intravenous methylprednisone given
significant wheezing. Given an initial acute kidney injury, her
home ___ was held and in that setting she developed flash
pulmonary edema and hypertensive urgency overnight ___. This
was felt related to recent steroid exposure and held home ___
dosing in background of small LV cavity and labile HTN. She
quickly stabilized on the medical floor with IV hydralazine and
briefly a non-rebreather. Her oxygenation improved over the next
several days initially diuresing with bolus dose IV lasix. She
was transitioned to lasix 20mg three times weekly. Although she
continued to cough and remained wheezy, she was eager to return
home to continue her recovery under the close watch of her 24
hour aide. Discharge weight 146lbs. Discharge sodium was 133.
Caregiver notes that pt has been gaining ___ lbs since
discharge. Pt endorses new dyspnea on exertion that improves. No
oxygen at home. No PND. This morning, pt developed chest pain
which has now resolved. Lasted a couple hours. Sharp over
center. Associated with SOB and nausea. Denies fever, belly
pain, urinary or bowel symptoms. Cut Lasix dose at discharge due
to concern for kidney function. Pt has also endorsed chronic
cough since being discharged.
Cardiologist at ___ (Dr. ___ ___ group:
___. Dr ___ PCP- out of town...Dr ___
on call: ___
Lab work in the ED showed a hyponatremia to 117. No seizures or
altered mental status. Added on urine lytes. For now patient is
hypervolemic. Received an initial dose of 20 mg of IV Lasix in
the emergency department.
In ED initial VS: 97.8 70 162/88 19 98% 2L NC
Exam: Decreased lung sounds on R. 1+ non pitting edema in legs
bilaterally
Labs significant for: Na 117
Patient was given: ASA 324, Lasix IV 20mg
Imaging notable for: Pleural effusion and pulmonary vascular
congestion on CXR.
Past Medical History:
- H/O PNA ___ ago c/b R-sided effusion requiring chest tube then
thoracotomy
- Hypertension
- LVH
- Renal artery stenosis s/p stent
- Stage I infiltrating ductal carcinoma breast CA, ER+, PR-,
___- s/p XRT/ lumpectomy
- Osteopenia, dx on a BMD of ___
- Dysfunctional uterine bleeding s/p D&C
- H/O Gangrenous appendicitis ___
- H/O C. Diff colitis
- hx of Hernia repair
- GERD
- Left elbow fracture ___ years ago
- Chest pain NOS, clean cardiac cath prior to ___ at ___
- h/o anxiety
- CHF
Social History:
___
Family History:
Mother with breast cancer
Physical Exam:
ADMISSION EXAM:
VITALS: Reviewed in MetaVision
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
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
DISCHARGE EXAM:
VS: ___ ___ Temp: 97.9 PO BP: 156/71 L Lying HR: 73 RR:
20
O2 sat: 91% O2 delivery: Ra
GENERAL: elderly woman resting comfortably in bed, pleasant and
conversant in no acute distress
HEENT: legally blind bilaterally, equal in size and reactive to
light
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS:CTAB in anterior and limited posterior lung exam, no
expiratory wheezes
ABDOMEN: nondistended, +BS, nontender in all quadrants
EXTREMITIES: 1+ edema to ankle, trace pretibial edema, left arm
edematous, with bruising
PULSES: 2+ DP pulses bilaterally
NEURO: AAOx3, CN II-XII intact. strength ___ in upper and lower
extremities
SKIN: warm and well perfused, L hand hematoma
Pertinent Results:
ADMISSION LABS:
___ 09:15PM NA+-118*
___ 06:10PM GLUCOSE-133* UREA N-16 CREAT-1.0 SODIUM-119*
POTASSIUM-4.9 CHLORIDE-81* TOTAL CO2-20* ANION GAP-18
___ 06:10PM cTropnT-<0.01
___ 02:30PM URINE HOURS-RANDOM UREA N-375 CREAT-47
SODIUM-43
___ 02:30PM URINE OSMOLAL-336
___ 01:30PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 12:52PM GLUCOSE-163* UREA N-16 CREAT-0.9 SODIUM-116*
POTASSIUM-4.9 CHLORIDE-82* TOTAL CO2-22 ANION GAP-12
___ 12:52PM ALT(SGPT)-24 AST(SGOT)-32 ALK PHOS-76 TOT
BILI-0.7
___ 12:52PM ALBUMIN-3.8
___ 12:52PM OSMOLAL-248*
___ 10:52AM ___ COMMENTS-GREEN TOP
___ 10:52AM LACTATE-1.4
___ 10:45AM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 10:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-300*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 10:45AM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-4
___ 10:42AM CK(CPK)-238*
___ 10:42AM cTropnT-0.01
___ 10:42AM CK-MB-7 ___ 10:42AM CALCIUM-8.7 PHOSPHATE-3.3 MAGNESIUM-1.7
___ 10:42AM ___ PTT-25.9 ___
___ 10:00AM GLUCOSE-174* UREA N-17 CREAT-1.0 SODIUM-117*
POTASSIUM-5.3 CHLORIDE-79* TOTAL CO2-18* ANION GAP-20*
___ 10:00AM estGFR-Using this
___ 10:00AM WBC-6.7 RBC-3.52* HGB-10.2* HCT-29.2* MCV-83
MCH-29.0 MCHC-34.9 RDW-13.6 RDWSD-40.7
___ 10:00AM NEUTS-77.9* LYMPHS-12.0* MONOS-8.2 EOS-0.3*
BASOS-0.3 IM ___ AbsNeut-5.20 AbsLymp-0.80* AbsMono-0.55
AbsEos-0.02* AbsBaso-0.02
___ 10:00AM PLT COUNT-362
IMAGING:
CXR ___:
Small left pleural effusion with mild pulmonary vascular
congestion and edema.
___ consider post diuresis films to exclude an underlying
pneumonia.
CXR ___:
In comparison with the study of ___ the lung volumes
are similarly low and bibasilar densities are suggestive of
atelectatic changes. There is mild pulmonary edema, improved
from the previous study. The cardiac silhouette is enlarged.
Slight blunting of the right costophrenic angle could suggest a
small pleural effusion.
MICROBIOLOGY:
___ 10:45 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Blood Cultures; Pending at time of discharge
DISCHARGE LABS:
___ 05:26AM BLOOD WBC-4.9 RBC-3.23* Hgb-9.4* Hct-27.8*
MCV-86 MCH-29.1 MCHC-33.8 RDW-14.6 RDWSD-45.3 Plt ___
___ 05:26AM BLOOD Glucose-139* UreaN-21* Creat-1.2* Na-128*
K-4.9 Cl-89* HCO3-24 AnGap-15
___ 02:01AM BLOOD ALT-20 AST-31 AlkPhos-63 TotBili-0.6
___ 05:26AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.3
Brief Hospital Course:
Patient Summary for Admission:
================================
Ms. ___ is a ___ female with a past medical history
of HFpEF, GERD who presented to the ED with chest pain and found
to be volume overloaded and hyponatremic to 117 without acute
changes in her mental status. She was transferred to the MICU
for management of hyponatremia which was felt to be secondary to
hypervolemia in the setting of acute exacerbation of heart
failure with preserved ejection fraction. Patient was diuresed
with ___ IV lasix daily with appropriate response in sodium.
Once patient was euvolemic on exam and sodium trended back
towards patient's baseline, Ms. ___ was felt safe to be
discharged home.
ACUTE Issues Addressed:
============================
#Hypervolemic Hyponatremia: Patient with initial CXR ___ with
pulmonary edema and vascular congestion with edema on lower
extremities suggesting patient was hypervolemic. She initially
required ICU management ___ given sodium 117 on
presentation. Urine lytes with Na <20 and FeNa <1% also
consistent with hypervolemic hyponatremia. Her sodium was
managed with ___ IV lasix PRN with up trending sodium. Of
note, patient was without neurologic deficits in setting of
hyponatremia and at baseline sodium is 125-130. At time of
discharge sodium 128.
#Acute on chronic diastolic heart failure: Patient presented
with evidence of volume overload on imaging and physical exam.
BNP elevated to ___. (Last BNP 911 in ___. Last echo in ___
with EV >55%. Likely trigger includes decreasing Lasix at
previous OSH hospital discharge and potentially worsened by
recent influenza infection. Her volume status was initially
managed with IV diuresis 20mg-40mg daily. Once euvolemic,
patient was transitioned to an oral regimen Lasix 20mg daily,
Spironolactone Q3 days. On discharge, patient's Sr Cr 1.2 and
weight 65.5kg. Additionally, she continued her home Losartan.
#Chest Pain: Patient presented with chest pain, EKG with slight
ST elevation in V1 and V2, however troponins negative x3 on
___ making ischemic etiology unlikely. Chest pain resolved
with management of patients volume status.
# Infiltrates on CXR ___: CXR ___ with concern for
retrocardiac opacification, however patient afebrile and without
leukocytosis. Antibiotic therapy was held and opacification
resolved on CXR ___.
CHRONIC Issues Addressed:
=============================
#Obstructive Lung Disease: Previous PFTs consistent with
obstructive lung disease. She was managed with duonebs and PRN
albuterol while inpatient. Her respiratory status was stable
during admission.
#HTN: Continued home nifedipine, irbesartan non-formullary so
patient was given 25mg Losartan daily (equivalent dosing). She
was transitioned back to her home medication at time of
discharge.
#Anxiety/Depression: Continue home paroxetine and Ativan.
TRANSITIONAL ISSUES:
[] Blood culture and urine culture pending at time of discharge.
Patient will be contacted by inpatient team if there is
abnormality. Should also be followed by PCP.
[] Sodium 128, Sr Cr 1.2 and weight 65.5kg at time of discharge.
[] Patient will require labs drawn (basic chemistry panel) to
monitor her sodium and Sr Cr on ___, these labs will be faxed
to patient's PCP and ___.
[] Patient with two admissions in last 6 months with evidence of
hypervolemia, consider repeat ECHO as outpatient.
[] Lasix dosed 20mg daily at time of discharge, Spironolactone
every 3 days, pending weight and exam, this should be uptitrated
as needed.
Medication Changes:
-New Medications: None
-Medication Changes: Lasix 20mg daily
-Medications Stopped: None
Health Care Proxy:Proxy name: ___
Relationship: daughter Phone: ___
Code Status: Full Code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. irbesartan 75 mg oral QHS
2. Calcium Carbonate 500 mg PO BID
3. umeclidinium-vilanterol 62.5-25 mcg/actuation inhalation
DAILY
4. LORazepam 0.25 mg PO BID anxiety
5. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line
6. NIFEdipine (Extended Release) 90 mg PO DAILY
7. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic (eye) BID
8. Spironolactone 25 mg PO EVERY 3 DAYS
9. Multivitamins 1 TAB PO DAILY
10. methylcellulose (laxative) 1000 mg oral BID
11. RABEprazole 20 mg oral DAILY
12. selenium 200 mcg oral DAILY
13. Aspirin 81 mg PO DAILY
14. Vitamin B Complex 1 CAP PO DAILY
15. PARoxetine 25 mg PO DAILY
16. Vitamin D 1200 UNIT PO DAILY
17. Align (Bifidobacterium infantis) 4 mg oral DAILY
18. Furosemide 20 mg PO EVERY THREE DAYS
19. Psyllium Powder 0.5 PKT PO QOD
20. Polyethylene Glycol 17 g PO QOD
21. GuaiFENesin ER 600 mg PO DAILY
Discharge Medications:
1. Furosemide 20 mg PO DAILY
2. Align (Bifidobacterium infantis) 4 mg oral DAILY
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line
5. Calcium Carbonate 500 mg PO BID
6. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic (eye)
BID
7. GuaiFENesin ER 600 mg PO DAILY
8. irbesartan 75 mg oral QHS
9. LORazepam 0.25 mg PO BID anxiety
10. methylcellulose (laxative) 1000 mg oral BID
11. Multivitamins 1 TAB PO DAILY
12. NIFEdipine (Extended Release) 90 mg PO DAILY
13. PARoxetine 25 mg PO DAILY
14. Polyethylene Glycol 17 g PO QOD
15. Psyllium Powder 0.5 PKT PO QOD
16. RABEprazole 20 mg oral DAILY
17. selenium 200 mcg oral DAILY
18. Spironolactone 25 mg PO EVERY 3 DAYS
19. umeclidinium-vilanterol 62.5-25 mcg/actuation inhalation
DAILY
20. Vitamin B Complex 1 CAP PO DAILY
21. Vitamin D 1200 UNIT PO DAILY
22.Outpatient Lab Work
Dx: I50.31 Acute on Chronic Diastolic Heart Failure
Please Check: Basic Metabolic Profile (Sodium, Potassium,
Chloride, Bicarbonate, BUN, Sr Cr)
Please fax results to the offices of:
Dr ___: ___
___: ___
Dr. ___: ___
Phone: ___
Phone:
Discharge Disposition:
Home With Service
Facility:
___
___:
Primary Diagnosis:
==================
Hypervolemic Hyponatremia
Acute on Chronic Heart Failure with Preserved Ejection Fraction
Obstructive Lung Disease
Secondary Diagnosis:
====================
Anxiety
Gastroesophageal Reflux
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
Thank you for choosing ___ as your site of care.
Why was I admitted to the hospital?
What was done for me while I was in the hospital?
-You initially had chest pain which is why you came to the
hospital. We took a tracing of your heart called and EKG and
checked labs which did not look like you had a blocked vessel in
your heart.
-Your sodium was very low when you came to the hospital.
-Your sodium was monitored very closely.
-In order to increase your sodium we used water pills through an
IV to remove extra fluid.
-Once your sodium was normal, we restarted oral water pills.
What should I do when I leave the hospital?
-Please take all of your medications as prescribed.
-You should weigh yourself daily, if you notice you gain more
than three pounds please call your doctor.
-___ weight at time of discharge 144lbs.
-Please get your labs drawn on ___, these will be faxed to
your primary care provided and your cardiologist.
-Please follow up with your providers as detailed below.
Your ___ treatment team
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10679238-DS-20
| 10,679,238 | 22,655,773 |
DS
| 20 |
2117-05-22 00:00:00
|
2117-05-22 17:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left arm weakness
Major Surgical or Invasive Procedure:
IV TPA administration
R hip ___ guided arthrocentesis
History of Present Illness:
The pt is an ___ year-old woman with hypertension, afib (not
currently on anticoagulation), vascular dementia, severe
osteoporosis with multiple fractures, who presents with acute
onset
of L hand/arm weakness and L facial droop at 1730 at her
assisted
living facility. BIBEMS. Code stroke called at 1843, neurology
at
bedside to assess within 3 minutes. Initial exam notable for R
gaze preference, L facial droop, LUE weakness, L neglect. CT
done
which showed evidence of acute R MCA occlusion. Pt was also
hypertensive with SBP 190-200, received 10 mg IV labetalol and
IV
morphine for hip pain. After speaking with patient and son
(health care proxy) and reviewing risks and benefits, pt
received
IV TPA in ED at ___. Around time of TPA bolus, exam showed
worsened L hemiparesis and new RLE paresis (pt previously moving
left leg slightly, now with triple flexion in left leg and
minimal movement of R leg). Pt developed episodes of vomiting
and
bradycardia to ___. Repeat CT scan prior to ___ admission
showed no change. Pt admitted to ___ for close monitoring of
neuro status after TPA.
Unable to obtain ROS due to patient's confusion
Past Medical History:
- hypertension
- afib (not currently on anticoagulation)
- aortic stenosis
- vascular dementia (most affecting short-term memory)
- severe osteoporosis with mult fractures (including pelvic fx
- requiring partial R hip replacement ___ ago).
Social History:
___
Family History:
Unknown
Physical Exam:
Vitals: P: 56 R: 12 BP: 175/52 SaO2: 97 RA
General: Very uncomfortable, intermittently awake, answering
questions and following commands
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: Irregular with systolic murmur
Abdomen: soft, midline abdominal hernia
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Intermittently awake, oriented to hospital and
self, sometimes month/year. Difficulty with sustained attention.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors. Pt. was able
to name some high and low frequency objects. Able to read but
difficulty with vision. Speech dysarthric. Able to follow both
midline and appendicular commands on R.
-Cranial Nerves:
I: Olfaction not tested.
II: R pupil ___ brisk, L pupil ___ sluggish. No BTT on L,
unable
to do finger counting in L field.
III, IV, VI: R gaze preference, unable to cross midline
VII: L lower face flattening
VIII: Hearing grossly intact
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Decreased bulk, not moving LUE, flaccid. Triple flexes
LLE in response to noxious stimuli
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 0 0 0 0 0 0 - 0 0 0 0 0 0 0
R 5 ___ 5 5 - 2 3 2 3 3 4 4
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 0 0 0 2 0
R 2 2 2 2 0
Plantar response was up on L, down on R.
-Coordination: No intention tremor. No dysmetria on RUE FNF.
-Gait: Unable to assess due to weakness, instability
Discharge exam: dense R MCA syndrome with L hemineglect, flaccid
L arm, L facial droop. Alert and oriented to place, occasionally
waxes and wanes and sometimes gets confused. Knows she had a
stroke, needs reassurance from staff.
Pertinent Results:
Admission labs:
___ 06:50PM BLOOD WBC-6.4 RBC-3.78* Hgb-10.9* Hct-31.3*
MCV-83 MCH-28.7 MCHC-34.7 RDW-13.8 Plt ___
___ 06:50PM BLOOD Plt ___
___ 06:50PM BLOOD ___ PTT-33.0 ___
___ 02:44AM BLOOD Glucose-148* UreaN-15 Creat-0.7 Na-125*
K-4.0 Cl-90* HCO3-24 AnGap-15
___ 02:44AM BLOOD ALT-14 AST-26 TotBili-0.2
___ 02:44AM BLOOD Albumin-3.9 Calcium-9.0 Phos-3.3 Mg-1.7
Cholest-139
___ 06:30AM BLOOD %HbA1c-5.4 eAG-108
___ 02:44AM BLOOD Triglyc-34 HDL-66 CHOL/HD-2.1 LDLcalc-66
___ 03:30PM BLOOD Osmolal-267*
___ 05:15PM BLOOD CRP-10.6*
___ 07:20PM URINE Color-Straw Appear-Hazy Sp ___
___ 07:20PM URINE Blood-MOD Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 07:20PM URINE RBC-8* WBC->182* Bacteri-FEW Yeast-NONE
Epi-8 TransE-1
___ 07:30PM URINE Hours-RANDOM UreaN-373 Creat-35 Na-95
K-31 Cl-83
___ 07:30PM URINE Osmolal-449
___ 06:00PM URINE Osmolal-617
.
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Hip joint fluid culture
___ 12:15 pm JOINT FLUID RIGHT HIP.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
CT Head with CTA and CT perfusion ___
Near complete occlusion of the right MCA at its bifurcation. By
CT perfusion criteria, there is evidence of right middle
cerebral artery completed infarction. No hemorrhage or area of
ischemia identified on non enhanced head CT.
CT Head ___
No evidence of hemorrhagic transformation of right MCA
territorial infarction.
NOTE ADDED AT ATTENDING REVIEW: I agree that there is no
evidence of
hemorrhage. The only region of possible early gray matter
hypodensity is in the right frontal lobe, images ___.
CXR ___
Mild interstitial pulmonary edema.
CT head ___
Evolving infarct in the right insula and frontal lobe, in the
MCA
territory, without hemorrhagic transformation.
ECHO ___
The left atrium is mildly dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF 65%). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The right ventricular free wall is hypertrophied.
The right ventricular cavity is mildly dilated with normal free
wall contractility. [Intrinsic right ventricular systolic
function is likely more depressed given the severity of
tricuspid regurgitation.] 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). Mild to
moderate (___) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to moderate (___) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The tricuspid valve leaflets are mildly thickened. Tricuspid
valve prolapse may be present. Moderate to severe [3+] tricuspid
regurgitation is seen. There is severe 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.
R hip US ___
No defined or drainable fluid collections identified around the
right hip joint. Tubular echogenic structure seen coiling within
the soft tissues overlying the greater trochanter of uncertain
etiology. While this may represent intentionally placed surgical
packing material of some sort, which is meant to stay inside the
body long term, retained foreign body cannot be excluded.
___ guided hip aspiration ___
Technically successful aspiration of the right hip joint, clear
fluid
aspirated. Microbiology is pending.
CXR ___
Regression of pulmonary congestion, increased local left basal
density suggestive of an inflammatory infiltrate.
MRI head ___
Large infarct in the territory of the right middle cerebral
artery with
petechial hemorrhage in the right parietal portion of the
infarct.
Punctate infarct in the right cingulate gyrus.
Cerebral atrophy and white matter signal abnormalities most
consistent with small vessel ischemic disease.
CT head ___
Edema secondary to right MCA territory infarction with a new
focus of
hyperdensity superiorly, concerning for hemorrhagic conversion.
CT head ___
Stable size of hemorrhagic conversion of right MCA stroke. No
new areas
of hemorrhage. No increased mass effect.
Video Swallow eval ___
Penetration and aspiration with thin and nectar thick liquids.
No evidence of aspiration or penetration with puree consistency.
L shoulder X ray ___
OLD UNUNITED FRACTURE OF THE LEFT HUMERAL SURGICAL NECK.
CXR ___
Radiograph centered at thoracoabdominal junction was obtained
for assessment of a feeding tube, which has now been advanced
into the stomach. Otherwise, no relevant short interval change
since the recent study performed less than two hours earlier.
DISCHARGE LABS
___ 06:25AM BLOOD WBC-10.7 RBC-3.81* Hgb-10.8* Hct-33.2*
MCV-87 MCH-28.4 MCHC-32.6 RDW-14.8 Plt ___
___ 10:15AM BLOOD ___ PTT-27.8 ___
___ 08:45AM BLOOD Glucose-89 UreaN-22* Creat-0.8 Na-143
K-4.3 Cl-107 HCO3-27 AnGap-13
___ 05:05AM BLOOD ALT-16 AST-25 AlkPhos-55 TotBili-0.3
___ 08:45AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.9
Brief Hospital Course:
The patient is an ___ year old woman with HTN, a fib not on
anticoagulation, dementia, osteoperosis, p/w L hand and arm
weakness, left facial droop, left sided neglect. She presented
with a code stroke. CT head showed evidence of acute infarction
of the R MCA. She got IV labetalol and IV TPA in the ED. She was
admitted to the SICU, and repeat head CT showed no bleeding, so
she was transfered to the floor. She also had evidence of UTI on
UA, so was started on CTX. Finally, she has a chronic ulcer in
her R hip that ortho followed in the hospital. She 1 seizure,
and repeat head CT showed a small amount of hemorrhagic
conversion, aspirin was held for 1 day and then restarted.
# R MCA stroke s/p TPA, small amount of hemorrhagic conversion:
CT scan was stable without bleeding, MRI scan did show a very
small amount of hemorrhagic conversion without clinical
consequence. A1C and LDL wnl. The patient's ASA 81 was
restarted. We considered A/C for her a fib but held off given
risk of hemorrhage from fall risk, and underlying dementia. BP
was initially allowed to autoregulate and then controlled with
atenolol and captopril. When the patient had a seizure she had a
slight increase in the amount of hemorrhagic conversion but not
clinically significant. ___ and OT recommended rehab placement.
# Seizure: the patient had 1 seizure on ___, and was started on
keppra. This initially made her sleepy but then her mental
status improved back to baseline once dose was reduced to 500
BID. No further seizure activity.
# CV, HTN, 3+ TR: Echo with 3+ TR. Tele showed a fib, rate well
controlled. Atenolol and captopril were started to control BP
after a period of autoregulation. The patient's furosemide was
held in the setting of low PO intake and fluid restriction for
SIADH, and she did not have signs of fluid overload in the
hospital.
- at rehab, please monitor BP frequently, adjust mediations as
needed, goal normotension
- monitor for signs of fluid overload, measure daily weight and
monitor Is and Os. If needed, can restart furosemide or give PRN
doses
# Renal: Na 125, trended up to normal with fluid restriction and
a brief trial of salt tabs. ddx SIADH vs. heart failure from TR.
Since she responded to fluid restriction and salt tabs SIADH is
more likely. Salt tabs were DCed and fluid restriction was
liberalized to 1.5 L daily when she began to look dry. Home
furosemide was held.
- check chem10 every other day to monitor hyponatermia, adjust
fluid restriction or start salt tabs as needed
# Poor PO intake: the patient was followed by nutrition in
house, and started on mirtazapine for appetite stimulation.
Bedside swallow eval was inconsistent and the patient sometimes
passed and sometimes appeared to be aspirating, so video swallow
eval was obtained, which showed no aspiration with purreed
solids and mild aspiration with thin and thickened liquids. We
discusssed the risks and benefits of liberalizing the patient's
diet with her HCP, given that she would be a poor candidate for
a feeding tube long term and that if she is to recover she will
need to take PO on her own. Further discussion with the son
confirmed that the HCP accepts risk of aspiration, and to give
her the best chance to eat on her own, is ok with trying the
patient on mechanically ground soft solids which would be more
appetizing, and continuing thin liquids.
- encourage PO intake, the patient should take at least 1 L PO
intake per day, although she is fluid restricted to 1.5 L for
hypoNatremia
- She passed video S+S eval for purreed solids, and for liquids
she had some aspiration, discussion with HCP revealed that the
patient was asking for liquids for comfort, and since she was
likely aspirating some saliva anyway, he felt it was appropriate
to continue to offer her liquids and soft solids.
- the patient prefers hot food and liquids such as hot tea.
- feed patient as needed at bedside
- check chem10 every other day, the patient may be at a small
risk for refeeding syndrome, so please replete K to 4, Phos to
normal, and Mg to 2 aggressively
# Epigastric pain: the patient had been constipated in the past
and the son says she often presents with abdominal pain when
constipated. Bowel regimin was uptitrated as needed. Mild
elevation in AST but without elevation in bili. Leukocytosis
resolved.
- titrate bowel medications as needed to avoid constipation,
goal ___ BMs per day
- if no BM in 24 hours, please give a soap suds enema daily PRN
# Difficulty with urination: Required intermittent straight cath
and then Foley catheter placement. Thought to have been related
to constipation. This occured after UTI had been treated and was
felt to be unrelated to infection. Foley catheter was DCed on
___ and she passed her trial of void therafter.
# Klebsiella UTI: got 4 days of treatment with CTX
# Transient Leukoytosis: resolved without specific tx. CXR with
possible conslidation, but the patient is afebrile and without
cough or resp sx
-if the patient becomes febrile or develops resp sx would
recheck CXR and consider tx for pna
# R hip ulcer: no further imaging needed for now per verbal
ortho recs. Due to concern for possible joint infection, her R
hip joint was aspirated. Final culture results showed no growth
for several days. Ortho spoke with ID team, and decided that no
treatment was indicated.
-wound care for right hip ulcer and outpt orthopedics follow up
# Old L arm fracture: the patient has an old L shoulder
dislocated fracture, ortho recommended a sling
- non weight bearing on left arm
- outpt ortho follow up
# Bradycardia: the patient was in a fib on tele, and had
asymptomatic bradycardia in the ___, which we tolerated.
# Pain: restarted home morphine at a low dose and increased as
needed and as tolerated by consitpation and mental status. also
started standing tylenol. cont home lidocaine patch
- titrate pain medicaion as needed to treat long standing pain
# Low mobility
- physical therapy
- out of bed TID at least with nursing assistance
# FEN: soft solids and thickened liquids per S+S recs
# Code Status:DNR/DNI (form in chart)
Health Care Proxy: Son ___, ___, alternate
___ ___
TRANSITIONAL ISSUES
- we deferred starting anticoagulation for her atrial
fibrillation given her underlying dementia and fall risk after a
stroke, and started the patient on aspirin for stroke prevention
- physical therapy and occupational therapy
- out of bed TID at least eith nursing assistance
- encourage PO intake, the patient should take at least 1 L PO
intake per day, although she is fluid restricted to 1.5 L for
hypoNatremia. Feed patient if needed. Continue thin liquids and
mechanically soft solids as tolerated, HCP understands the risks
of aspiration and accepts them.
- She passed video S+S eval for purreed solids, and for liquids
she had some aspiration, discussion with HCP revealed that the
patient was asking for liquids for comfort, and since she was
likely aspirating some saliva anyway, he felt it was appropriate
to continue to offer her liquids if she desired for comfort.
- check chem10 every other day to monitor hyponatermia, adjust
fluid restriction or start salt tabs as needed
- replete electrolytes aggressively in order to avoid refeeding
syndrome due to low PO intake in the hospital, check chem10 at
least every other day
- manage blood pressure, adjust mediations as needed, goal
normotension
- monitor for signs of fluid overload, measure daily weight and
monitor Is and Os. If needed, can restart furosemide or give PRN
doses
- titrate bowel medications as needed to avoid constipation,
goal ___ BMs per day
- if she does not have a bowel movement x 24 hours, she should
get a soap suds enema
- titrate pain medicaion as needed to treat long standing pain
- wound care for right hip ulcer
- non weight bearing on L arm for ___
- sling for L arm should remain in place, the patietn is non
weight bearing on the L arm
- outpatient orthopedics follow up
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Senna 2 TAB PO BID
2. Lidocaine 5% Patch 1 PTCH TD DAILY
3. Furosemide 20 mg PO DAILY
4. Docusate Sodium 200 mg PO BID
5. Polyethylene Glycol 17 g PO EVERY OTHER DAY
6. Lactulose 10 mL PO DAILY
7. Lorazepam 0.5 mg PO BID
8. Morphine Sulfate (Concentrated Oral Soln) 5 mg PO Q4H
Discharge Medications:
1. Docusate Sodium 200 mg PO BID
2. Lidocaine 5% Patch 1 PTCH TD DAILY
3. Senna 2 TAB PO BID
4. Acetaminophen 650 mg PO/PR Q6H pain
5. Mirtazapine 15 mg PO HS
6. Morphine Sulfate (Concentrated Oral Soln) 3 mg PO Q4H
7. Aspirin 81 mg PO DAILY
8. Atenolol 12.5 mg PO DAILY
9. Bisacodyl ___AILY Constipation
10. Captopril 25 mg PO TID
11. Multivitamins 1 TAB PO DAILY
12. Lactulose 10 mL PO DAILY
13. LeVETiracetam 500 mg PO BID
14. Polyethylene Glycol 17 g PO EVERY OTHER DAY
15. enema
Please give 1 soap suds enema daily PRN no bowel movement in 24
hours
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis.
1. right middle cerebral artery infarct
Secondary diagnosis
1. atrial fibrillation
2. hypertension
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 ___
___. You were admitted for an acute stroke, and you
got a clot busting medication (TPA) in the emergency room. You
were monitored closely in the ICU and you were stable. On the
floor you had some abdominal pain, and some difficulty
urinating. You had a right hip ulcer and you had your hip fluid
tested for infection, which was negative. You had a seizure, and
you were started on keppra, which you should continue to prevent
future seizure. You were found to have low sodium and you were
treated with fluid restriction. You had some trouble swallowing
but improved. You have an old fracture of your L arm which
requires a sling and orthopedics follow up.
It is important that you take all medications as prescribed, and
keep all follow up appointments.
Followup Instructions:
___
|
10679239-DS-14
| 10,679,239 | 29,868,531 |
DS
| 14 |
2173-03-22 00:00:00
|
2173-03-22 16:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Stroke
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ yo woman with medical history of COPD,
anxiety, and substance abuse who is transferred from OSH for
management of acute RT MCA stroke.
Per report the patient was in her usual state of health until
___ at 8:45pm. At the time she was watching TV with her
sister and noticed her speech was slurred. She got up went to
blow her nose in the bathroom. Her sister followed her and found
her to be on the floor on hands and knees trying to reach the
toilet paper. The patient herself recalls the event as stumbling
and feeling that she had drool out of her mouth. The family
called ___ and she was taken to an OSH where she had a negative
NCHCT. She was given tPA at 10:45pm and an MRI w/o contrast
showed restricted diffusion in the RT MCA territory (likely
inferior division). She was transferred to ___ for evaluation
and possible thrombectomy.
On arrival the patient was awake alert and oriented with NIHSS
of
3 scoring for LT arm sensory loss, mild LT NLFF, and extinction
to double simultaneous stimulation on LT arm. She was taken for
NCHCT which showed hypodensity of RT MCA territory corresponding
to the initial MRI.
General and neurologic review of systems limited by anxiety.
However other than the above mentioned symptoms the patient does
report headache.
Past Medical History:
Depression
Anxiety
COPD
Social History:
___
Family History:
Mother: Large RT sided stroke and subsequent seizures. Passed
away 5 months ago. Prosthetic heart valve.
GF: Brain tumor
GM: CAD
Physical Exam:
==============
ADMISSION EXAM
==============
___ Stroke Scale - Total [3]: 4. Facial Palsy -1 / 8. Sensory -___
/ ___. Extinction and Neglect -1.
General: Anxious and tearful
HEENT: NCAT
___: RRR
Pulmonary: CTAB
Extremities: Warm, no edema
Neurologic Examination:
Mental Status: Awake, alert, oriented x 3. Attention to examiner
easily maintained. Recalls a coherent history. Responses are
slowed
but peech is fluent with full sentences, intact repetition, and
intact verbal comprehension. Naming intact. No paraphasias.
Normal prosody. No dysarthria.
Cranial Nerves: PERRL 3.5->2 brisk. VF full to confrontation
with
red pin. EOMI, no nystagmus. V1-V3 without deficits to light
touch bilaterally. Mild LT NLFF. Hearing intact to finger rub
bilaterally. Palate elevation symmetric. SCM/Trapezius strength
___ bilaterally. Mild dysarthria. Tongue midline.
Motor: Normal bulk and tone. No drift. No tremor or asterixis.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L 5 ___ 5 5 5 5 5 5 5 5
R 5 ___ 5 5 5 5 5 5 5 5
Sensory: Decreased light touch and pinprick of the left arm and
leg, extinguishes to DSS LT on the left
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response flexor bilaterally.
Coordination: No dysmetria with finger to nose testing
bilaterally.
Gait: Deferred.
==============
DISCHARGE EXAM
==============
Essentially unchanged except:
GENERAL: In no distress, slightly hyperactive, only
intermittently tearful.
MOTOR: Left deltoid ___.
SENSORY: Still decreased sensation to LT/PP on left side, but
slightly improved on left lower extremity.
Pertinent Results:
=============
SELECTED LABS
=============
___ 01:20AM BLOOD WBC-6.2 RBC-3.85* Hgb-11.2 Hct-34.4
MCV-89 MCH-29.1 MCHC-32.6 RDW-12.6 RDWSD-41.1 Plt ___
___ 05:10AM BLOOD WBC-5.7 RBC-4.41 Hgb-13.0 Hct-38.4 MCV-87
MCH-29.5 MCHC-33.9 RDW-12.7 RDWSD-40.1 Plt ___
___ 01:20AM BLOOD ___ PTT-32.3 ___
___ 09:30AM BLOOD ___ PTT-34.0 ___
___ 03:50AM BLOOD Glucose-88 UreaN-12 Creat-0.8 Na-139
K-3.4 Cl-102 HCO3-23 AnGap-17
___ 03:50AM BLOOD ALT-10 AST-15 LD(LDH)-183 AlkPhos-96
TotBili-0.6
___ 03:50AM BLOOD Albumin-4.0 Calcium-9.4 Phos-3.8 Mg-1.8
Cholest-175
___ 09:30AM BLOOD D-Dimer-598*
___ 03:50AM BLOOD %HbA1c-5.3 eAG-105
___ 03:50AM BLOOD Triglyc-93 HDL-57 CHOL/HD-3.1 LDLcalc-99
___ 03:50AM BLOOD TSH-1.5
___ 01:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:30AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-POS* amphetm-NEG oxycodn-NEG mthdone-NEG
BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA, IGM, IGG) ** PENDING **
CARDIOLIPIN ANTIBODIES (IGG, IGM) ** PENDING **
LUPUS ANTICOAGULANT ** PENDING **
=======
IMAGING
=======
- CT Head WO Contrast (___)
There is hypoattenuation and loss of gray-white matter
differentiation along the right parietal and temporal lobes
(03:17, 19)compatible with cytotoxic edema from infarction in
the territory of the right MCA.
- CTA Head & Neck (___):
1. Loss of right frontotemporal gray-white matter
differentiation
corresponding to known acute infarct.
2. No intracranial hemorrhage.
3. Relative reduction in vascularity in area of the right MCA
territory infarct, with loss of opacification of some of the
distal M4 branches.
4. Otherwise patent principal intracranial vasculature without
significant stenosis, additional occlusion, or aneurysm.
5. Patent cervical vasculature without significant stenosis,
occlusion, or dissection.
6. Mild biapical centrilobular and paraseptal emphysema. There
are scattered subcentimeter mm pulmonary nodules, potentially
representing infectious/inflammatory etiology.
7. A 5 mm right upper lobe pulmonary nodule with pleural
tagging. While this may represent scarring, given the
emphysematous changes, if the patient has risk factors such as
smoking, a six-month CT follow-up is recommended to document
stability. If there are no risk factors, a 12 month CT
follow-up is recommended per ___ guidelines.
- TTE (___)
GENERAL COMMENTS: Contrast study was performed with 3 iv
injections of 8 ccs of agitated normal saline, at rest, with
cough and post-Valsalva release. Suboptimal image quality - poor
echo windows.
CONCLUSIONS: The left atrial volume index is normal. No atrial
septal defect or patent foramen ovale is seen by 2D, color
Doppler or saline contrast with maneuvers. Normal left
ventricular wall thickness, cavity size, and regional/global
systolic function (biplane LVEF = 66 %). 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. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. Normal study. Normal
biventricular cavity sizes with preserved regional and global
biventricular systolic function. No valvular pathology or
pathologic flow identified. No definite structural cardiac
source of embolism identified.
- CT Head WO Contrast (___)
1. Expected evolution of right MCA infarct.
2. No intracranial hemorrhage.
- CXR (___)
No comparison available. Of the a known trauma, the patient has
a slightly displaced lateral fracture of the ___ and probably
___ left rib. There is no pneumothorax and no pleural
effusion. Otherwise the radiograph is normal.
- ___ (___)
CONCLUSIONS: 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
or patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. Overall left ventricular systolic
function is normal (LVEF>55%). There is no ventricular septal
defect. with normal free wall contractility. The aortic valve
leaflets (3) are mildly thickened. No masses or vegetations are
seen on the aortic valve. The mitral valve appears structurally
normal with trivial mitral regurgitation. No mass or vegetation
is seen on the mitral valve.
IMPRESSION: No evidence for an atrial septal defect or patent
foramen ovale.No left atrial or left atrial appendage thrombus.
Brief Hospital Course:
___ year-old woman with history of COPD, depression, anxiety, and
substance abuse who presented to OSH with right hemibody
numbness, mild facial weakness and dysarthria. She was found to
have right-inferior MCA stroke, was given tPA, and transferred
to ___ for post-tPA monitoring in the Neuro ICU. She was
stable and later transferred to the floor. Vessel imaging with
CTA did not demonstrate any significant atherosclerosis, TTE and
TEE were negative for thrombus or ASD/PFO, diabetes and lipid
panels were within normal. Her only risk factors were smoking
and crack cocaine use the day prior to presentation. D-dimer and
LDH were negative for malignancy-associated hypercoagulability.
Antiphospholipid panel is pending. Most likely etiology was
determined to be crack cocaine use on day prior to stroke -- it
is known to cause thrombosis as well as hypertensive bleeds. She
was seen by physical, occupational, and speech therapy who
determined she did not require any form of rehab unless desired.
She was given prescriptions for outpatient speech and
occupational therapy if needed. We started her on aspirin 81mg
and atorvastatin 10mg daily.
- To follow-up with Dr. ___ stroke neurology at ___ in
___.
- Cardiolipin Ab, Lupus anticoagulant, and Beta-2 glycoprotein
results pending.
# Crack cocaine use
We discussed with her the risks of continue cocaine use --
especially the propensity for hemorrhagic strokes -- and told
her that aspirin will increase her risks of bleeding in such a
situation, for up to 10 days after last aspirin use. She voiced
acknowledgement of this, was given resources for drug counseling
local to her by our social worker, and she described prior
sponsors she had whom she would seek out. Her son was also
observed in the hallway calling her friends and other family,
warning them one-by-one not to facilitate her drug use in any
way, or they would have to answer to him.
# Tobacco use
She was given a 28-day prescription for nicotine patches for
smoking cessation.
# Rib Fractures
She was noted to have bruising on her left flank on admission,
and chest X-ray noted two fractures of the ___ and ___ left
ribs. These were non-painful to her. She was directed to avoid
strenuous or potentially traumatic activity.
# Incidental pulmonary nodule
Incidental 5 mm right upper lobe pulmonary nodule with pleural
tagging was noted on CTA. Recommended 6-month follow-up CT scan
but patient said this was already being monitored by other
providers and she recently had a CT scan for this.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Venlafaxine 75 mg PO DAILY
2. Gabapentin 300 mg PO QHS
3. TraZODone 100 mg PO QHS:PRN Insomnia
4. Tiotropium Bromide 1 CAP IH DAILY
5. Albuterol Inhaler ___ PUFF IH Q6H:PRN Shortness of Breath /
Wheezing
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*3
2. Atorvastatin 10 mg PO QPM
RX *atorvastatin 10 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*3
3. Nicotine Patch 14 mg TD DAILY:PRN nicotine withdrawal
RX *nicotine 14 mg/24 hour Apply 1 patch DAILY Disp #*14 Patch
Refills:*1
4. Albuterol Inhaler ___ PUFF IH Q6H:PRN Shortness of Breath /
Wheezing
5. Gabapentin 300 mg PO QHS
6. Tiotropium Bromide 1 CAP IH DAILY
7. TraZODone 100 mg PO QHS:PRN Insomnia
8. Venlafaxine 75 mg PO DAILY
9.Outpatient Occupational Therapy
10.Outpatient Speech/Swallowing Therapy
Discharge Disposition:
Home
Discharge Diagnosis:
Right inferior MCA ischemic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of left-sided numbness and
facial weakness resulting from an ACUTE ISCHEMIC STROKE, a
condition where a blood vessel providing oxygen and nutrients to
the brain is blocked by a clot. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
You did not have any cardiac causes, nor any
hardening-of-the-arteries, which are the most common causes.
Your only risk factor was drug use on the day prior to your
stroke. In order to prevent future strokes, we plan to modify
your risk factors. Your risk factors are:
- Smoking
- Cocaine use
We are changing your medications as follows:
- START taking aspirin 81mg (Baby Aspirin) ONCE DAILY. This is a
mild blood thinner that will help reduce your risk for future
strokes.
- START taking atorvastatin 10mg (Lipitor) ONCE DAILY. This is a
cholesterol-lowering medications that has many additional
effects on protecting your blood vessels and reducing
inflammation in them. It will also help reduce your risk for
future stroke.
- START a nicotine patch ONCE DAILY. This will help you quit
cigarettes, in combination with supportive therapy.
Please take your other medications as prescribed.
Please follow-up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Thank you,
Your ___ Neurology Team
Followup Instructions:
___
|
10679464-DS-10
| 10,679,464 | 28,441,548 |
DS
| 10 |
2194-08-22 00:00:00
|
2194-08-22 18:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril / spironolactone / amlodipine / gabapentin
Attending: ___.
Chief Complaint:
hand swelling, pain across the neck and chest
and ribcage
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH of bifasicular block, copd, new diagnosis of small
cell lung CA on ___ (___) who presents
reporting ribcage and chest pain and new right hand swelling.
He states that this past ___ he woke up with a stiff neck
on
both sides to the point that he could barely turn it. Prior to
that he has been having issues off and on with right sided
jaw/tooth infections, and was supposed to have surgery but his
lung CA diagnosis has derailed that. Per review of OMR, seems he
has h/o mandibular cyst infection: appears to have begun in ___
- ___ admitted for IV unasyn overnight, had drain
placed
by OMFS, drain ultimately removed in ___ (pt still on
course of PO augmentin) with ultimately plan for surgery which
he
today states never occurred as above. He denies sore throat or
trouble swallowing. States that the jaw pain has also been
acting
up similar to how it has been in the past. No headaches,
rhinorrhea, or nasal congestion. Denies fevers at home. States
that although he felt awful generally, on ___ he did go to RT
mapping. He felt that day and over the weekend that " all his
ribs are sore with bending over". He describes two "bumps" on
the
upper left part of the neck which are painful and also pain that
shoots across the chest and the left lower ribcage even with
slight movements. It feels like sharp stabbing pains that last a
few seconds to a minute but then dissipate. He has not been able
to take deep breaths or cough because of this pain either. 2
days
ago he noted his right arm swelling up. He thinks he banged it
or
scratched it while working on his boat (not in the water, was
working on it on land) or while putting a screen canopy up
outside. It has been swelling up progressively since then and
become increasingly painful even with moving the fingers.
He denies diarrhea, abd pain, nausea/vomiting, dizziness,
fevers,
palpitations. He isn't sure if he really has a cough or if
mucous
is just building up because he isn't able to take deep breaths
or
cough he states.
He also has a remote history of admission at ___ for diverticulitis vs right sided colitis treated in
___. Denies any history of IV drug use.
He denies headaches, nausea/vomiting, neck stiffness, rash, leg
swelling, abdominal pain, diarrhea, dysuria, back pain. All
other
10 point ROS neg.
ED COURSE:
98.8 95 126/74 24 93% on 3L NC. Lactate 1.5. trop <0.01.
Chem
with Na 127 from 133 on ___. WC 24, Hct 35. plts 287. 78% pmns,
4 bands. He was given vanc/cefepime. CTA showed no PE. Consulted
hand who recommended CT scan of his hand and wrist to evaluate
for fluid collection and other sequelae of infection. CT upper
extremity showed mild soft tissue swelling about the wrist, no
drainable fluid collection. no subcu gas, no fracture.
Past Medical History:
PAST ONCOLOGIC HISTORY:
ONCOLOGICAL HISTORY:
- Mr. ___ was in his normal state of health until ___, he noticed pleuritic chest pain and intermittent
hemoptysis. At that time, he was shoveling snow, therefore
initial workup was focused on cardiac etiology. During the
workup, he was found to have a new hilar lung mass with
mediastinal lymphadenopathy. The patient was admitted to the
hospital for expedited workup. He received EBUS biopsy on
___. The biopsy of the lung mass showed small cell lung
cancer pathology. During the hospital stay, the patient had a
brain MRI, which was negative for metastatic disease; however,
followup was recommended. A CT of the abdomen and pelvis was
negative for metastatic disease.
- PET-CT showed a isolated liver mass that was FDG-avid, that
was
not seen on CT. Liver U/S showed no lesions.
- C1D1 ___ ___ with neulasta support
- C2D1 ___ ___ with neulasta support
PAST MEDICAL HISTORY:
1. COPD, on ___ liters of oxygen at baseline.
2. Type 2 diabetes.
3. History of alcohol abuse.
4. Hypertension.
5. Heart block.
6. Recurrent right jaw infection.
Social History:
___
Family History:
Father had esophageal cancer.
Physical Exam:
===ADMISSION PHYSICAL EXAM===
VITAL SIGNS: 97.6 154/89 93 20 95% on 3L NC
General: NAD at rest but with even small movements shouts in
pain
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
GI: BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: exam of right arm per hand surgery team description; pt
now with cast on. Also per photos taken by hand surgery team -
discussed w/ them, neurologically intact, exam with swelling but
not significant erythema, abrasion noted. Currently in cast.
NEURO: Oriented x3. Cranial nerves II-XII are within normal
limits excluding visual acuity which was not assessed, no
nystagmus; strength is ___ of the proximal and distal upper and
lower extremities though exam limited by pain with movements or
resitance.
===DISCHARGE PHYSICAL EXAM===
VITAL SIGNS: 97.5PO 142 / 79 84 18 95 3L
General: NAD
HEENT: MMM
CV: RR, NL S1S2 no MRG
PULM: CTAB
GI: BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: on exam of right arm per hand surgery team description;
pt
now with cast on. Also per photos taken by hand surgery team -
discussed w/ them, neurologically intact, exam with swelling but
not significant erythema, abrasion noted. Currently in cast.
NEURO: Oriented x3. Cranial nerves grossly II-XII
Pertinent Results:
===ADMISSION LABS===
___ 09:40PM BLOOD WBC-24.0* RBC-3.78* Hgb-12.4* Hct-35.4*
MCV-94 MCH-32.8* MCHC-35.0 RDW-14.5 RDWSD-49.2* Plt ___
___ 09:40PM BLOOD Neuts-78* Bands-4 Lymphs-10* Monos-7
Eos-0 Baso-0 ___ Metas-1* Myelos-0 AbsNeut-19.68*
AbsLymp-2.40 AbsMono-1.68* AbsEos-0.00* AbsBaso-0.00*
___ 09:40PM BLOOD Glucose-168* UreaN-16 Creat-0.9 Na-127*
K-3.8 Cl-85* HCO3-28 AnGap-18
___ 07:25AM BLOOD Calcium-9.0 Phos-2.9 Mg-1.7
___ 09:49PM BLOOD Lactate-1.5
===DISAHRGE LABS===
___ 07:12AM BLOOD WBC-13.1* RBC-3.33* Hgb-10.6* Hct-31.1*
MCV-93 MCH-31.8 MCHC-34.1 RDW-14.3 RDWSD-48.5* Plt ___
___ 07:45AM BLOOD Neuts-71 Bands-1 Lymphs-12* Monos-13
Eos-1 Baso-1 ___ Metas-1* Myelos-0 AbsNeut-11.81*
AbsLymp-1.97 AbsMono-2.13* AbsEos-0.16 AbsBaso-0.16*
___ 07:12AM BLOOD Glucose-161* UreaN-24* Creat-0.9 Na-132*
K-4.2 Cl-91* HCO3-29 AnGap-16
___ 07:12AM BLOOD Calcium-8.9 Phos-4.4 Mg-2.1
===MICRO===
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
===STUDIES===
___ Imaging MR ___ W/O CONTR/T-SPINE W &W/O
CONTR/L-SPINE W & W/O CONT
1. Multilevel degenerative changes in the cervical spine are
most severe at
C4-C5, resulting in moderate narrowing of the spinal canal and
remodeling of
the spinal cord. No definite cord signal abnormality.
2. Degenerative changes in the lumbar spine are most prominent
at L4-5 and
L5-S1 levels without high-grade spinal canal or neural foraminal
stenosis.
3. The spinal cord is normal in caliber and signal intensity
without abnormal
enhancement.
4. There is no evidence of osseous metastatic disease.
___ Imaging UNILAT UP EXT VEINS US
No evidence of deep vein thrombosis in the right upper
extremity.
___ Imaging CT SINUS/MANDIBLE/MAXIL
1. No evidence of infection.
2. Probable incisive canal cyst.
___ Imaging CT NECK W/O CONTRAST
1. Periapical lucency in the right posterior mandible about an
unerupted tooth is most likely a dentigerous cyst, previously
demonstrated in the mandibular series dated ___.
The differential diagnosis also includes ameloblastoma or
odontogenic keratocyst.
2. No evidence of infectious process in the neck given the
limitations of a noncontrast study.
3. Heterogeneous thyroid with calcifications. A discrete nodule
cannot be
measured on this noncontrast study. If clinically indicated, a
nonemergent
thyroid ultrasound can be obtained for further evaluation.
4. An incisive canal cyst is better depicted in the
maxillofacial CT performed concurrently.
___ Imaging CT UP EXT W/C RIGHT
Mild soft tissue swelling about the wrist. No drainable fluid
collection. No subcutaneous gas. No fracture.
___ Imaging CTA CHEST
1. No evidence of pulmonary embolism or aortic abnormality.
2. Interval improvement when compared to ___ and ___,
with
substantial decrease in left suprahilar mass and mediastinal
adenopathy.
3. Multinodular right thyroid, unchanged from prior.
Brief Hospital Course:
___ with PMH of bifasicular block, copd, new diagnosis of small
cell lung CA on ___ (___) who presents
reporting ongoing pleuritic chest pain and new right hand
swelling along with leukocytosis, concerning for cellulitis.
# Diffuse shooting pains
# Bilateral neck pain
# History of right mandibular infections
Difficult constellation of symptoms to integrate. Recent PET
without evidence of FDG avid lesions in spine, though
degenerative changes noted, and nerve compression is a possible
etiology of pain. It was thought possible that hematogenous
spread of infection related to incompletely treated jaw
infection (cellulitis, epidural abscesses) could explain
patient's symptoms. In order to further evaluate these possible
etiologies, the patient underwent a noncontrast max/facial CT
and noncontrast CT of soft tissues of neck, which did not have
any evidence of infection. Patient also underwent a MRI of C/T/L
spine to assess for metastatic disease, nerve impingement,
epidural abscess, or other etiology of patient's diffuse pains.
MRI revealed multilevel degenerative changes in the cervical
spine, most severe at C4-C5, resulting in moderate narrowing of
the spinal canal and remodeling of the spinal cord. This may
account for some of patient's presenting symptoms. Other
degenerative changes were noted in the lumbar spine. No
metastatic disease or evidence of infection. Patient's pain was
significantly improved with cyclobenzaprine, oxycodone, and
toradol for breakthrough pain.
# Leukocytosis
# cellulitis of the hand
# R hand swelling
Lactate reassuring at 1.5. Neurologic and sensory function of
hand intact. Pt reports cut on the hand likely portal of entry
for infection. While some component of his leukocytosis may be
sequela of neulasta, this elevation seems a bit protracted for
an injection last given on ___. From photos from ED, hand/arm is
swollen, but no significant erythema. Per hand surgery, doubt
septic joint given no focal tenderness of one joint but rather
diffuse swelling of the hand - though exam not that impressive,
given chemo, the abrasion, swelling, immunocompromise - per hand
team reasonable to treat as cellulitis. Patient was started on
vanc/ceftriaxone on ___, and was transitioned to PO
Bactrim/Keflex on ___ with plan for 7 day course. Hand surgery
continued to follow, and noted CT of hand demonstrates no fluid
collection or fracture/foreign body. Patient remained
neurovascularly intact and has near full ROM (limited by pain).
Patient was maintained in a splint with hand elevated.
# Pleuritic chest pain
___ has been reporting this pleuritic chest pain for months; in
fact it is what prompted his chest imaging which resulted in his
new diagnosis of malignancy. Suspect related to his lung cancer.
Prior cardiac workup was reassuring, and EKG stable compared to
prior with normal troponin and CTA without e/o PE.
# Hyponatremia - Ulytes with Na 39 c/w SIADH, may be in setting
of pain and/or malignancy. Improved during admission with better
pain control.
# Diabetes - held home metformin during hospitalization.
# COPD - stable on home ___ O2.
# Anxiety - cont prn Xanax home med
TRANSITIONAL ISSUES:
=====================
- continue Bactrim/Keflex through ___
- nonemergent thyroid ultrasound can be obtained for further
evaluation of heterogeneous thyroid with calcifications
- continue elevation of R hand; monitor for resolution of edema
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob
2. Ascorbic Acid ___ mg PO DAILY
3. Chlorthalidone 25 mg PO DAILY
4. Daliresp (roflumilast) 500 mcg oral DAILY
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB, wheeze
7. Metoprolol Succinate XL 150 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Rosuvastatin Calcium 40 mg PO QPM
10. Tiotropium Bromide 1 CAP IH DAILY
11. Gabapentin 600 mg PO BID
12. irbesartan 300 mg oral DAILY
13. MetFORMIN (Glucophage) 500 mg PO BID
14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
15. Vitamin D 1000 UNIT PO DAILY
16. GuaiFENesin ___ mL PO Q6H:PRN cough
17. Aspirin 81 mg PO DAILY
18. ALPRAZolam 0.5 mg PO TID:PRN anxiety
Discharge Medications:
1. Cephalexin 500 mg PO Q12H
RX *cephalexin 500 mg 1 tablet(s) by mouth twice a day Disp #*8
Tablet Refills:*0
2. Cyclobenzaprine 5 mg PO BID:PRN back/neck pain or spasm
RX *cyclobenzaprine 5 mg 1 tablet(s) by mouth twice a day Disp
#*6 Tablet Refills:*0
3. OxyCODONE (Immediate Release) ___ mg PO BID:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg 1 capsule(s) by mouth twice a day Disp #*20
Capsule Refills:*0
4. Sulfameth/Trimethoprim DS 2 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*8 Tablet Refills:*0
5. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob
6. ALPRAZolam 0.5 mg PO TID:PRN anxiety
7. Ascorbic Acid ___ mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Chlorthalidone 25 mg PO DAILY
10. Daliresp (roflumilast) 500 mcg oral DAILY
11. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
12. GuaiFENesin ___ mL PO Q6H:PRN cough
13. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB, wheeze
14. irbesartan 300 mg oral DAILY
15. MetFORMIN (Glucophage) 500 mg PO BID
16. Metoprolol Succinate XL 150 mg PO DAILY
17. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
18. Omeprazole 20 mg PO DAILY
19. Rosuvastatin Calcium 40 mg PO QPM
20. Tiotropium Bromide 1 CAP IH DAILY
21. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Cellulitis
Secondary Diagnoses:
Multilevel degenerative cervical spine disease
___
DM
COPD
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___
because you were experiencing severe pain, along with multiple
other symptoms. While you were here, we performed multiple
imaging studies to help evaluate what the source of your pain
was. Based on these studies, we found that there was some bony
loss of the bones in your spine, which may be contributing to
your pain. You were feeling much better by the time you were
discharged.
We also treated you with antibiotics for a skin infection on
your arm, which was improving during your hospitalization.
It is important that you continue taking your medications as
prescribed.
It was a pleasure caring for you!
Your ___ Care Team
Followup Instructions:
___
|
10679582-DS-18
| 10,679,582 | 21,145,327 |
DS
| 18 |
2124-10-07 00:00:00
|
2124-10-07 13:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old lady with a history of IgM lambda
restricted neoplasm with plasmacytic differentiation refractory
to multiple treatments, who was transferred from ___
___ for altered mental status, found to have GNR bacteremia
of unclear source.
Patient reportedly found to be sleeping next to dumpster at her
house by neighbor, unable to recognize surroundings and did not
know her son's phone number, but was able to speak in full
sentences. At baseline lives alone, walks without assistance,
able to cook, do chores, and pay her own bills. Neighbor called
EMS, who took her to ___.
She returned to baseline in CHA ED after ~1 hour of confusion.
Primary oncologist Dr. ___ was contacted, and he requested
that patient be transferred to ___ for plasmapheresis. Last
plasmapheresis was on ___. CTH performed in CHA ED
reportedly was unremarkable, but BCx with ___ bottles of GNR.
She was unable to go to ___ due to bed unavailability and hence
was routed to ___.
In ED initial VS: 98.6 104/58 16 98% RA
Exam: CN III-XII intact, strength ___ throughout, sensation to
light touch intact, normal cerebellar testing and gait, CTAB,
RRR.
She had fever to Tmax of 103 degrees but remained
hemodynamically stable. In the setting of fevers she had waxing
and waning episodes of confusion (~1:30 AM forgot where she was
and urinated on self, another episode at 4:00 AM).
Labs significant for:
WBC 3.7 Hgb 6.8 Plt 49
Na 141 K 4.1 Cl 100 CO2 26 BUN 28 Cr 1.5
AST 8 ALT 11 AP 49 LDH 158 Tbili 0.3 Alb 3.2 TP 7.6
Hapto 109
Free Kappa/Free lambda/IgM pending
Influenza A/B PCR negative
Lactate 1.8
Flu PCR negative
VBG 7.51/35/29 (pH/pCO2/HCO3)
No LP was performed given significant thrombocytopenia
Patient was given:
- NS 2.5L
- Vancomycin 1000 mg IV once
- Ceftriaxone 1 g IV x 2
- Ampicillin 2 g IV q4H
Imaging notable for:
- CTH without contrast:
1. No evidence of mass, hemorrhage or infarction.
2. Numerous lytic lesions throughout the calvarium and in the
right mandibular condyle are suspicious for myeloma lesions.
3. Complete opacification of the right mastoid air cells. This
finding is nonspecific, but can be seen in mastoiditis.
4. Additional paranasal sinus inflammatory changes.
- MR head and MRA neck with and without contrast:
1. Multiple enhancing lesions at the right skullbase involving
the petrous apex, right Meckel's cave, right occipital condyle,
right mandibular condyle/ramus with adjacent soft tissue
involvement of the medial pterygoid and masseter muscles. Of
note, there is expansion and evidence of cortical destruction of
the right mandibular condyle. Findings are suspicious for
metastatic disease.
2. Evidence of associated compression of the right sigmoid sinus
without occlusion.
3. Numerous enhancing cervical spine and calvarial lesions
compatible with metastatic disease, likely representing multiple
myeloma.
4. Complete opacification the right mastoid air cells can be
seen in setting of mastoiditis.
5. Normal MRA head and neck.
6. Evidence of mild white matter chronic small vessel disease.
CXR ___
Mild interstitial edema. No definite focal consolidation.
Consults:
- Neurology: Most concerning for toxic metabolic encephalopathy
in setting of underlying malignancy and infection. MRI/MRA can
be performed but unlikely to show stroke.
- Heme/onc: ___ be related to hyperviscosity syndrome versus
toxic metabolic encephalopathy, would pull pheresis catheter and
follow up labs. No strong feeling about LP.
VS prior to transfer: 103.2 121 110/41 97% RA
On arrival to the MICU, patient was sleepy but arousable to
voice. She was able to answer yes/no questions but would doze
off mid-conversation. Knew that she was in a hospital.
Of note, 2 weeks ago she developed symptoms of a cough
productive of white sputum, and also had recent admission to ___
___ for TLS in setting of venetoclax initiation. Other past
infections include pneumonia in ___ treated with
levofloxacin, and in ___ had vaginal/labial soft tissue with
doxycycline.
Per heme/onc note, most recent labs from ___ ___
demonstrate:
WBC 2.63, ANC 1.51, Hb 8.3, Hct 24.5, plt 91, BUN/Cr ___ (0.9
on ___. Ca 9.5, P 4.0, Uric acid 3.6, Total protein 9.5,
Albumin 3.5, Globulin 6.0, LDH 169, IgG<40, IgA<5, IgM 5950.
Also of note, reportedly she is usually not symptomatic from
hyperviscosity until IgM > 8000 mg/dL, and typical symptoms are
weakness, fatigue, bilateral foot pain/neuralgia.
Past Medical History:
ONCOLOGIC HISTORY:
- ___: Presented with anemia, found to high protein level IGM
> 3000 mg/dl., wbc 6.7, Hb 10.5. SPEP showed 3.5 g/dl monoclonal
spike, immunofixation c/w IgM lambda monoclonal band.
- ___: Bone marrow aspirate and biopsy showed moderately
hypercellular marrow with > 80% involvement by diffuse
monotonous population of plasma cells with irregular nuclei,
dispersed chromatin and prominent nucleoli. Immunoperoxidase
studies showed monotypic cytoplasmic reactivity with CD 138
positive plasma cells for lambda light chain. Flow cytometric
analysis showed a monotypic B cell population positive for CD19,
CD20, FMC7, CD23, and lambda positive. Orginal gain on plasma
cells showed that they are psotivie for CD138, CD38, negative
fro CD19, CD20, CD56. MYD88 mutation was sent to ___ and was
reportedly negative, although her patologists determined that
this is a hematopoietic neoplasm with predominantly plasmacytic
differentiation. Although there are clonal B cells and clonal
plasma cells which questions possibility of lymphoplasmacytic
lymphoma, pathologists favor MM.
- ___: Started revlimid/bortezomib/dexamethasone.
- ___: VWD screening demonstrated low levels
- ___: C1 CyBorD therapy started
- ___: PET: 5.0 x 6.9z 8.7 cm circumscribed ovoid gluteal
mass (later upon biopsy identified as benign nerve sheath tumor)
- ___: Plasmapheresis
- ___: CyBorD
- ___: Bendamustine/Rituxan
- ___: Daratumumab
- ___: Carfilzomib, dexamethasone, lenalidomide (CaRD)
- ___: elotuzumab, lenalidomide, dexamethasone
- ___: Ixazomib/melphalan/prednisone (C2 delayed ___ PNA)
- S/p C2 Everolimus
- Retinal hemorrhages identified
- Discussed auto-transplant with Dr. ___ and
son/patient agreed to defer
- ___: C1 ixazomib 4 mg/venetoclax 200 mg/dexamethasone 20
mg
- ___: Evidence of TLS on labs, admitted for TLS s/p 1 dose
rasburicase, received allopurinol. Ventoxlax dose reduced to 200
mg on ___
- ___: Disease progression requiring multiple plasmapheresis
- ___: Venetoclax dose increased to 400 ___
MEDICAL & SURGICAL HISTORY:
Multiple myeloma (followed by DFCI/DWH, receives weekly
pheresis on ___
Anemia
Hypertension
Diabetes mellitus
Hyperlipidemia
Tumor Lysis Syndrome
Ocular hemorrhages
Peripheral neuropathy
Acute Kidney Injury
Fever
Pancytopenia
VWD
Senile osteoporosis
Astigmatism
Low Back Pain
Colonic Polyps
Social History:
___
Family History:
Mother- ___
Father- DM
Sister- ___ cancer
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
===========================
VITALS: Reviewed in ___
GENERAL: Alert, oriented, sleepy and drifts off mid-conversation
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Crackles in bilateral bases R>L
CV: R pheresis port site c/d/I, Regular rate and rhythm, normal
S1 S2, ___ SEM at LSB
ABD: soft, mildly TTP in RUQ, 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 appreciated
NEURO: CN II-XII intact, AO x 2 (self, hospital, month), moves
all four extremities symmetrically and with purpose, strength
___ throughout, cerebellar testing not assessed
PHYSICAL EXAM ON DISCHARGE:
===========================
Vitals: 98.5PO 132 / 70 62 16 100% RA
General: Well-appearing, well nourished, in no acute distress.
Heent: PERRLA. EOMI Anicteric sclerae. Oropharynx without
erythema or exudate.
Neck: Supple without thyromegaly or adenopathy.
Heart: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops.
Lungs: Clear to auscultation bilaterally without rhonchi,
rales,
or wheezes. Normal respiratory effort.
Abdomen: Soft, nontender, nondistended, normoactive bowel
sounds
throughout. No hepatosplenomegaly.
Skin: Skin type V. No significant lesions or eruptions.
Extremities: Warm, well perfused, trace peripheral edema.
Neuro: Alert and oriented x3. No gross focal deficits.
Access: port clean, dry
Pertinent Results:
LAB RESULTS ON ADMISSION:
=========================
___ 09:13PM BLOOD WBC-5.8 RBC-2.16* Hgb-6.5* Hct-19.7*
MCV-91 MCH-30.1 MCHC-33.0 RDW-17.0* RDWSD-55.4* Plt Ct-62*
___ 09:13PM BLOOD Neuts-79* Bands-5 Lymphs-8* Monos-7 Eos-1
Baso-0 ___ Myelos-0 AbsNeut-4.87 AbsLymp-0.46*
AbsMono-0.41 AbsEos-0.06 AbsBaso-0.00*
___ 09:13PM BLOOD Plt Smr-VERY LOW* Plt Ct-62*
___ 01:10PM BLOOD SerVisc-2.1*
___ 03:33AM BLOOD VWF AG-320* VWF ___
___ 09:13PM BLOOD Glucose-155* UreaN-28* Creat-1.5* Na-141
K-4.1 Cl-100 HCO3-26 AnGap-15
___ 09:13PM BLOOD ALT-11 AST-8 LD(LDH)-158 AlkPhos-49
TotBili-0.3
___ 09:13PM BLOOD TotProt-7.6 Albumin-3.2* Globuln-4.4*
Calcium-8.7 Phos-4.5 Mg-2.0
___ 09:13PM BLOOD PEP-AWAITING F FreeKap-0.8* FreeLam-1816*
Fr K/L-0.00* IgG-LESS THAN IgA-LESS THAN IgM-5195* IFE-PND
___ 05:55AM BLOOD Tobra-1.6*
___ 06:43AM BLOOD ___ pO2-34* pCO2-35 pH-7.51*
calTCO2-29 Base XS-4 Intubat-NOT INTUBA
___ 06:43AM BLOOD O2 Sat-66
DISCHARGE LABS:
===============
___ 05:18AM BLOOD WBC-3.7* RBC-1.93* Hgb-5.8* Hct-18.4*
MCV-95 MCH-30.1 MCHC-31.5* RDW-17.5* RDWSD-60.9* Plt Ct-55*
___ 05:18AM BLOOD ___ PTT-30.4 ___
___ 01:10PM BLOOD SerVisc-2.1*
___ 03:33AM BLOOD SerVisc-2.0*
___ 11:34AM BLOOD SerVisc-2.4*
___ 07:54AM BLOOD SerVisc-2.8*
___ 09:30AM BLOOD SerVisc-3.1*
___ 06:25AM BLOOD SerVisc-2.9*
___ 03:33AM BLOOD FacVIII-138
___ 03:33AM BLOOD VWF AG-320* VWF ___
___ 05:18AM BLOOD Glucose-104* UreaN-13 Creat-0.8 Na-144
K-3.9 Cl-109* HCO3-20* AnGap-15
___ 05:18AM BLOOD ALT-22 AST-9 LD(___)-218 AlkPhos-57
TotBili-0.2
___ 05:18AM BLOOD TotProt-8.2 Albumin-2.8* Globuln-5.4*
Calcium-8.6 Phos-2.8 Mg-2.0
___ 09:13PM BLOOD PEP-ABNORMAL B FreeKap-0.8* FreeLam-1816*
Fr K/L-0.00* IgG-LESS THAN IgA-LESS THAN IgM-5195*
IFE-MONOCLONAL
___ 03:33AM BLOOD IgM-___*
___ 05:55AM BLOOD IgG-<40* IgA-<5* IgM-4998*
___ 05:35AM BLOOD IgM-5342*
___ 07:54AM BLOOD IgM-5802*
___ 09:30AM BLOOD IgM-6258*
___ 06:25AM BLOOD IgM-___*
___ 05:18AM BLOOD IgM-6000*
MICROBIOLOGY:
=============
Blood Culture, Routine COLLECTED ___
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 11:00 am BLOOD CULTURE: NO GROWTH
___ 2:38 pm CATHETER TIP-IV WOUND CULTURE (Final
___: No significant growth.
___ 5:35 am BLOOD CULTURE, NO GROWTH TO DATE
___ 7:00 pm BLOOD CULTURE Blood Culture, NO GROWTH TO DATE
IMAGING:
=========
CT HEAD ___:
1. No evidence of mass, hemorrhage or infarction.
2. Numerous lytic lesions throughout the calvarium and in the
right mandibular
condyle are suspicious for myeloma lesions.
3. Complete opacification of the right mastoid air cells. This
finding is
nonspecific, but can be seen in mastoiditis.
4. Additional paranasal sinus inflammatory changes.
MRI BRAIN ___:
1. Multiple enhancing lesions at the right skullbase involving
the petrous
apex, right Meckel's cave, right occipital condyle, right
mandibular
condyle/ramus with adjacent soft tissue involvement of the
medial pterygoid
and masseter muscles. Of note, there is expansion and evidence
of cortical
destruction of the right mandibular condyle. Findings are
suspicious for
metastatic disease.
2. Evidence of associated compression of the right sigmoid sinus
without
occlusion.
3. Numerous enhancing cervical spine and calvarial lesions
compatible with
metastatic disease, likely representing multiple myeloma.
4. Complete opacification the right mastoid air cells can be
seen in setting
of mastoiditis.
5. Normal MRA head and neck.
6. Evidence of mild white matter chronic small vessel disease.
CTA ABDOMEN PELVIS ___:
1. Numerous small lucent lesions are noted throughout the imaged
osseous
structures, compatible with the patient's history of multiple
myeloma.
2. A large lucent lesion with associated marrow replacement,
cortical thinning and posterior cortical discontinuity is seen
in the proximal left femur. This places the patient at
significant risk for pathologic fracture, and consideration of
nonweightbearing status is recommended.
3. Heterogeneously enhancing soft tissue mass adjacent to the
proximal left femur is not imaged in its entirety on this study.
Recommend further
evaluation with comparison to prior studies and contrast
enhanced MRI of the left femur.
4. Small bilateral pleural effusions.
5. No acute process in the abdomen or pelvis.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a history of IgM lambda
restricted neoplasm with plasmacytic differentiation refractory
to multiple treatments, who was transferred from ___
___ for altered mental status, found to have high grade E.
coli bacteremia of unclear source s/p L pheresis catheter
removal, and incidental finding of L IJ thrombus.
ED course ___
================
In the ED, neurology was consulted for evaluation of altered
mental status. She received CTH without contrast which did not
demonstrate mass, hemorrhage or infarction, but with
opacification of R mastoid air cells. MR head and MRA neck
without contrast was also pursued with findings of mild white
matter chronic small vessel disease, enhancing cervical spine
and calvarial lesions compatible with metastatic disease, as
well as enhancing lesions at the right skullbase. She developed
fever to Tmax of 103. Given altered mental status and low
platelets count of 39-49, it was felt that LP was
contraindicated, and she was covered empirically with vancomycin
1000 mg + ceftriaxone 1 g IV x 2, and ampicillin 2 g due to
concern for meningitis. Heme/onc was consulted due to concern
for hyperviscoscity contributing to altered mental status but as
IgM level was ~5000, below the threshold for which she typically
experiences symptoms, pheresis was not pursued.
During ED course, blood cultures from CHA returned as positive
for ___ bottles of GNR, with time to positivity of ~8 hours. Due
to concern that his pheresis cathether could be source of her
bacteremia, it was removed in the ED and catheter tip was sent
for culture. She received 2.5L NS.
MICU course ___
=======================
On admission to the MICU, patient initially had persistently
altered mental status, dozing off mid-sentence, but no focal
neurologic findings. Due to concern for sepsis from high grade
GNR bacteremia, antibiotics were initially broadened to
vancomycin + cefepime + ampicillin, and she received 1 dose of
tobramycin for double coverage. MAPs were initially in ___, and
she received further fluid resuscitation with subsequent
improvement to MAPs of ___.
Despite CT/MRI findings, mastoditis was thought to be unlikely
given absence of symptoms, and urine cultures returned as
negative. To further investigate source of bacteremia, she
received CT A/P to evaluate for abdominal source (unrevealing
for source) as well as bilateral UE ultrasounds to look for
thombus as nidus of infection (nonocclusive thrombus in the left
internal jugular vein). No anticoagulation for LIJ thrombus was
pursued given persistent thrombocytopenia. On the morning of
___, mental status improved to baseline, hence antibiotics
were de-escalated to cefepime. Infectious diseases was consulted
because of concern for seeding of port, and recommended removal
of R portacath.
Course was complicated by anemia with Hgb ~6 which was
significantly off of her recent baseline of 8, so was transfused
1 U only as per heme/onc in order to prevent significant
elevation in viscosity. No evidence of significant
hyperviscocity hence pheresis continued to be deferred. She was
transferred to the floor in stable condition.
Oncology medicine course ___
====================================
She was transferred to the oncology floor in stable condition.
#E.coli bacteremia
Patient presented with fever and AMS found to have GNR
bacteremia at outside hospital initially treated with broad
spectrum as meningitis could not be ruled out as LP
contraindicated with low platelets. E. coli grew from admission
Bcx of unclear source as UA negative and CT A/P without
explanation. Patient had L IJ thrombus, pheresis line was
removed on ___ given concern for source of infection. Port was
left in place and patient has been receiving antibiotic locks in
port. Can consider removal of port given concern for seeding.
Treated initially with cefepime (___) transitioned to
ceftriaxone (___). Patient will require prolonged course of
abx therapy given presence of intravascular thrombus, likely 4
weeks. Also receiving Ceftazadime port antibiotic locks.
#Multiple myeloma
Patient with IgM level 6033 on ___ and viscocity 2.9. Per
patient she usually becomes symptomatic with IgM at 8000.
Pheresis catheter was removed on ___ for source control of GNR
bacteremia. Cultures were clear as of ___, pheresis catheter
was replaced on ___ following discussion with Dr. ___.
She did not receive pheresis during this admission. She was
continued on home Ixazomib, Venetoclax, Dexamethasone.
#Anemia
Pt was found to have anemia with Hgb ~6 which was significantly
off of her recent baseline of 8. Patient received 1unit pRBCs on
___. Held additional transfusions in setting of
hypedrviscocity. H/H at time of transfer 5.___.9, patient
asymptomatic. Patient will need additional blood transfusions
following pheresis.
#Thrombocytopenia
Likely ___ her disease and chemotherapy agents, as did not have
indices suggestive of hemolysis. She received one unit of
platelets on ___ prior to placement of pheresis catheter. DVT
ppx held given platelets <50.
#Left IJ thrombus
Identified during duplex of upper extremity while looking for
source of bacteremia. Of note, patient had tunneled pheresis
catheter on that side so may have had slower drainage in IJ as a
result. Patient was not anticoagulated after identification. She
remained thrombocytopenic, anticoagulation contraindicated at
current plt level.
#Risk of fracture ___ femur erosion by soft tissue mass
CT of A/P ordered for ID workup identified a large lucent lesion
with associated marrow replacement, cortical thinning and
posterior cortical discontinuity seen in the proximal left femur
which places the patient at significant risk for pathologic
fracture. A heterogeneously enhancing soft tissue mass adjacent
to the proximal left femur was seen as well and was thought to
be related to her malignancy. Outside records from ___
show left femur lesions, unclear if soft tissue mass is new.
Consider orthopedics consultation.
Additional information for transfer to ___ (also verbally
communicated to Dr. ___: Resistant ___ has been
detected recently on this ___ medical floor. The patient
on has been cared for on Contact Precautions at ___ out of an
abundance of caution. ___ has not been isolated in any of
this patients clinical specimens and she has no current signs
of infection. If she develops clinical signs of infection and a
yeast infection is on the differential, would consider including
coverage for ___ auris, a multidrug-resistant strain, with
an echinocandin.
#HCP/Contact: son ___ ___
#Code: Full confirmed
TRANSITIONAL ISSUES:
====================
[ ] New pheresis line placed on ___. Last positive blood
culture ___.
[ ] Continued home Ixazomib (received weekly dose on ___ and
Venetoclax.
[ ] Ensure treatment for E.coli bacteremia, given presence of
thrombus infectious disease is recommending at least 4 week
course of antibiotics.
[ ] Patient with L IJ thrombus, associated pheresis line removed
on ___. Anticoagulation not initiated given low platelets.
[ ] Patient with anemia, plan for transfusion in conjunction
with pheresis.
[ ] Consider removal of port given concern for seeding following
bacteremia. Given patient afebrile with negative surveillance
cultures, port was left in place and antibiotic locks have been
used.
[ ] Lytic lesions of left femur with adjacent soft tissue mass,
correlate with prior imaging and consider orthopedics
consultation.
[ ] Lytic lesions of calvarium, correlate with prior imaging
[ ] DVT ppx held given low platelets
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. ixazomib 4 mg oral 1X/WEEK
2. Acyclovir 400 mg PO DAILY
3. Allopurinol ___ mg PO DAILY
4. venetoclax 400 mg oral DAILY
5. Dexamethasone 4 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
8. MetFORMIN (Glucophage) 500 mg PO BID
9. Atenolol 50 mg PO DAILY
10. Hydrochlorothiazide 25 mg PO DAILY
11. Famotidine 20 mg PO BID
Discharge Medications:
1. CefTAZidime-Heparin Lock 1.25 mg LOCK PRN port
2. CefTRIAXone 2 gm IV Q 24H
3. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
4. Acyclovir 400 mg PO Q12H
5. Allopurinol ___ mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Dexamethasone 4 mg PO DAILY
8. Famotidine 20 mg PO BID
9. ixazomib 4 mg oral 1X/WEEK
10. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
11. venetoclax 400 mg oral DAILY
12. HELD- Atenolol 50 mg PO DAILY This medication was held. Do
not restart Atenolol until you no longer have an infection.
13. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until you no longer
have an infection.
14. HELD- MetFORMIN (Glucophage) 500 mg PO BID This medication
was held. Do not restart MetFORMIN (Glucophage) until you go
home.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary diagnosis: High grade E. coli bacteria bloodstream
infection
Secondary diagnosis: Hyperviscocity Syndrome, IgM Multiple
Myeloma
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. ___,
Why you were here?
- You were found to have an E. Coli blood stream infection.
What we did while you were here?
- You were treated with IV antibiotics
- We removed your pheresis line and gave you a new line.
You were then transferred to ___ where you
receive your medical care.
It was a pleasure taking care of you.
Your ___ Team
Followup Instructions:
___
|
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2160-03-31 00:00:00
|
2160-03-31 18:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
s/p assault
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: ___ ___ speaking transferred from ___ s/p
assault. Patient was apparently punched and hit with a bottle in
his face and head. Initially in ED at OSH was agitated and
combative, got repeated sedation and was eventually intubated
after several hours in ED before being transferred. Found to
have
small left sided SAH on CT head prior to transfer. The CT scan
of
his C-spine was read as negative. Small nasal fracture noted on
CT.
Past Medical History:
None per OMR
Social History:
___
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
VSS
Gen: Sedated/intubated
HEENT: Pupils: Reactive bilaterally, good cough and gag reflex
Neck: Patient in hard collar
Extrem: Warm and well-perfused. No C/C/E.
Neuro:Mental status: Sedated/intubated
Motor: Normal bulk and tone bilaterally. Withdraws all
extremities to noxious stimuli, purposeful movement in all
extremeites.
Labs: Na:147 K:3.4 Cl:110 TCO2:20 Glu:117 Lactate:4.1
WBC: 16.1, Hgb: 14.2, Hct: 40.6, Plt: 280
___: 12.4 PTT: 28.1 INR: 1.1
Etoh: 80 Urine: Pos for Benzo
Reapeat Head CT Impression:
1. Subarachnoid hemorrhage in the left frontal lobe, not
significantly changed from the prior exam.
2. Small 5 mm focal extra-axial hemorrhage along the left
temporal lobe, likely subdural hemorrhage, also not
significantly
changed.
3. Some apparent effacement of the left lateral ventricle may be
from edema within the left temporal and frontal lobes, though it
may represent a congenital/developmental asymmetry. Close
interval follow-up is recommended.
4. Nondisplaced right occipital fracture extending into the
occipital condyle.
PHYSICAL EXAM ON DISCHARGE:
VSS
Gen: Awake, no acute distress
HEENT: Pupils: Reactive bilaterally
Extrem: Warm and well-perfused.
Neuro:Mental status: A&Ox3, CN II -XII grossly intact. No neuro
deficits noted.
Motor: Strength full in upper and lower extremeties
Pertinent Results:
___ CT head:
1. Subarachnoid hemorrhage in the left frontal lobe, not
significantly
changed from the prior exam.
2. Small 5 mm focal extra-axial hemorrhage along the left
temporal lobe,
likely subdural hemorrhage, also not significantly changed.
3. Some apparent effacement of the left lateral ventricle may
be from edema within the left temporal and frontal lobes, though
it may represent a congenital/developmental asymmetry. Close
interval follow-up is recommended.
4. Nondisplaced right occipital fracture extending into the
occipital
condyle.
___ CT head Impression:
1.Stable appearing subarachnoid hemorrhage within the left
frontal lobe. No new hemorrhage identified.
2.Stable appearing right occipital fracture which spares the
occipital
condyles.
___ 01:55PM GLUCOSE-90 UREA N-6 CREAT-0.7 SODIUM-145
POTASSIUM-3.5 CHLORIDE-113* TOTAL CO2-23 ANION GAP-13
___ 01:55PM CALCIUM-7.3* PHOSPHATE-3.4 MAGNESIUM-1.6
___ 01:55PM WBC-14.7* RBC-4.52* HGB-12.7* HCT-38.6*
MCV-85 MCH-28.0 MCHC-32.8 RDW-13.9
___ 01:55PM PLT COUNT-268
___ 01:55PM ___ PTT-29.5 ___
___ 08:35AM TYPE-ART O2-100 PO2-487* PCO2-40 PH-7.30*
TOTAL CO2-20* BASE XS--5 AADO2-190 REQ O2-40 INTUBATED-INTUBATED
VENT-CONTROLLED
___ 08:35AM LACTATE-3.8*
___ 08:02AM COMMENTS-GREEN TOP
___ 08:02AM GLUCOSE-117* LACTATE-4.1* NA+-147* K+-3.4
CL--110* TCO2-20*
___ 08:02AM O2 SAT-90
___ 07:50AM UREA N-7 CREAT-0.8
___ 07:50AM estGFR-Using this
___ 07:50AM LIPASE-17
___ 07:50AM ASA-NEG ETHANOL-80* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 07:50AM URINE HOURS-RANDOM
___ 07:50AM URINE HOURS-RANDOM
___ 07:50AM URINE GR HOLD-HOLD
___ 07:50AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 07:50AM WBC-16.1* RBC-4.86 HGB-14.2 HCT-40.6 MCV-84
MCH-29.3 MCHC-35.0 RDW-13.5
___ 07:50AM PLT COUNT-280
___ 07:50AM ___ PTT-28.1 ___
___ 07:50AM ___
___ 07:50AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-100 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
Brief Hospital Course:
Mr. ___ was admited to the ICU, observed overnight and
subsequently transferred to the floor when a repeat head CT
showed a stable left frontal hemorrhage.
His cervical spine was cleared after he was extubated. On ___
he had a repeat head CT which showed the same small stable SAH
within the left frontal lobe and right occipital fracture. On
___ he had yet another repeat head CT which still showed the
same small stable SAH within the left frontal lobe and right
occipital fracture. On ___ he was completely neuro intact. He
met criteria for discharge and was release with instructions to
remain on dilantin for the full 10 days and to return for follow
up appointment with CT scan in 4 weeks.
Medications on Admission:
None
Discharge Medications:
1. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth Every ___ hours as
needed for headaches/pain control Disp #*30 Tablet Refills:*0
2. Phenytoin Infatab 100 mg PO TID
RX *phenytoin 100 mg/4 mL 4 ml by mouth Three times daily for
seizure prevention. Disp ___ Milliliter Refills:*0
3. Acetaminophen 325-650 mg PO Q6H:PRN pain
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth Twice daily as
needed for constipation Disp #*14 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left miniscule frontal Subarrachnoid hemorrhage
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.
**You have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCPs office, but please have the results faxed to ___.
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:
___
|
10680081-DS-7
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2138-11-15 00:00:00
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2138-11-16 15:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Dapsone / Strawberry / lanilon / Oysters / Provocholine /
Tegaderm Transparent Dressing
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___: 8 mm TIPS placed; Lysis catheter removed
removed
___: Transjugular transheptic SMV lysis catheter placement
History of Present Illness:
___ PMHx bullous pemphigoid, HTN, and HLD presents as
transfer from ___ w/ c/o three days of diffuse abdominal
pain and bloody diarrhea w/ CT findings at ___ concerning
for
mesenteric ischemia due to venous thrombosis extending into the
portal vein with small bowel edema and free fluid concerning for
bowel ischemia. Patient reports she had mild abdominal pain
starting ___ and assumed it was constipation and so took
laxatives. She then began having large volume bloody diarrhea on
___ and ___. As of now, she continues to have loose
bowel movements but they are no longer bloody. She has had poor
solid PO due to abdominal pain, but is tolerating fluids. She
presented to ___ this morning because her abdominal
pain continued to worsen, and she was noted to having rebound
and
guarding on abdominal exam.
Patient is a former smoker and denies any previous vascular
disease, blood clots, or hormone replacement therapy. Patient
otherwise denies fevers/chills, nausea/vomiting, chest pain/SOB,
lightheadedness/dizziness. Her lactate at the OSH was 1.3, WBC
10.2, and Hct 42.
Past Medical History:
___: HLD, HTN, pemphigoid, colonic adenoma last colonoscopy
___, osteoporosis
PSHx: BUNIONECTOMY, no prior abdominal operations
Social History:
___
Family History:
amily History Hx:
-no family history of hypercoagulable disorders
-no family history of GI malignancy or IBD
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
Vitals - T 99.3 / HR 92 / BP 123/85 / RR 20 / O2sat 96% RA
General - comfortable, NAD
HEENT - PERRLA, EOMI, moist mucous membranes
Cardiac - RRR, no M/R/G
Chest - CTAB
Abdomen - soft, diffusely tender, positive rebound and guarding,
nondistended
Extremities - warm and well-perfused
Neuro - A&OX3
DISCHARGE PHYSICAL EXAM:
=======================
General - NAD
HEENT - PERRLA, EOMI, moist mucous membranes
Cardiac - RRR, no M/R/G
Chest - CTAB
Abdomen - soft, mildly tender, no rebound, no guarding
Extremities - warm and well-perfused
Neuro - A&OX3
Pertinent Results:
ADMISSION LABS:
===============
___ 03:15PM BLOOD WBC-9.6 RBC-4.97 Hgb-13.9 Hct-40.8 MCV-82
MCH-28.0 MCHC-34.1 RDW-13.1 RDWSD-39.1 Plt ___
___ 03:15PM BLOOD Neuts-78.9* Lymphs-12.2* Monos-7.7
Eos-0.2* Baso-0.6 Im ___ AbsNeut-7.55* AbsLymp-1.17*
AbsMono-0.74 AbsEos-0.02* AbsBaso-0.06
___ 03:15PM BLOOD ___ PTT-150* ___
___ 03:15PM BLOOD Glucose-104* UreaN-13 Creat-0.7 Na-142
K-3.9 Cl-109* HCO3-19* AnGap-14
___ 03:15PM BLOOD ALT-85* AST-36 AlkPhos-64 TotBili-0.6
___ 03:15PM BLOOD Albumin-3.5
___ 10:32PM BLOOD ___ pO2-68* pCO2-44 pH-7.34*
calTCO2-25 Base XS--2 Comment-GREEN TOP
DISCHARGE LABS:
==================
___ 04:15AM BLOOD WBC-7.6 RBC-3.65* Hgb-10.1* Hct-31.0*
MCV-85 MCH-27.7 MCHC-32.6 RDW-13.2 RDWSD-41.1 Plt ___
___ 11:21AM BLOOD ___ PTT-40.5* ___
___ 04:15AM BLOOD Glucose-116* UreaN-10 Creat-0.6 Na-141
K-4.3 Cl-104 HCO3-25 AnGap-12
___ 04:15AM BLOOD ALT-70* AST-23 AlkPhos-73 TotBili-0.4
___ 04:15AM BLOOD Calcium-8.4 Phos-2.7 Mg-1.9
IMAGING:
========
CAT SCAN - CT ABD & PEL ___
IMPRESSION:
1. Findings consistent with mesenteric vein thrombosis in the
right lower quadrant with extension of thrombus to the main
Portal
vein. Marked bowel wall edema with associated free fluid and
mesenteric stranding is noted concerning for bowel ischemia
secondary to
the thrombosis. No definite evidence for feeding mesenteric
artery
cutoff however study is suboptimal on this non arteriographic
phase and would be better assessed on dedicated angiogram.
2. Portal vein thrombosis with extension to the right and left
main portal branches as above.
3. Small amount of perihepatic, pelvic, and mesenteric free
fluid. No frank free air.
4. Bibasilar opacities, left greater than right with trace
bilateral pleural effusions.
FINDINGS:
1. Right basilic vein double-lumen PICC tip in the superior vena
cava.
2. Pre-TIPS right atrial pressure of 20 .
3. CO2 portal venogram failed to show portal veins.
4. Contrast portal venogram showing nonocclusive thrombus
within the portal veins.
5. Venogram of 2 superior mesenteric vein branches, ultimately
demonstrated
thrombus within 1 branch extending into the portal veins.
6. Post procedure ultrasound.
PORTAL VENOGRAPHY
Study Date of ___ 5:48 ___
IMPRESSION:
Technically successful right internal jugular access with
transjugular
transhepatic placement of a superior mesenteric vein lysis
catheter using a 65 cm, 5 cm infusion length ___
infusion catheter.
Successful placement right basilic vein double lumen PICC with
tip in the
superior vena cava. OK to use immediately.
___ Portable CXR
IMPRESSION:
In comparison with the study of ___, there are
lower lung
volumes, which may account for some of the increased prominence
of the cardiac
silhouette. Indistinctness of pulmonary vessels is consistent
with some
elevation of pulmonary venous pressure. Retrocardiac
opacification with
obscuration of the hemidiaphragm is consistent with substantial
volume loss in
the left lower lobe and small pleural effusion.
Right subclavian PICC line extends to the lower SVC.
___ PORTAL VENOGRAPHY
FINDINGS:
1. Superior mesenteric venogram demonstrates patent superior
mesenteric vein
with hepatopetal flow. Patent right portal vein with residual
thrombus in the
left portal vein.
2. Pre-TIPS portal pressure measurement of 13 mm Hg.
3. Post-TIPS portal venogram showing brisk antegrade flow
through the TIPS
with residual thrombus in the left portal vein.
4. Post-TIPS right atrial pressure of 8 mm Hg and portal
pressure of 13 mm Hg
resulting in portosystemic gradient of 5 mmHg.
IMPRESSION:
Successful right internal jugular approach lysis catheter check
and
transjugular intrahepatic portosystemic shunt placement with
porto-systemic
pressure gradient of 5 mm Hg following TIPS placement.
RECOMMENDATION(S): 1. Continue heparin drip with goal PTT of
60-90.
MICROBIOLOGY:
=============
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
Ms ___ was transferred to this ___ with complaints
of abdominal pain, and extensive thrombosis of the portal vein
and SMV, and ischemic bowel changes on CT scan but no frank sign
of perforation or necrosis.
She was taken to the ___ suite, and underwent a lysis catheter
placement via a transhepatic approach. She was taken to the
trauma ICU where she was started on cipro and flagyl and,
received TPA and heparinized saline through the lysis catheter
as well as systemic heparin through PICC line.
On ___, she was taken back to the ___ suite for a venogram
rate was found to have deep calcified cysts has been partially
successful and clot burden has decreased. The patient felt that
the pain has improved considerably and she was started on a
regular diet before going back to the ___ suite for final time on
___, where it was found that the clot burden has decreased
significantly, therefore the catheter was removed and a tips
stent was placed in case further intervention was indicated in
the future.
On ___, she was continuing systemic heparin tolerating a
regular diet. She will need a US for TIPS evaluation in one
week.
Hepatology service was consulted and recommended coagulopathy
workup which is pending at the time of discharge.
Transitional Issues:
[] Follow up INR (2.6 at discharge)
[] Follow up Beta-2-Glycoprotein 1 Antibodies, Cardiolipin
Antibodies
[] Patient needs an ultrasound in 1 week (from ___ to evaluate
patency of TIPS. Needs to follow up with ___ in ___
on ___ floor after ultrasound is done.
[] Test for consideration post-discharge: JAK2 V617F Mutation
Detection, Blood
Medications on Admission:
Alendronate 70mg weekly, amlodipine 10mg, cyclobenzaprine 10mg,
mycophenolate mofetil 250mg every other day, pravastatin 40mg,
aspirin 81mg daily,
Discharge Medications:
1. Rivaroxaban 15 mg PO BID Duration: 3 Weeks
RX *rivaroxaban [Xarelto] 15 mg 1 tablet by mouth twice a day
Disp #*40 Tablet Refills:*0
2. amLODIPine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Mycophenolate Mofetil 500 mg PO EVERY OTHER DAY
Discharge Disposition:
Home
Discharge Diagnosis:
Mesenteric and portal vein thrombosis
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 ___ and
underwent interventional radiology placement of a lysis catheter
and a TIPS procedure. You are recovering well and are now ready
for discharge. Please follow the instructions below to continue
your recovery:
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
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.
Warm regards,
Your ___ Surgery Team
Followup Instructions:
___
|
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|
2149-07-04 22:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ M with a history of rectal cancer on chemotherapy, who
presents with nausea, vomiting, and abdominal pain. The patient
states that over the past day, he has been experiencing
worsening
abdominal pain, nausea and vomiting. This caused him to present
to an outside hospital, where CT showed evidence of an SBO. On
review of systems, the patient states that he feels feverish and
has chills. He not report chest pain, shortness of breath, and
changes in bowel or bladder habits. He is unsure when he last
passed gas, but is not passing lots of gas.
In the ___, initial VS were 97.7 70 128/83 18 99% on RA.
Labs show H/H of 12.3/37.3. BMP WNL. Lactate 0.9.
He was seen in the ___ by colorectal surgery. They felt that
during his time, he was clinically improved with continued
flatus
and improved abdominal pain.
Unfortunately, the patient's evaluation by the ___ MD
was
delayed by several hours. When I go to evaluate the patient at
the start of my shift, he is extremely angry and upset that he
was told he would be seen by a doctor hours ago and that he had
requested pain medications without receiving them. He is not
interested in speaking at length about his presenting complaints
because he feels he is in too much pain and is too upset. He
states that he had acute onset abdominal pain approximately two
days. He describes it as abdominal soreness. He continues to
feel
nauseous with retching. To me, he denies flatus. He denies chest
pain, shortness of breath, back pain, dysuria, fevers, chills,
or
pain at the port site. He reports that he can not have a NG tube
because they tried to place one and it just resulted in blood
everywhere. He reports he can not have one at this time.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
PAST MEDICAL/SURGICAL HISTORY:
PAST ONCOLOGIC HISTORY:
Rectal Cancer stage IV KRAS w/t
- ___ Developed on and off abdominal discomfort
- ___ Presented to ___ with abdominal pain. CT
abdomen showed multiple liver lesions and a possible sigmoid
lesion.
- ___ MR abdomen showed similar findings consistent with
a
sigmoid/high rectal cancer and liver mets
- ___ Colonoscopy reveals a near obstructing rectal
mass.
Biopsies showed adenocarcinoma.
- ___ Liver biopsy showed metastatic adenocarcinoma
- ___ C1D1 CapeOx (Capecitabine 1500 mg BID D1-14,
Oxaliplatin 130 mg/m2 D1). CT chest showed multiple concerning
pulmonary nodules.
- ___ C2D1 CapeOx (Capecitabine 1500 mg BID D1-14,
Oxaliplatin 130 mg/m2 D1)
- ___ C3D1 CapeOx (Capecitabine 1500 mg BID D1-14,
Oxaliplatin 130 mg/m2 D1)
- ___ CT torso showed significant decrease in lung
nodules
- ___ Hold chemo for toxicity from capecitabine.
- ___ C1D1 FOLFOX6
- ___ C2D1 FOLFOX6
- ___ C1D1 de Gramont given oxali neuropathy
- ___ CT torso showed improved lung mets and rectal
primary, stable liver mets
- ___ C2D1 de Gramont ___ LV
- ___ C3D1 de Gramont ___ LV, delayed for the ___
- ___ C4D1 de Gramont ___ LV
- ___ C5D1 de Gramont ___ LV, delayed ___ insurance
issues
- ___ CT torso showed ongoing response to therapy
- ___ C6D1 de Gramont ___ LV
- ___ C7D1 de Gramont ___ LV
- ___ C8D1 de Gramont ___ LV
- ___ C9D1 de Gramont ___ LV
- ___ Held chemo per patient preference
- ___ CT torso showed stable disease
- ___ C10D1 de Gramont ___ LV
- ___ C11D1 de Gramont ___ LV delayed per patient
preference
- ___ C12D1 de Gramont ___ LV
- ___ CT torso shows stable disease
- ___ Start treatment break
- ___ CT torso showed stable disease
- ___ CT torso showed stable disease
- ___ CT torso showed stable disease
- ___ Colonoscopy shows stricture in the ___
MEDICAL HISTORY:
- Metastatic rectal cancer
- Incisional hernia
- Mesenteric clots on apixaban
- LAR, SBR, diverting loop ileostomy with Dr. ___ in
___ followed by uncomplicated ileostomy reversal ___
Social History:
___
Family History:
sister passed away from lung cancer at age ___.
Physical Exam:
ADMISSION EXAM:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert, appears very uncomfortable
EYES: Anicteric
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
Mucous membranes dry
CV: Heart regular, no murmur
RESP: Slightly tachypnea (in the setting of poorly controlled
pain), occasional expiratory wheeze
GI: Abdomen soft, tender to palpation in all quadrants with
involuntary guarding, no voluntary guarding
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM:
NEURO: Alert, oriented, moves all extremities
PSYCH: agitated, escalating
Pertinent Results:
___ 10:24AM BLOOD WBC: 4.0 RBC: 3.44* Hgb: 11.5* Hct: 34.2*
MCV: 99* MCH: 33.4* MCHC: 33.6 RDW: 14.2 RDWSD: 51.8* Plt Ct:
306
___ 01:00AM BLOOD WBC: 4.9 RBC: 3.67* Hgb: 12.3* Hct: 37.3*
MCV: 102* MCH: 33.5* MCHC: 33.0 RDW: 14.1 RDWSD: 53.2* Plt Ct:
311
___ 10:24AM BLOOD Neuts: 67.1 Lymphs: ___ Monos: 8.0 Eos:
0.3* Baso: 0.5 Im ___: 0.5 AbsNeut: 2.68 AbsLymp: 0.94*
AbsMono:
0.32 AbsEos: 0.01* AbsBaso: 0.02
___ 01:00AM BLOOD Neuts: 70.7 Lymphs: ___ Monos: 9.7 Eos:
0.0* Baso: 0.2 Im ___: 0.2 AbsNeut: 3.49 AbsLymp: 0.95*
AbsMono:
0.48 AbsEos: 0.00* AbsBaso: 0.01
___ 01:00AM BLOOD ___: 11.4 PTT: 25.4 ___: 1.1
___ 10:24AM BLOOD Glucose: 97 UreaN: 12 Creat: 0.8 Na: 140
K: 4.4 Cl: 104 HCO3: 27 AnGap: 9*
___ 01:07AM BLOOD Lactate: 1.6
___ 10:24AM BLOOD Lactate: 0.9
CT A/P ___
1. Overall unchanged hepatic metastases and mesenteric and
retroperitoneal lymphadenopathy.
2. Mild nodular appearance of the omentum is not significantly
changed from
prior, and remains concerning for early omental carcinomatosis.
3. Please refer to separate report of CT chest performed on the
same ___ for
description of the thoracic findings.
CT A/P ___ ___ changes within the
rectum consistent with a history
of rectal cancer. Additional postsurgical changes noted within
the small and large bowel. There are multiple dilated loops of
small bowel, most prominently measuring almost 4 cm close to 1
of
the enteroenteric anastomoses within the left abdomen. This is
associated with small bowel feces sign. Upstream and downstream
small bowel loops appear decompressed. Findings consistent with
a
component of small bowel obstruction. Exact etiology is
uncertain. There could be a closed-loop component or there may
be
associated peritoneal disease.
Multiple hepatic hypoattenuating lesions, largest within the
right inferior liver measuring up to 3.9 cm. Central mesenteric
conglomerate nodular mass measuring up to 5.7 cm along the
SMA/SMV branches. There may be some attenuation of vascular
branches.
KUB ___
There is contrast within the stomach and small bowel. The
dilated
loops of small bowel are not significantly changed in size,
measuring up to 3.7 cm.
There are no abnormally dilated loops of large bowel. Air is
seen
within the rectum. There is no free intraperitoneal air,
although
evaluation is limited by supine technique. There are no
unexplained soft tissue calcifications or radiopaque foreign
bodies.
Brief Hospital Course:
___ M with a history of rectal cancer on chemotherapy, who
presents with nausea, vomiting, and abdominal pain and imaging
consistent with a small bowel obstruction, ultimately leaving
against medical advice following a large bowel movement.
# Small bowel obstruction: Patient presenting with nausea,
vomiting, and abdominal pain, with CT imaging consistent with
small bowel obstruction, with some improvement of passing flatus
during his ___ course. He underwent gastrograffin study with the
initial KUB shot. He initially refused NG tube because he
reported a failed placement with significant bloody nose (though
unclear if this occurred at ___ or a hospital prior to
transfer). He subsequently had fecal incontinence that awoke him
from sleep and became extremely agitated and upset and demanded
to go home to shower. He did not want to stay and shower here at
___ and was not amenable to strategizing with nursing.
He initially became agitated, but later was apologetic and
remorseful. He subsequently left against medical advice after
verbalizing the risks of leaving. He was encouraged that he was
always welcome back at ___ and that we hope he would
seek care again, especially if his presenting complaints persist
or fail to resolve. His oncologist was notified by email of this
event.
# History of mesenteric thrombus: Initially, home apixaban held
and the patient was started on heparin, while awaiting
resolution of small bowel obstruction. His discharge paperwork
encouraged him to restart apixaban.
# Anemia: Admission H/H of 11.5/34.2 which is decreased from
prior baseline of Hb ___. Of note, he recently had bebacizumab
added on ___ so there may be some effect of this addition to
his chemotherapy. No symptoms of active bleeding, though
reportedly the patient had significant bleeding during an
attempted placement of an NG tube.
# Metastatic rectal adenocarcinoma: Patient of Dr. ___
___ currently receiving chemotherapy with palliative
intent. Patient underwent imaging at ___ in the
setting of small bowel obstruction above. Dr. ___ was
notified of the patient's discharge and hospital course.
# Coping: The ___ hospital course was notable for
significant agitated and angry outbursts, with his final
outburst accompanied by significant grief and remorse. It is
unclear which family members or support systems he has in place
and no additional numbers are listed in our system. It may be
useful to identify and incorporate any support systems within
our medical record, which could be useful should the patient
require repeated admissions.
TRANSITIONAL ISSUES:
- Patient left against medical advice in the setting of small
bowel obstruction, however, had a large bowel movement prior to
discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D ___ UNIT PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Apixaban 5 mg PO BID
4. ValACYclovir 1000 mg PO DAILY:PRN outbreak
5. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
6. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - Second Line
Discharge Medications:
1. Apixaban 5 mg PO BID
2. Omeprazole 20 mg PO DAILY
3. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - Second
Line
4. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
5. ValACYclovir 1000 mg PO DAILY:PRN outbreak
6. Vitamin D ___ UNIT 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:
Mr. ___,
You were admitted at ___ due to concern of a small bowel
obstruction. This is a serious condition that requires medical,
and occasionally, surgical treatment. You chose to leave the
hospital AGAINST MEDICAL ADVICE. You were able to understand
that leaving the hospital with this condition could result in
worsening abdominal pain, perforation of the bowel, severe
infection affecting blood pressure, and even death. You should
seek medical attention if you develop worsening symptoms such as
nausea, vomiting, abdominal pain, unable to pass gas or have
bowel movements.
Followup Instructions:
___
|
10680314-DS-10
| 10,680,314 | 23,726,859 |
DS
| 10 |
2166-11-08 00:00:00
|
2166-11-08 17:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
epigastric pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with intermittent episodes of substernal chest pain in
the setting of known hiatal hernia presents with a recurrent
episode of substernal chest pain at 6PM last night. However,
this
time, he also experience epigastric pain, which was new for him,
and persisted over multiple hours. He also vomited, which
prompted him to come in to be evaluated. He initially presented
to ___, where he had a CT scan, which was concerning
for
a strangulated hiatal hernia, now containing stomach and small
bowel, pneumatosis of the small bowel in the abdomen, and free
air with concern for possible perforation. He was transferred to
___, as this is where he receives his care.
He is a patient known to Dr. ___ has undergone a full
___ (___) of this known hiatal hernia. His ___ showed
that his symptoms of occasional chest pain was a result of
esophageal dysmotility, and not from the hiatal hernia itself,
so
elective repair was not indicated.
Since arriving to ___, his pain is much improved. He is
nauseated, but has not vomited, and has no abdominal pain on
exam.
Past Medical History:
PMH: Rectal prolapse, BPH, cervical spondylosis, erectile
dysfunction, glaucoma, hx colonic adenomatous polyps (last
c-scope ___, GERD, hx hematuria, ? hx sacral ileitis, eczema
PSH: hemorrhoidectomy (___), vasectomy (___), cystoscopy for
hematuria (___), b/l cataract surgery
Social History:
___
Family History:
Father - prostate cancer, kidney failure
Mother - stroke
Physical ___:
VS: 98.1 120/77 55 18 94RA
GEN: Pleasant male in NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI
CARDIAC: RRR, no murmurs
CHEST: No increased work of breathing, (-) cyanosis.
ABDOMEN: soft, nontender, nondistended.
EXTREMITIES: Warm, well perfused, no edema
NEURO: AA&O x 3
Pertinent Results:
___ 04:30AM BLOOD WBC-6.1 RBC-4.22* Hgb-12.5* Hct-38.8*
MCV-92 MCH-29.6 MCHC-32.2 RDW-12.7 RDWSD-42.5 Plt ___
___ 06:10AM BLOOD WBC-6.6 RBC-3.92* Hgb-12.0* Hct-35.6*
MCV-91 MCH-30.6 MCHC-33.7 RDW-13.2 RDWSD-43.7 Plt ___
___ 04:30AM BLOOD Glucose-123* UreaN-12 Creat-0.9 Na-139
K-4.3 Cl-105 HCO3-24 AnGap-14
___ 06:10AM BLOOD Glucose-84 UreaN-10 Creat-0.9 Na-143
K-3.6 Cl-105 HCO3-25 AnGap-17
___ 04:55AM BLOOD Glucose-87 UreaN-10 Creat-0.9 Na-144
K-4.1 Cl-109* HCO3-26 AnGap-13
___ 04:30AM BLOOD ALT-8 AST-18 AlkPhos-73 TotBili-0.3
___ 04:30AM BLOOD Lipase-19
___ 04:30AM BLOOD cTropnT-<0.01
___ 04:30AM BLOOD Albumin-3.4*
___ 04:43AM BLOOD Lactate-1.7
Imaging:
CT OSH ___: Concerning for incarcerated loop of bowel, distal
small intestine, potentially perforated within moderate size
hiatal hernia with pneumotosis proximal to it and decreased
enhancement of this loop of bowel. Free air.
UGI w/ SBFT ___: Water-soluble contrast was administered with
the patient upright. Scout image showed large hernia in the mid
thorax. Barium passed freely through the esophagus into the
stomach and then into the proximal small bowel to the level of
the ligament of Treitz without holdup. There is no evidence of
leak or obstruction. Small-bowel follow-through imaging showed
contrast within multiple loops of small bowel, which was normal
in caliber and without signs of obstruction. Transit through
the small bowel was slightly delayed without filling of hernia,
which is likely a loop of small bowel. Recommend follow-up KUB
in 2 hours to assess further transit of contrast.
IMPRESSION:
No evidence of leak or obstruction to the level of the ligament
of Treitz. Contrast within multiple loops of small bowel is
normal in caliber without signs of frank obstruction. Recommend
follow-up KUB in 2 hours from 1700 in order to assess transit
into concerning, herniated loop of bowel.
KUB ___:
Continued pneumoperitoneum, slightly decreased from previous
exam. Contrast now within the colon down to the rectum.
Nonobstructive bowel gas pattern.
Brief Hospital Course:
The patient was admitted to the general surgery service after
presenting to the an OSH ER with compliant of epigastric pain.
CT performed at OSH showed bowel within his known hiatal hernia
with concern for possible bowel obstruction and perforation
given findings of pneumoperitoenum and pneumatosis. However,
upon transfer to our ER, the patient was found to be afebrile,
hemodynamically stable, and with a benign abdominal exam. He
complained of some epigastric pain but no abdominal pain. His
labwork was within normal limits without a leukocytosis or
elevated lactate. Additionally, upon review of prior imaging, it
was noted that the patient had previously had benign
pneumoperitoneum noted on prior CT imaging in ___. Given he
appeared clinically well and had a prior history of
pneumoperitoneum, it was decided that he did not need urgent
surgical intervention. He therefore was started on NPO/IVF, IV
antibiotics (cipro/flagyl), and serial abdominal exams.
He underwent an UGI series with small bowel follow on HD1
through with several repeat KUB exams showing persistent
pneumoperitoneum, contrast passage through the small bowel loop
in the hiatal hernia through to the colon, and no obvious
contrast extravasation concerning for perforation. This
minimized concern for an obstruction or perforation. Following
the series, he had some nausea and non-bilious emesis that
resolved the following morning without recurrence. The following
day on HD2, he continued to have a benign abdominal exam so was
started on clears, which he tolerated well. He was advanced to
regular diet on HD3 which was also well tolerated. He was
transitioned to oral cipro/flagyl to complete a total 5-day
course at home. He remained afebrile and hemodynamically stable
throughout his stay. He will follow up in general surgery clinic
in ___ weeks to schedule an outpatient elective hernia repair.
Also of note, the patient was intermittently bradycardic to the
mid40s while inpatient but asymptomatic and not hypotensive. EKG
showed sinus bradycardia without ischemic changes. He was
advised to follow up with his primary care physician for further
___.
Medications on Admission:
zioptan eye drops, timolol eye drops, tamsulosin 0.4',
ranitidine 150''
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Do not exceed 3500mg in one day
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days
Take for three days.
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth q12 Disp #*6
Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO TID
Take for three days. Take your last dose the morning of ___.
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*6 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Hiatal hernia with intermittent small bowel obstruction
Pneumoperitoneum
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 general surgery service due to concern
for possible bowel obstruction or perforation within your known
hiatal hernia. Imaging demonstrated that your bowel was not
obstructed, however. You clinically looked very well and
tolerated a diet so you will be discharged home to follow up in
clinic regarding scheduling an elective hernia repair.
Please continue to take all your regular home medications. You
will continue on oral antibiotics for three days to complete a
total 5-day course.
Please call the doctor's office or return to the emergency room
if you develop any of the following symptoms:
-severe nausea and vomiting
-severe abdominal pain, chest pain
-fevers, chills
-if you stop passing gas or having bowel movements
Followup Instructions:
___
|
10680329-DS-10
| 10,680,329 | 24,898,647 |
DS
| 10 |
2187-10-13 00:00:00
|
2187-10-13 14:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ pmh of large ASD, small VSD and 4 leaftlet aortic valve here
c/o cp. Pt reports 3 weeks of bouts of severe chest pain. These
last about 10 minutes and are not associated exertion. There is
radiation to the flanks and down to the abdomen. The pain seems
to be worse with the patient lying on his back. There is no
associated diaphoresis, nausea, vomiting. No syncope,
pre-syncope, dyspnea, orthopnea, or PND. Of note, he was a
victim of trauma 3 weeks ago, someone apparently hit him in the
chest.
In the ED, initial VS were: T: 97.8 BP 140/68 HR 58 RR 16
O297%RA. Labs were remarkable for troponin negative, chemistries
wnl, EKG showed CXR showed enlarged cardiac silhouette with no
signs of pulmonary edema or consolidation. Pt was seen by
cardiology, who recommended admission to ___. Pt was given
nitro which did not improve his pain; however, morphine did
improve his pain substantially.
ON review of systems, Denies f/c, palpitations, n/v/d.
Past Medical History:
CARDIAC MEDICAL HISTORY
large secundum ASD
ECHO ___ IMPRESSION: Large secundum ASD and perimembranous
VSD are seen. The RV is mildly dilated with borderline normal
function. Borderline pulmonary artery systolic hypertension.
Quadricuspid aortic valve with mild aortic insufficiency.
Biatrial enlargement and mild symmetric LVH are present with
preserved LV function.
Compared with the prior study (images reviewed) of ___,
the RV size and function are not significantly changed. The
estimated pulmonary artery systolic pressure is lower today than
seen previously. The degree of aortic insufficiency is slightly
increased. LV wall thickness is slightly increased.
Social History:
___
Family History:
No history of early cardiac disease among first-degree
relatives.
Physical Exam:
Admission:
VS: 98.7 BP: 122/72 P: 50 RR: 18 SaO2: 95% RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- bradycardic, holosystolic harsh murmur heard best at apex
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- CNs2-12 intact, motor function grossly normal
Discharge
VS: 97.5 ___ ___ 18 98-100% RA
55.9Kg
Telemetry- rate is persistently in the ___ with an ectopic
atrial beat. Rises to ___ on standing
GENERAL: AA OX3 NAD, breathing comfortably completely recumbent
on CPAP
HEENT: NCAT. PERRLA, EOMI, MMM. Sclera anicteric, no
conjunctival pallor. OP clear, trachea midline, no thyromegaly
or cervical LAD.
NECK: Supple, with JVP of 5 cm without evidence of HJR. Carotids
benign bilaterally.
CARDIAC: bradycardic. S1/S2 without MGR. PMI non-enlarged,
non-displaced. No parasternal or subxiphoid heaves, precordial
thrills, or palpable pulsations in the 3LICS.
LUNGS: Lungs CTAPB without WRR. Resp unlabored, no accessory
muscle use.
ABDOMEN: Soft, NT, ND. BS + X4, No HSM or tenderness. Abd aorta
not enlarged by palpation. No abdominal bruits.
EXTREMITIES: No CCE or edema. No femoral bruits. L femoral
access site unremarkable.
SKIN: No concerning lesions.
Pertinent Results:
___ 06:00AM BLOOD WBC-6.3 RBC-4.20* Hgb-13.3* Hct-39.2*
MCV-93 MCH-31.6 MCHC-33.8 RDW-12.2 Plt ___
___ 06:00AM BLOOD Glucose-80 UreaN-14 Creat-0.6 Na-140
K-4.1 Cl-103 HCO3-28 AnGap-13
___ 10:30AM BLOOD Glucose-92 UreaN-14 Creat-0.7 Na-138
K-4.1 Cl-102 HCO3-28 AnGap-12
___ 08:30PM BLOOD cTropnT-<0.01
___ 10:30AM BLOOD cTropnT-<0.01
___ 06:00AM BLOOD Calcium-8.7 Phos-3.1 Mg-1.9
Brief Hospital Course:
This is a ___ man with congenital heart disease (large secundum
ASD) who presents with 3 weeks of atypical chest pain and
asymptomatic bradycardia.
#Chest pain: patient history was quite atypical for ACS and he
had negative troponins and no ischemic changes on EKG. A stress
test showed no abnormalities of tracer uptake in his LV, though
he did experience an asymptomatic 20mmHg drop in blood pressure
after 6 minutes of exercise that is thought to be due to his
structural heart disease. Furthermore, his chest pain actually
improved with exercise. A CT chest with contrast did not show
aortic or pulmonary pathology. Therefore, he was placed on
ibuprofen and counseled to take it with food.
Of note, an echo in house was similar to a prior done in ___ -
It showed: Large secundum ASD. Perimembranous VSD. Mild
symmetric left ventricular hypertrophy with preserved systolic
function. Mildly dilated right ventricle with borderline normal
function. Quadricuspid aortic valve with mild regurgitation.
#Bradycardia: on telemetry, the patient was noted to be
bradycardic to the ___ without symptoms and with blood pressures
in the 110s systolic. His HR increased to the ___ upon standing.
Given his lack of symptoms and stable hemodynamic status, he was
monitored and advised to follow this up as an outpatient with
his outpatient cardiologist.
Transitional issues:
-follow up bradycardia
-patient will likely require ASD repair in the future.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 400 mg PO Q8H:PRN pain
2. Diclofenac Sodium ___ 50 mg PO BID:PRN pain
Discharge Medications:
1. Ibuprofen 400 mg PO Q8H:PRN pain
RX *ibuprofen [Advil] 200 mg 3 tablet(s) by mouth Three times
per day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Non-cardiac chest pain
Bradycardia
Atrial septal defect
Ventricular septal defect
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
___,
Usted fue ___ hospital porque tenia dolor en el pecho.
___ pruebas ___ a ___ conclusion ___
este dolor ne es por causa cardiaca. Tambien, nos aseguramos ___
___ aorta y sus pulmones ___ bien.
Si continua el dolor, por favor tome unas pastillas
anti-inflammatorias, como Ibuprofen, para calmarlo. Por favor
llame al doctor ___ de emergencia si usted tiene
dolor muy ___, falta de aire, mareos, o hinchazon ___
___.
Notamos ___ late muy despacio. Si usted siente mareos
y se desmaya, ___ ___ hospital.
Followup Instructions:
___
|
10680329-DS-12
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| 12 |
2188-08-08 00:00:00
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2188-08-08 13:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain and bradycardia
Major Surgical or Invasive Procedure:
___
1. Closure of secundum atrial septal defect.
2. Closure of perimembranous ventricular septal defect.
History of Present Illness:
Mr. ___ is a ___ yo who is s/p ASD/VSD repair with Dr. ___ on
___. His post op course was complicated by RUQ abdominal pain,
work up included negative RUQ
US and pain improved after patient moved his bowels. He was
discharged home and was seen for a wound evaluation on ___. At
that time he was sent for an R upper extremity ultrasound as the
patient was complaining of pain in his R arm. The ultrasound
showed occlusive thrombus in the axillary, brachial, basilic,
and cephalic veins. He was started on lovenox and coumadin and
was
seen by his PCP for ___ draw today and he was found to be
bradycardic and complaining of chest pain. He was sent for
further evaluation in the ED. A CTA showed right lower lobe
subsegmental pulmonary embolism, Assessment for left lower lobe
pulmonary emboli is limited by respiratory motion, no evidence
of
right heart strain, bibasilar atelectasis.
Past Medical History:
- Secondum ASD/Restrictive Membranous VSD
- Quadricuspid Aortic Valve with mild AI
- History of Atrial Fibrillation s/p successfull DCCV
- Bradycardia(asymptomatic)
- Congenital Hearing Loss
- s/p Collarbone fracture ___
- s/p attempted percutanous ASD closure on ___ via right
femoral approach
Social History:
___
Family History:
No history of early cardiac disease among first-degree
relatives.
Physical Exam:
Physical Exam
Pulse:39 SB Resp:14 O2 sat:97% on RA
B/P Right:127/54 Left:
Height: Weight:
General:well appearing in no distress
Skin: Dry [x] intact []
HEENT: PERRLA [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] No Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] +RUQ tenderness to
palpation,
all other quadrants negative, no guarding or rebound bowel
sounds
+[x]
Extremities: Warm [x], well-perfused [x] No Edema [x] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
DP Right:2+ Left:2+
___ Right:2+ Left:2+
Radial Right:2+ Left:2+
R arm tender to palpation over anterior portion and anterior
shoulder, no cord appreciated, no erythema, no edema
sternal incision clean, dry sternum stable
Pertinent Results:
CTA ___
1. Right lower lobe and right middle lobe subsegmental
pulmonary emboli. Assessment for left lower lobe pulmonary
emboli is limited by respiratory motion, the pulmonary embolism
cannot be excluded in this region. No evidence of large central
pulmonary embolism or right heart strain.
2. Normal post-operative changes, status post cardiac surgery.
3. Right lower lobe atelectasis and left lower lobe atelectasis
or less
likely ischemic change.
.
___ 08:00AM BLOOD WBC-4.9 RBC-3.56* Hgb-10.2* Hct-32.0*
MCV-90 MCH-28.7 MCHC-31.9 RDW-12.9 Plt ___
___ 08:00AM BLOOD ___
___ 07:25AM BLOOD ___ PTT-40.4* ___
___ 11:56PM BLOOD ___
___ 10:40AM BLOOD Glucose-120* UreaN-16 Creat-0.8 Na-137
K-4.2 Cl-99 HCO3-26 AnGap-16
___ 07:25AM BLOOD ALT-35 AST-43* AlkPhos-117 Amylase-36
TotBili-0.2
___ 10:40AM BLOOD Mg-2.0
Brief Hospital Course:
Mr. ___ was readmitted to the ___ on ___ for further
management of his chest pain and deep vein thrombosis. A CT scan
revealed pulmonary emboli and he was started on heparin as a
bridge to coumadin. He will be discharged on Lovenox and
Coumadin. He will follow-up at the ___
___ tomorrow for further anti-coagulation management.
Medications on Admission:
1. Aspirin EC 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*0
5. Metoprolol Tartrate 25 mg PO BID
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day
Disp #*30 Tablet Refills:*0
6. Lovenonx-?dose, started ___
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 60 mg SC Q12H Duration: 10 Days
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 60 mg/0.6 mL 1 dose sc every twelve (12) hours
Disp #*20 Syringe Refills:*0
4. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth q4h prn Disp #*40 Tablet
Refills:*0
5. Warfarin 5 mg PO DAILY16
dose to change daily per Dr. ___ goal INR ___, dx: PE
RX *warfarin 5 mg 1 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
6. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
Discharge Disposition:
Home with Service
Discharge Diagnosis:
- pulmonary embolism s/p Closure of VSD and ASD
- Quadricuspid Aortic Valve with mild AI
- History of Atrial Fibrillation s/p successfull DCCV
- Bradycardia(asymptomatic)
- Congenital Hearing Loss
- s/p Collarbone fracture repair
- s/p attempted percutanous ASD closure on ___ via right
femoral approach
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tramadol
Incisions:
Sternal - healing well, no erythema or drainage
Edema - trace
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 ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10680402-DS-17
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| 17 |
2182-11-16 00:00:00
|
2182-11-19 14:15:00
|
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:
None
attach
Pertinent Results:
ADMISSION LABS:
==============
___ 11:55AM BLOOD WBC-11.4* RBC-3.87* Hgb-11.8* Hct-37.8*
MCV-98 MCH-30.5 MCHC-31.2* RDW-15.8* RDWSD-54.5* Plt ___
___ 11:55AM BLOOD Neuts-90.9* Lymphs-5.0* Monos-2.6*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-10.34* AbsLymp-0.57*
AbsMono-0.29 AbsEos-0.00* AbsBaso-0.02
___ 06:10PM BLOOD Glucose-124* UreaN-18 Creat-0.5 Na-139
K-4.5 Cl-98 HCO3-26 AnGap-15
___ 11:55AM BLOOD ALT-111* AST-36 LD(LDH)-227 AlkPhos-111
TotBili-0.3
___ 06:10PM BLOOD cTropnT-0.33* proBNP-1319*
___ 06:10PM BLOOD Albumin-3.6 Calcium-9.0 Phos-3.8 Mg-2.2
___ 11:55AM BLOOD Ferritn-395
___ 11:55AM BLOOD Triglyc-196*
___ 06:10PM BLOOD Lactate-3.5*
INTERVAL LABS:
===============
___ 07:20AM BLOOD cTropnT-0.42*
___ 05:00AM BLOOD CK-MB-2 cTropnT-0.34*
___ 09:30PM BLOOD Lactate-1.1
DISCHARGE LABS:
===============
___ 06:02AM BLOOD WBC-3.7* RBC-3.55* Hgb-11.0* Hct-34.0*
MCV-96 MCH-31.0 MCHC-32.4 RDW-16.5* RDWSD-57.7* Plt ___
___ 06:02AM BLOOD Plt ___
___ 06:02AM BLOOD Glucose-119* UreaN-28* Creat-0.5 Na-139
K-3.8 Cl-101 HCO3-27 AnGap-11
___ 06:02AM BLOOD ALT-142* AST-41*
IMAGING:
========
___ Echo Report
CONCLUSION: The estimated right atrial pressure is ___ mmHg.
There is normal left ventricular wall thickness with a normal
cavity size. There is normal regional left ventricular systolic
function. Overall left ventricular systolic function is normal.
Quantitative biplane left ventricular ejection fraction is 59 %
(normal 54-73%). The visually estimated left ventricular
ejection fraction is 55%. Tricuspid annular plane systolic
excursion (TAPSE) is normal. There is a moderate circumferential
pericardial effusion. There are no 2D or Doppler
echocardiographic evidence of tamponade. IMPRESSION: Follow-up
study for pericardial effusion. Moderate circumfrential
pericardial effusion with subtle systolic RA collapse but no
signs of frank tamponade. Normal biventricular function.
Compared with the prior TTE (images reviewed) of ___, the
findings are similar
___: SKIN, LEVELS X2PENDING
___ OPINION CT TORSO
IMPRESSION:
1. No acute aortic process or central pulmonary embolism.
2. Small pericardial effusion appears similar to prior.
3. Interval complete resolution of pleural effusions and lower
lung
consolidations.
___ (PA & LAT)
IMPRESSION: No acute intrathoracic process. PICC line appears
well positioned.
MICROBIOLOGY:
=============
__________________________________________________________
___ 6:09 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 5:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 2:46 pm BLOOD CULTURE Source: Line-PICC.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
Brief Hospital Summary
======================
Mr. ___ is a ___ old male with a very complicated recent
hospital course ___ for septic/cardiogenic shock requiring
broad-spectrum antibiotics and multiple pressors ultimately
thought to be due to EBV infection and fusobacterium bloodstream
infection. Also found to have myopericarditis and small pleural
effusion at that time. Etiology felt to be from acute EBV
infection & fusobacterium blood stream infection.
He initially represented to the ___ on ___
with palpitations and chest pain that occurred while he was
sitting and watching television. He noted he was feeling anxious
at the time. At ___, his heart rates were into the 150s
with a troponin leak of 0.43. He was transferred to ___ where
he had a repeat echocardiogram which demonstrated improved EF of
59% and continued moderate pericardial effusion, stable from
___. Telemetry demonstrated sinus tachycardia. During his
hospitalization he was noted to have several episodes of
palpitations which coincided with runs of ectopy on telemetry.
He was continued on low dose beta blocker, colchicine BID for
his myocarditis and pericardial effusion as well as prednisone
taper and antibiotics. He was noted to have a new rash this
hospitalization which was biopsied by dermatology and thought to
be adult acne brought on by high dose prednisone. He was
discharged with follow up by heme/onc, and ID as well as the ___
service with plans for weekly echocardiograms to assess
improvement and cardiac MRI scheduled for ___.
# CORONARIES: n/a
# PUMP: EF 59% on ___
# RHYTHM: sinus
TRANSITIONAL ISSUES
===================
Cardiology:
[] outpatient echo in one week
[] outpatient CMRI in ___
[] CDAC HF follow-up next week
[] Ziopatch f/u
ID
[] ID f/u ___ for Lemierre's syndrome
[] please repeat LFTs next week, if still uptrending RUQ US for
evaluation of transaminitis. Unclear whether this is due to
resolving HLH vs EBV.
ACUTE ISSUES:
=============
#Pericardial effusion, STABLE
Patient recently admitted with severe septic shock and
myopericarditis ___ mono as below now presenting with
palpitations. TTE ___ with moderate pericardial effusion and
EF 59%. Effusion size moderate, appearing stable from prior
echos. Initial thought of possible pericardiocentesis not
undertaken due to posterior location of pocket, and risks felt
to outweigh benefits. Planned to monitor with serial echos and
CMR in ___. Pt outfitted with Zio patch to monitor for
ectopy given his palpitations.
#Sinus tachycardia
CTA negative for PE. DDx for sinus tach includes: worsening of
pericardial effusion (as above) vs drug reaction vs anxiety.
Pt's metroprolol was changed to 25mg metop succinate.
#Rash
Upper back with pink, small papulues diffusely. Patient states
it started acutely. ___ be due to Bactrim vs steroid vs HLH.
Derm consulted ___ and he is now s/p punch biopsy with derm
thinking it is likely due to steroid use vs possible drug rxn.
#Recent myopericarditis
#Heart failure w/ recovered EF, COMPENSATED
During last admission, met criteria for clinically suspected
myocarditis by unexplained cardiogenic shock + cardiac enzyme
elevation (trop peaked @ 5.33, CK MB 201) + ST changes.
Myocarditis likely lymphocytic iso acute EBV infection. EF
recovered at time of discharge, now EF 59% ___. Euvolemic on
exam. Pt with outpatient cardiac MRI scheduled for ___.
Continued colchicine 0.6mg BID (likely 3 month course),
metoprolol. Regarding goal directed medical therapy: no ___
iso recent shock.
#Recent fusobacterium Blood Stream Infection
#Lemierre's syndrome
#Recent acute EBV Infection
During prior admission, OSH BCx grew fusobacterium in ___
aerobic bottles. Unclear source, but per ID most likely lemierre
syndrome iso EBV illness (monospot positive at OSH). This
diagnosis was supported by discovered LIJ vein occlusion. Given
poor data for anticoagulation in Lemierre's syndrome, lack of
other clots on extensive imaging & no apparent clot progression
on repeat imaging, deferred initiation of coumadin. Currently on
CTX via PICC and flagyl for ___ week course (D1: ___ per OPAT.
Ceftriaxone 2g IV q24h continued, metronidazole 500mg PO TID
continued.
#HLH
Heme-onc consulted during prior admission and performed BMBx
that demonstrated hemophagocytic histiocytes c/w hemophagocytic
syndrome most likely ___ infection. Patient did meet criteria
for HLH and was empirically started on steroids, currently
tapering per heme-onc.
-continued Dexamethasone 8 mg PO DAILY (tapering to 4mg qd on
___, then to discuss with heme-onc)
-continued Bactrim ppx while on steroids
-continued insulin as below for hyperglycemia ___ steroids which
was discontinued on discharged.
#Elevated transaminases
ALT 114, AST 45 on admission, stable from discharge. Per last
discharge summary, thought to be iso shock liver vs EBV
infection vs hepatic congestion from heart failure.
#Normocytic anemia
Hb 11.3 on admission, stable from last discharge. Likely iso
infection.
#Hyperglycemia
No history of DM, hyperglycemia iso steroid use.
-FSBG qACHS while in house, insulin not continued.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. CefTRIAXone 2 gm IV Q 24H
2. MetroNIDAZOLE 500 mg PO/NG TID
3. Colchicine 0.6 mg PO BID
4. Famotidine 20 mg PO Q12H
5. Metoprolol Succinate XL 12.5 mg PO DAILY
6. Calcium Carbonate 1000 mg PO DAILY
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Dexamethasone 8 mg PO DAILY
10. NPH 10 Units Breakfast
Discharge Medications:
1. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
RX *heparin lock flush (porcine) 10 unit/mL 1 flush IV once a
day Disp #*60 Vial Refills:*0
2. LORazepam 0.5 mg PO QHS:PRN anxiety Duration: 7 Doses
3. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
RX *sodium chloride 0.9 % 0.9 % 1 flush IV once a day Disp #*750
Milliliter Milliliter Refills:*0
4. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
5. Calcium Carbonate 1000 mg PO DAILY
6. CefTRIAXone 2 gm IV Q 24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 g IV once a
day Disp #*45 Intravenous Bag Refills:*0
7. Colchicine 0.6 mg PO BID
8. Dexamethasone 8 mg PO DAILY
9. Famotidine 20 mg PO Q12H
10. MetroNIDAZOLE 500 mg PO TID
11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis
Pericardial effusion
Myocarditis
Secondary diagnosis
Lemierre's syndrome
EBV Infection
Fusobacterium blood stream infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
=====================================
- You were admitted to the hospital because you were having
chest palpitations.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
============================================
- In the hospital we monitored your heart on telemetry for any
abnormal rhythms.
- We took pictures of your heart using ultrasound which showed
that you still have some fluid around your heart (pericardial
effusion).
- We placed an event monitor called a ziopatch which you will
continue to wear when you go home to monitor your heart rhythm.
- We increased the dose of metoprolol you were taking to try to
help control the palpitations.
- You have a new rash on your back which we believe is probably
related to being on steroids. We consulted the dermatology team
to evaluate you and they biopsied the rash. They believe the
rash is related to the steroids you are on.
- We continued your antibiotics for your recent infection and
___ syndrome.
WHAT SHOULD I DO WHEN I GO HOME?
==================================
- Please continue to take your medications as prescribed.
- Please keep your scheduled followup appointments.
- You will wear the ziopatch for 14 total days to monitor your
heart rhythm. You are scheduled for a follow-up echocardiogram
(ultrasound of your heart) as well as a cardiac MRI to continue
to monitor your heart function.
- If you are experiencing new or concerning chest pain,
palpitations, or other symptoms that are concerning please call
your doctor or seek medical care.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10680436-DS-17
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| 17 |
2112-09-09 00:00:00
|
2112-09-10 06:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
ALS, failure to thrive
Major Surgical or Invasive Procedure:
Lumbar puncture
PICC
History of Present Illness:
The patient is a ___ year old ___ speaking only with
clinically definite ALS followed by Dr. ___ in the
___ clinic who presents with functional decline.
Per the ___ clinic note by Dr. ___ initialed
had with left hand weakness in ___. He initially saw
Dr. ___ at ___ in ___ where he
was having weakness and numbness in the hands, heaviness in the
legs and muscle twitching. At his clinic visit in ___ his
exam was notable for left arm and leg mild weakness,
hyperreflexia and spasticity. MRI brain and C-spine performed
and unremarkable. EMG/NCS with evidence of "acute denervating
features in both upper extremities concerning for motor neuron
disease. There is prolonged median motor and median
and ulnar sensory response latencies that suggest underlying
sensorimotor polyneuropathy." The recommendation was made for
the patient to have evaluation at a tertiary care center. He
then presented to ___ in ___ where he reportedly had
repeat work-up with MRI of the brain and total spine which were
normal. He also had a repeat EMG/NCS which showed normal sensory
responses but reduced motor amplitudes as EMG changes consistent
with ALS (reports not available to us). He then presented to
___ clinic in ___ with Dr. ___
___. At that time he was having difficulty using his left
hand at all for dressing or using utensils. He also was having
right hand weakness for several months. At that visit his ALS
functional score was 35/48 for requiring assistance to walk,
dressing, turning in bed, cutting food and slower and sloppier
handing writing. His exam was notable for "intact mental status
bulbar musculature, atrophy of the hands, increased tone in the
upper extremities with left > right upper extremity weakness."
he had diffuse hyperreflexia. The impression was ALS. He was
started on Riluzole. Radicava infusion was as approved as well
but he has not received yet.
Since that visit in ___ he has progressively worsened. He now
has no use of his left arm. He requires assistance with all ADLs
cannot feed himself or toilet. He is now walking with a walker.
He has had several falls in the past few months, most recently 1
month ago without actually hitting the floor (brother in law
caught him). He reports occasional difficult with swallow "large
bites" but does not cough with fluids. He often with maneuver
his head to help with swallowing pulls and large bites of food.
He denies shortness of breath or chest pain. He does report some
constipation. When he was seen in ___ clinic today due
to functional decline and progression of disease he was sent to
the emergency department.
He has quite an unfortunate social history in recent months. He
is living with his two sisters who have been his caregivers, but
his mother is now on home Hospice and his brother-in-law is in a
coma at ___. This complex social situation has made it
difficult for his sisters to provide the kind of care he is now
requiring.
On neurologic review of systems, the patient denies headache,
lightheadedness, or confusion. Denies difficult comprehending
speech. Denies loss of vision, blurred vision, diplopia,
vertigo, tinnitus, hearing difficulty, dysarthria, or dysphagia.
Denies numbness, parasthesia. Denies loss of sensation. Denies
bowel or bladder incontinence or retention at home, but did have
to be straight cathed in the ED.
On general review of systems, the pt denies recent fever or
chills. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No dysuria. Denies arthralgias
or myalgias. Denies rash.
Past Medical History:
ALS
HTN
Social History:
___
Family History:
No family history of ALS. No family history of neurologic
disease. No history of dementia.
Physical Exam:
ADMISSION EXAM:
===============
Vitals: 98.8 81 138/80 16 95% RA
General: Awake, cooperative
HEENT: Arcus senilis bilaterally. NC/AT, no scleral icterus
noted
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl.
Abdomen: soft, NT/ND
Extremities: No ___ edema
Skin: no rashes or lesions noted
Neurologic:
-Mental Status: Limited given phone interpreter in ED. Within
these constraints he was alert, oriented to his recent decline.
He says the year is ___ and day is ___ but says he
doesn't
know the month. He could not tell me recent events in the news
but instead tells me he needs vitamins. He says days of week
backward and forward but requires directions likely due to
difficulty with interpreter. Language is fluent with intact
comprehension for complex two step cross body commands. Speech
not dysarthric but voice is hypophonic. No evidence of apraxia
or
neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: Left nasolabial fold flattening with symmetric activation.
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 is normal bulk and protrudes in midline with full
excursions.
-Motor: Diminished bulk in upper ext>lower ext and left>right in
upper ext (___), increased tone throughout L>R in upper
extremities, increased tone in lower ext seemingly equal.
Fasciculation seen in many muscle groups bilaterally including
deltoids, triceps, biceps, quads, TAs and gastrocs. No tongue
fasciculations.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 3 4 4+ ___ 0 4 5 4+ 5 5
R 4 ___ 4+ ___ 5 5- 5 5
**NECK EXT/FLEX ___ bilaterally
-Sensory: No deficits to light touch.
-DTRs: 3+ throughout upper and lower extremities with ___,
pec jerks, prepatellars, crossed adductors, 1 beat of clonus
bilateral ankles
Plantar response was flexor bilaterally.
-Coordination: no dysmetria on right finger nose chest, left
could not be assessed
-Gait: not assessed as walker not present at bedside
DISCHARGE EXAM:
===============
General: Awake, cooperative, NAD, sitting upright in chair
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Pulmonary: Breathing comfortably on RA
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented. Speech was not dysarthric, mild
hypophonia.
-Cranial Nerves: EOM grossly intact. No ptosis. Face
grossly symmetric.
-Motor: Formal strength testing deferred this AM.
Pertinent Results:
ADMISSION LABS:
===============
___ 04:55PM CEREBROSPINAL FLUID (CSF) PROTEIN-41
GLUCOSE-79
___ 04:55PM CEREBROSPINAL FLUID (CSF) TNC-0 RBC-0 POLYS-0
___ ___ 07:40AM GLUCOSE-95 UREA N-18 CREAT-0.7 SODIUM-143
POTASSIUM-4.6 CHLORIDE-103 TOTAL CO2-27 ANION GAP-13
___ 07:40AM CALCIUM-9.7 PHOSPHATE-4.8* MAGNESIUM-2.0
___ 07:40AM WBC-6.2 RBC-4.12* HGB-13.5* HCT-40.0 MCV-97
MCH-32.8* MCHC-33.8 RDW-12.6 RDWSD-45.1
___ 07:40AM PLT COUNT-232
___ 04:40PM GLUCOSE-98 UREA N-12 CREAT-0.6 SODIUM-141
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-23 ANION GAP-16
___ 04:40PM estGFR-Using this
___ 04:40PM ALT(SGPT)-30 AST(SGOT)-24 ALK PHOS-64 TOT
BILI-1.1
___ 04:40PM LIPASE-17
___ 04:40PM cTropnT-<0.01
___ 04:40PM ALBUMIN-4.5 CALCIUM-9.9 PHOSPHATE-4.1
MAGNESIUM-2.0
___ 04:40PM TSH-1.0
___ 04:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 04:40PM URINE HOURS-RANDOM
___ 04:40PM URINE UHOLD-HOLD
___ 04:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 04:40PM WBC-7.2 RBC-4.45* HGB-14.5 HCT-42.3 MCV-95
MCH-32.6* MCHC-34.3 RDW-12.4 RDWSD-43.3
___ 04:40PM NEUTS-67.4 ___ MONOS-7.1 EOS-0.4*
BASOS-0.6 IM ___ AbsNeut-4.82 AbsLymp-1.71 AbsMono-0.51
AbsEos-0.03* AbsBaso-0.04
___ 04:40PM PLT COUNT-256
___ 04:40PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:40PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
___ 04:40PM URINE RBC-4* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 04:40PM URINE MUCOUS-RARE*
IMAGING:
========
Video Oropharyngeal Swallow ___:
FINDINGS:
Trace aspiration with thin liquids via straw.
IMPRESSION:
Trace aspiration with thin liquids via straw.
CXR ___:
FINDINGS:
Right-sided PICC line was retracted and now terminates at the
cavoatrial
junction or very shortly below. Cardiac, mediastinal and hilar
contours
appear stable. Lungs appear clear. There is no pleural
effusion or
pneumothorax.
IMPRESSION:
Retraction of PICC line, now terminating at the cavoatrial
junction or very shortly below.
___ 04:36AM BLOOD WBC-5.8 RBC-3.60* Hgb-11.9* Hct-35.9*
MCV-100* MCH-33.1* MCHC-33.1 RDW-12.5 RDWSD-45.0 Plt ___
___ 04:36AM BLOOD Glucose-94 UreaN-16 Creat-0.6 Na-140
K-4.6 Cl-101 HCO3-27 AnGap-12
___ 04:40PM BLOOD ALT-30 AST-24 AlkPhos-64 TotBili-1.1
___ 04:40PM BLOOD Lipase-17
___ 04:40PM BLOOD cTropnT-<0.01
___ 04:36AM BLOOD Calcium-9.7 Phos-4.7* Mg-2.1
___ 04:40PM BLOOD TSH-1.0
___ 04:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 04:36AM BLOOD WBC-5.8 RBC-3.60* Hgb-11.9* Hct-35.9*
MCV-100* MCH-33.1* MCHC-33.1 RDW-12.5 RDWSD-45.0 Plt ___
___ 04:36AM BLOOD Glucose-94 UreaN-16 Creat-0.6 Na-140
K-4.6 Cl-101 HCO3-27 AnGap-12
___ 04:36AM BLOOD Calcium-9.7 Phos-4.7* Mg-2.1
Brief Hospital Course:
PATIENT SUMMARY:
================
Mr. ___ is a ___ year old man with ALS originally presenting
for neurologic evaluation in ___ who was admitted for
worsening functional decline including worsening ability to
complete ADLs and reported swallowing difficulties.
ACUTE ISSUES:
=============
#ALS
While in the hospital, the patient remained clinically stable
from a respiratory and nutrition standpoint. Per speech and
swallow, he was still safe to consume solids and thin liquids PO
with appropriate aspiration precautions. He was started on a
regimen of regular exercises by ___. LP with CSF analysis was
performed, which was negative for infection, paraneoplastic
antibodies, or other concerning process to explain patient's
motor neuron disease. Patient's neuropathic pain was controlled
with gabapentin.
A PICC was placed for future Radicava treatments as an
outpatient.
He had a video swallow study performed this admission. PFTs were
attempted. Despite patient, technician and interpreters best
efforts, we were unable to obtain reportable PFT data.
#Urinary retention
Patient was noted to have some urinary retention by RN staff,
started on tamsulosin 0.4mg qHS, after which it improved.
TRANSITIONAL ISSUES:
====================
# PICC placed for future Radicava treatments
Medications on Admission:
1. riluzole 50 mg oral BID
2. Aspirin 81mg PO daily
3. Lisinopril 10 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Gabapentin 100 mg PO TID
3. Lisinopril 10 mg PO DAILY
4. Polyethylene Glycol 17 g PO DAILY
5. Senna 8.6 mg PO BID
6. Tamsulosin 0.4 mg PO QHS
7. riluzole 50 mg oral BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Amyotrophic Lateral Sclerosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
You came to the hospital because of worsening weakness and
frequent falls at your home.
While in the hospital, you had a swallow study as well as a
lumbar puncture. You were evaluated by our physical and
occupational therapists who felt it was safest for you to be
discharged to a rehabilitation facility.
You also had a PICC line placed to allow you to received an IV
medication called Radicava as an outpatient.
After leaving the hospital, you should take all of your
medications as prescribed and follow up with your doctors as
___ below.
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
10680436-DS-18
| 10,680,436 | 28,690,197 |
DS
| 18 |
2113-02-18 00:00:00
|
2113-02-18 17:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
nursing home concerns
Major Surgical or Invasive Procedure:
PEG tube placement by ___ ___
Video Swallow evaluation by Speech Pathology
History of Present Illness:
Mr. ___ is a ___ male with PMH of recently
diagnosed ALS now residing at ___, presents to the
___ ED due to agitation/anxiety, transient abdominal pain, and
desire to be transferred to a different rehab facility
According to the ED record and my discussion with his sister on
the phone, in the evening of ___ per the rehab center he had
more anxiety/agitation and began hitting the wall. He initially
reported abdominal pain, but also had a large BM that was not
cleaned up for apparently a up to 2 hours. Due to family request
he was transferred to the ER. Patient and his sister have stated
that he does not want to go back to the rehab center.
Of note, his condition is made worse by his complex family
situation. His wife and children are ___ from ___,
currently residing in ___ and attempting to gain a visa to
come to ___.
In the ED, initial vitals were: 97.6 74 189/99 16 95% RA
Exam notable for: Hypertonic with slow dysarthric speech likely
baseline given his ALS. normal cardiorespiratory and abdominal
exam. Patient is appropriate and conversive here without
agitation.
He reported in the ED: no chest pain/dyspnea/palpitations. no
abdominal pain, n/v/d. Passing urine normally but is incontinent
at baseline.
Labs and urine negative for any abnormalities
Patient was given 650 mg of acetaminophen and 50 mg tramadol.
On transfer, vitals were 97.9 59 ___ 96% RA
Decision was made to admit to medicine for CM evaluation for
placement.
On arrival to the floor, I was initially unable to obtain a full
ROS or history from the patient. He speaks minimal ___ so
was
able to report R shoulder pain but no abdominal pain or other
discomfort. I attempted to use a telephone ___ interpreter,
but due to the patient's dysarthria and particular dialect, the
interpreter was unable to understand him. I subsequently spoke
with his sister ___ who confirmed the above story. She was
also under the impression that he had abdominal pain but was
unclear of any further details.
I also spoke with his outpatient neurology neuromuscular fellow
who confirmed that since he was placed at ___ in ___, he
has been upset with ___ and ___ not wanted to be there, but
has needed to stay due to his progressive weakness and inability
to be home. They have been trying to get him into the ___ house, which is a special ___ rehab, and he
is
on the waitlist. She also reported that they have been working
up
a new orthopnea that she feels is related to his ALS, and have
also wanted to schedule a time for a PEG tube placement given
ongoing concerns for dysphagia. He has been on a modified diet
for dysphagia with nectar thick liquids, soft solids.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were not able to be reviewed due to dysarthria and
lack of appropriate interpreter. Will obtain a more full ROS
when
sister arrives.
PAST MEDICAL/SURGICAL HISTORY:
ALS
HTN
SOCIAL HISTORY:
He worked as a ___ and ___ and inhaled noxious
fumes. He had to stop because of the symptoms. He was living
with
his sister for the last ___ years until recently when he was
transitioned to ___. Former smoker, quit ___,
had been smoking since age ___. Never alcohol, nor drug use.
Originally from ___, came to the ___ in ___.
His mother is currently on hospice, brother-in-law (sister
___ husband) also very ill, and his family is currently
in
___ and unable to come to the ___ until they obtain a Visa.
Neurology team ___ fellow) have been
in touch with ___ ___ office and the family is working
on getting paperwork to send there to try to get his family
here.
Past Medical History:
ALS
HTN
Social History:
___
Family History:
No family history of ALS. No family history of neurologic
disease. No history of dementia.
Physical Exam:
ADMISSION EXAM:
===================
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress, lying comfortably in
bed. Dysarthric speech but able to articulate simple answers in
___.
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation. No foley
in place.
MSK: Unable to participate in full strength exam given language
barrier- will attempt later with sister.
SKIN: No rashes or ulcerations noted
NEURO: Unable to participate in full neurologic exam given
language barrier- will attempt later with sister.
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM:
====================
Vital Signs: reviewed in OMR afebrile and hemodynamically stable
General: no acute distress
HEENT: atraumatic, anicteric, eomi, oropharynx clear
Neck: supple
Heart: s1 s2
Lungs: ctab
Abdomen: soft nt nd no masses
Ext: no c/c/e
Neuro: aaox2 (not to date) which is his baseline
Psych: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS:
==================
___ 03:05AM BLOOD WBC-6.4 RBC-4.53* Hgb-13.9 Hct-42.4
MCV-94 MCH-30.7 MCHC-32.8 RDW-13.0 RDWSD-44.4 Plt ___
___ 03:05AM BLOOD Neuts-62.9 ___ Monos-8.6 Eos-1.1
Baso-0.5 Im ___ AbsNeut-4.04 AbsLymp-1.71 AbsMono-0.55
AbsEos-0.07 AbsBaso-0.03
___ 03:05AM BLOOD Glucose-93 UreaN-13 Creat-0.6 Na-140
K-4.4 Cl-103 HCO3-27 AnGap-10
MICRO:
=================
___ 2:40 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000 CFU/mL.
IMAGING:
=================
___ CHEST XRAY
Comparison to ___. Lung volumes have slightly
decreased. There
is a new parenchymal opacity in the left lower lobe, with air
bronchograms and
ill-defined borders, the location and morphology would be
consistent with
aspiration pneumonia. Borderline size of the cardiac silhouette
without
pulmonary edema. No pleural effusions. No pneumothorax.
___ HEAD CT
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass.
The ventricles
and sulci are normal in size and configuration.
No osseous abnormalities seen. The paranasal sinuses, mastoid
air cells, and
middle ear cavities are clear apart from minimal mucosal
thickening of the
right maxillary sinus. The orbits are unremarkable.
IMPRESSION:
No acute intracranial abnormality.
Brief Hospital Course:
This is a ___ male with past medical history of ALS
admitted ___ with abdominal pain, subsequently found to
have constipation, now status post resolution of constipation,
discharged to rehab.
#Abdominal pain:
#Constipation:
Patient presented with abdominal pain, thought to be from
constipation. Treated with bowel regimen with good effect.
Subsequently he had regular bowel movements with resolution of
symptoms--they did not recur. Maintained on daily miralax, with
prn Bisacodyl, then if not moving bowels prn fleet enema, then
if not moving bowels prn Magnesium Citrate 300mL. At discharge
he was pain free.
# Dysphagia secondary to ALS
During this admission patient had PEG electively placed. He was
seen by SLP and recommended to continue his modified diet. He
was seen by nutrition and underwent a calorie count. He was
felt to still be able to meet his nutritional needs with oral
intake--this was dependent on attentive assisted feedings, with
supplements: Magic Cup TID, Skandishake.
A video swallow study was performed by Speech pathology and
advised the following:
1. Diet: Pureed solids with nectar-thick liquids
2. Meds: whole or crushed in puree
3. Recommend allowing the patient to participate in the ___
Free Water protocol:
-Between meals, after oral care, allow the patient to drink
thin liquid water for comfort/quality of life. Continue to
adhere
to the below aspiration precautions.
4. Frequent oral care: Before and after meals; prior to
allowance
of thin liquid water as above.
5. Aspiration precautions:
- 1:1 feeding assistance
- Fully upright for all meals
- NO STRAWS; small, single sips of thin liquid via cup ONLY
- Alternate bites and sips
# ALS
Home regimen of riluzole and Nudexta unable to be continued
while admitted since family did not bring in, and they are
non-formulary. Restarted at discharge.
# BPH
Continued Tamsulosin
# Depression
Continued Sertraline
# R shoulder pain
Continued prn tramadol
Transitional issues
- Discharged to rehab
- Outpatient neurology team is ___; and
___
- Please utilize assisted feedings to ensure he is taking in
adequate nutrition; please check weights 3 times per week to
ensure he is meeting nutritional needs via PO intake; when
patient no longer felt to be able to meet nutritional needs via
PO intake, ___ nutrition recommends the following:
- Tube feeds: Jevity 1.5 starting @ 10 mL/hr and advance to
goal
of 55ml/hr (1980kcal, 84g protein and ~1L free water/day)
-Flush with 175ml H20 q6h (total ~1.7L free water/day )
- Monitor tolerance via abdominal exam, stool output and patient
complaint
- Cycle: Jevity 1.5 @ 110 mL/hr x 12 hrs
- Bolus: 5.5 cans/day (1320 mL)
- Adjust tube feeds based on % calories from po
> 30 minutes spent on discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild/Fever
2. LORazepam 0.5 mg PO DAILY:PRN anxiety
3. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
4. magnesium hydroxide 400 mg (170 mg) oral DAILY:PRN
constipation
5. sodium phosphates 7.2-2.7 gram/15 mL oral DAILY:PRN
constipation
6. dextromethorphan-quinidine ___ mg oral BID
7. riluzole 50 mg oral BID
8. TraMADol 50 mg PO QHS
9. Aspirin 81 mg PO DAILY
10. Tamsulosin 0.4 mg PO QHS
11. Sertraline 150 mg PO DAILY
12. Polyethylene Glycol 17 g PO DAILY
13. TraMADol 25 mg PO BID:PRN Pain - Moderate
14. Magnesium Citrate 300 mL PO DAILY:PRN constipation ___ line
Discharge Medications:
1. Artificial Tears ___ DROP BOTH EYES Q4H:PRN dry eyes
2. Fleet Enema (Saline) ___AILY:PRN constipation ___
line
3. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild/Fever
4. Aspirin 81 mg PO DAILY
5. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
6. dextromethorphan-quinidine ___ mg oral BID
7. LORazepam 0.5 mg PO DAILY:PRN anxiety
8. Magnesium Citrate 300 mL PO DAILY:PRN constipation ___ line
9. Polyethylene Glycol 17 g PO DAILY
10. riluzole 50 mg oral BID
11. Sertraline 150 mg PO DAILY
12. Tamsulosin 0.4 mg PO QHS
13. TraMADol 50 mg PO QHS
RX *tramadol 50 mg 1 tablet(s) by mouth at bedtime Disp #*2
Tablet Refills:*0
14. TraMADol 25 mg PO BID:PRN Pain - Moderate
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth twice a day
Disp #*3 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
# Dysphagia secondary to ALS
# Abdominal pain secondary to constipation
# ALS
# BPH
# Depression
# R shoulder pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. ___:
It was a pleasure caring for you at ___. You were admitted
with abdominal pain from constipation. You were treated with
laxatives and it improved.
While you were admitted, you had a PEG tube placed to help with
feeding in the future. We did not start any tube feeds because
you were able to meet your nutritional needs by eating. A video
swallow evaluation was performed by speech pathology and a
pureed solid/nectar thick liquid regular diet advised (no pork
or milk).
We wish you the best.
Sincerely,
Your care team at ___
Followup Instructions:
___
|
10680448-DS-6
| 10,680,448 | 29,967,987 |
DS
| 6 |
2134-08-05 00:00:00
|
2134-08-06 10:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
L shoulder pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENTING ILLNESS: Patient is a ___ with history of
CAD s/p CABG x2 ___, ___ and dyslipidemia who presents to
___ iso of several days of L-shoulder discomfort/pleuritic
chest pain associated with mild fatigue.
Patient returned from a regular trip to ___ ~10days ago (he
regularly travels long distances for work). Within the past four
days, patient began to experience mild, ___ discomfort 'deep
within' his left shoulder. He is unable to qualify the pain,
though says that it is neither sharp nor dull. No radiation or
associated SOB/diaphoresis. He also describes some anterior
left-sided chest pain with inspiration. There is no exertional
exacerbation. The pain seems to come and go at random. Patient
originally attributed his symptoms to exercise/over-use (he is
an avid athlete, often jogging/swimming nearly everyday of the
week). No recent trauma. Given his history of CAD as well as
persistent symptoms and also generalized fatigue, patient
decided to present to ___ Urgent Care. He was given
ASA 81x4 and told to present to the ___ for further
evaluation.
In the ED initial vitals were: 98.0 72 130/64 18 97% RA
EKG: NSR 69bpm, normal axis, isolated Qwave in III, TWI in III,
submm STE laterally
Past Medical History:
-CAD, s/p CABG ___ in ___: LIMA to LAD, RIMA to
posterior segment of marginal of circ, Radial to posterior
descending of RCA
-Hyperlipidemia
Social History:
___
Family History:
FAMILY HISTORY:
Grandfathers with CAD/MI
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VS: 97.8 124/74 67 18 95 RA
GENERAL: Pleasant male in NAD, breathing comfortably on RA
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: No JVP elevation.
CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops. No
thrills, lifts.
LUNGS: Resp were unlabored, no accessory muscle use. No
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: WWP. No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAM
=========================
VS: 98.3 PO 147 / 75 L Lying 75 18 95 RA
GENERAL: no acute distress, pleasant and conversant
HEENT: PERRL, EOMI, MMM
NECK: No JVP elevation, supple, full ROM
CARDIAC: regular rate and rhythm, no rubs murmurs or gallops.
LUNGS: clear to auscultation bilaterally, no wheezes or crackles
ABDOMEN: bowel sounds present, soft, NTND. No organomegaly.
EXTREMITIES: no cyanosis, clubbing, edema
SKIN: scattered psoriatic plaques on extensor surface of legs up
to knees bilaterally.
PULSES: 2+ distal pulses lower and upper extremities bilaterally
Pertinent Results:
ADMISSION LABS
================
___ 10:12PM BLOOD WBC-9.8 RBC-5.23 Hgb-15.0 Hct-44.0 MCV-84
MCH-28.7 MCHC-34.1 RDW-12.7 RDWSD-38.5 Plt ___
___ 10:12PM BLOOD Neuts-70.8 Lymphs-17.1* Monos-9.2 Eos-2.6
Baso-0.1 Im ___ AbsNeut-6.95* AbsLymp-1.68 AbsMono-0.90*
AbsEos-0.26 AbsBaso-0.01
___ 10:12PM BLOOD Plt ___
___ 01:25AM BLOOD ___ PTT-29.1 ___
___ 10:12PM BLOOD Glucose-116* UreaN-12 Creat-0.8 Na-141
K-4.5 Cl-101 HCO3-21* AnGap-19*
___ 10:12PM BLOOD ALT-63* AST-49* CK(CPK)-128 AlkPhos-125
TotBili-0.4
___ 10:12PM BLOOD Lipase-28
___ 10:12PM BLOOD cTropnT-0.13*
___ 10:12PM BLOOD CK-MB-3 proBNP-27
___ 10:12PM BLOOD Albumin-4.6
___ 10:37PM BLOOD Lactate-1.6
STUGIES/IMAGING
==================
EXERCISE STRESS
INTERPRETATION: This ___ yo man with h/o CAD, s/p CABG ___, was
referred to the lab from the inpatient floor for evaluation of
chest
discomfort with elevated troponins. The patient exercised for
9.5
minutes of ___ protocol and was stopped for fatigue. The
estimated
peak MET capacity was 10.6, which represents an average exercise
tolerance for his age. There were no reports of chest, back,
neck, or
arm discomforts during the study. There were no significant ST
changes
noted during exercise or recovery. Rhythm was sinus with rare
isolated
VPBs and two isolated APBs. There was a mildly blunted heart
rate
response to exercise in the absence of beta blockade. Mild
resting
diastolic hypertension with an appropriate blood pressure
response
during exercise and recovery.
IMPRESSION: No anginal type symptoms or ischemic EKG changes at
a high
cardiac demand and average functional capacity. Echo report sent
separately.
EXERCISE ECHO
The patient exercised for 9 minutes 30 seconds according to a
___ treadmill protocol ___ METS) reaching a peak heart rate
of 146 bpm and a peak blood pressure of 178/80 mmHg. The test
was stopped because of fatigue. This level of exercise
represents an average exercise tolerance for age and gender. In
response to stress, the ECG showed no ST-T wave changes (see
exercise report for details). with normal blood pressure and
heart rate responses to stress.
.
Resting images were acquired at a heart rate of 76 bpm and a
blood pressure of 136/90 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 36 seconds after peak stress
at heart rates of 138-118 bpm. These demonstrated appropriate
augmentation of all left ventricular segments. There was
augmentation of right ventricular free wall motion.
IMPRESSION: Average functional exercise capacity for age and
gender. No ECG or 2D echocardiographic evidence of inducible
ischemia to achieved workload. Normal hemodynamic response to
exercise. Mild mitral regurgitation at rest.
RUQ US
1. Normal liver parenchyma.
2. Echogenic hepatic lesion, consistent with hemangioma.
3. Mild splenomegaly.
DISCHARGE LABS
================
___ 04:35AM BLOOD WBC-8.1 RBC-4.93 Hgb-14.4 Hct-41.9 MCV-85
MCH-29.2 MCHC-34.4 RDW-13.0 RDWSD-39.9 Plt ___
___ 04:35AM BLOOD Plt ___
___ 04:35AM BLOOD ___ PTT-42.7* ___
___ 04:35AM BLOOD Glucose-92 UreaN-12 Creat-0.8 Na-143
K-4.3 Cl-103 HCO3-25 AnGap-15
___ 03:05PM BLOOD cTropnT-0.05*
___ 03:16AM BLOOD CK-MB-3 cTropnT-0.10*
___ 04:35AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.0 Cholest-184
___ 03:16AM BLOOD Iron-44*
___ 03:16AM BLOOD calTIBC-330 Ferritn-230 TRF-254
___ 04:35AM BLOOD %HbA1c-5.0 eAG-97
___ 04:35AM BLOOD Triglyc-105 HDL-45 CHOL/HD-4.1
LDLcalc-118
___ 03:16AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
___ 03:16AM BLOOD HCV Ab-NEG
Brief Hospital Course:
Mr. ___ is a ___ year old man with a history of CAD s/p CABG
x2 ___, ___ and dyslipidemia who presented with several
days of low-grade nonspecific L-shoulder discomfort and one hour
of pleuritic chest pain associated with mild fatigue, found to
have elevated troponin to 0.13. Problems addressed during this
hospitalization include the following:
# Chest pain
# Troponinemia:
Concern for ACS/ischemia given history of severe CAD s/p CABG,
TIMI score 4. Troponinemia improved during admission (0.13 10PM
--> 0.1 3AM --> 0.05 3PM). ___ be residual elevation from missed
MI 4 days ago, when pt had isolated hour of pleuritic chest pain
which has since resolved. EKG on admission, although without a
baseline for comparison, was not concerning. Left shoulder pain
may be musculoskeletal in the setting of increased exercise
regimen over the last week. Despite patient's frequent airplane
travel history, and recent trip to ___ ~10 days ago, concern
for PE was low due to Well's and PERC scores of 0. Exercise
stress test with echo was without evidence of ischemia. Heparin
gtt was given for <24 h. Patient remained hemodynamically stable
throughout admission, with continued low grade left shoulder
pain.
# Transaminitis: elevated liver enzymes (AST 49, ALT 63) Likely
fatty liver disease given obesity and history of dyslipidemia.
Hepatitis serologies and iron studies were normal. RUQ US was
also normal.
# Dyslipidemia: lipid panel and HbA1C were normal, continued
home rosuvastatin.
# TRANSITIONAL ISSUES:
- Please see medication list for any additions or changes to
medications.
- Set up PCP and cardiologist providers in ___,
current physicians are all located in ___.
- Consider monitoring of LFTs and concern for fatty liver
disease in outpatient setting.
# CODE STATUS: Full (confirmed)
# CONTACT: ___ (WIFE) ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Rosuvastatin Calcium 20 mg PO QPM
2. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Rosuvastatin Calcium 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Missed myocardial infarction
SECONDARY
Transaminitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you at the ___
___. You came to the hospital because you developed
pain in your chest when breathing, and also pain in your left
shoulder. You were concerned that these symptoms were related to
your heart function.
While you were in the hospital, we checked the function of your
heart with blood tests, EKGs, and an exercise stress test. Some
levels heart enzymes in your blood were elevated when you came
to the hospital, but the levels improved during your admission.
The results of all other tests we performed to evaluate your
heart were normal. We believe that your heart is healthy and you
are able to safely return home.
We also found that your liver enzymes slightly elevated when you
came to the hospital. We performed blood tests and an ultrasound
of your liver to evaluate this. These tests were all normal. We
believe these changes in your liver are related to your high
cholesterol levels. You should follow up your liver function
with your primary care physician.
Please be sure to follow up with your cardiologist and primary
care physician and to take all of your home medications.
We wish you all the best!
-Your ___ care team
Followup Instructions:
___
|
10680544-DS-21
| 10,680,544 | 22,728,334 |
DS
| 21 |
2138-03-26 00:00:00
|
2138-03-26 15:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abd Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ with no known PMHx who presented to the ED
today with the sensation that she has a blockage in her abdomen.
History is obtained from ED report only as pt is unable to given
any hx and I was unable to reach the listed contact (number
listed disconnected). Per report, the patient ate chocolate
last night and awoke today with the sensation that she has
something blocking her bowels. She attempted an enema, but had
no stool but had a small, normal BM without blood. In the ED,
the patient denied abdominal pain, chest pain, nausea, vomiting,
fevers, chills. She gestures to her lower abdomen where she
indicates she feels a blockage.
In the ED, initial vitals were: 99.1 ___ 16 98% RA.
Labs were notable for UA with lg leuks, blood, WBCs and
bacteria. CTAP was done and showed no acute process or
obstruction. EKG showed NSR without any acute changes. Pt
became agitated and was given quetiapine, Haldol x2, ceftriaxone
and KCL prior to admission for AMS and UTI
On the floor, unable to illicit any complaints.
Review of systems: unable to obtain
COLLATERAL HISTORY OBTAINED ___
The patient's friend of ___ years, and co-resident at her senior
housing complex, ___ came to visit and relayed the
following: ___ used to be quite vibrant and artistic, she
enjoyed beading and maintained a colorful room. She kept to
herself and does not really have any close supports to ___
knowledge. Lately, ___ has noted significant decline in the
patient's functioning. She states that ___ has been unkempt
and relates concern that she is probably not able to care for
herself at home as she does not leave the complex, she has no
known visitors bringing her groceries or food, and there are
foul
smells coming from both the patient and her apartment. She has
noted significant cognitive decline in ___ and ___ that
___ has been saying "I don't think I'm going to be around
much longer" and giving away her possessions to her and ___
___ does not know who ___ is but thinks she must be from
___, who assists some of the elders with meals. ___
states she is willing to act as a healthcare proxy for ___.
___ later told social work that she would like to designate
___ as her healthcare proxy.
Past Medical History:
no known, per report, patient has not seen a doctor in many
years
Social History:
___
Family History:
Patient does not know
Physical Exam:
ADMISSION PHYSICAL EXAM
======================
Vitals: 98.8 134/110 18 97% RA
Constitutional: Not responding to questions, mildly agitated,
not following commands, exhibiting odd behavior, putting socks
in pants and shirt, using them to blow her nose.
HEENT: unable to fully assess, yellow discharge from R eye, mm
dry
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Respiratory: Difficult to assess given pt making noises, clear
to auscultation bilaterally, no wheezes, rales, rhonchi
GI: Soft, non-tender, non-distended, bowel sounds present, no
organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, no CCE
Neuro: difficult to assess, moves all extremities freely
Skin: no rashes or lesions
DISCHARGE PHYSICAL EXAM
======================
VS: 98.5 PO 138 / 53 R Lying 79 18 100 RA
Gen: Ambulating around the floor with a walker, no acute
distress
Eyes: EOMI, no scleral icterus
HENT: NCAT
Neuro: Moving all extremities, ambulating without difficulty
Psych: Not oriented, good affect/mood
Pertinent Results:
ADMISSION LABS
___ 05:00PM URINE HOURS-RANDOM
___ 05:00PM URINE UHOLD-HOLD
___ 05:00PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 05:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-LG
___ 05:00PM URINE RBC-17* WBC-78* BACTERIA-FEW YEAST-NONE
EPI-2
___ 04:18PM LACTATE-1.3
___ 04:10PM GLUCOSE-95 UREA N-12 CREAT-0.6 SODIUM-135
POTASSIUM-3.0* CHLORIDE-99 TOTAL CO2-22 ANION GAP-17
___ 04:10PM estGFR-Using this
___ 04:10PM ALT(SGPT)-8 AST(SGOT)-22 ALK PHOS-131* TOT
BILI-1.2
___ 04:10PM LIPASE-16
___ 04:10PM ALBUMIN-3.9
___ 04:10PM TSH-8.6*
___ 04:10PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 04:10PM WBC-8.6# RBC-3.91 HGB-12.6 HCT-38.8 MCV-99*
MCH-32.2* MCHC-32.5 RDW-14.0 RDWSD-51.0*
___ 04:10PM NEUTS-82.6* LYMPHS-8.1* MONOS-7.9 EOS-0.1*
BASOS-1.0 IM ___ AbsNeut-7.13* AbsLymp-0.70* AbsMono-0.68
AbsEos-0.01* AbsBaso-0.09*
___ 04:10PM PLT COUNT-251
MICRO: cxs pending
CT ABD / PELVIS ___
1. A 1.2 cm pill is identified in the distal esophagus.
2. Large fecal load.
3. Pelvic floor descent.
4. Calcifications near the expected location of the urethra is
nonspecific and
may reflect urethral calculi.
CHEST X-RAY ___
No previous images. Hyperexpansion of the lungs is consistent
with underlying
chronic pulmonary disease. Cardiac silhouette is at the upper
limits of
normal in size and there is no evidence of vascular congestion,
pleural
effusion, or acute focal pneumonia.
EKG: NSR
MICROBIOLOGY
Blood cultures - E.Coli, S to CTX and ciprofloxacin
Urine cultures - E. coli, S to CTX and ciprofloxacin
Pertinent labs:
___ 06:50AM BLOOD calTIBC-265 Ferritn-78 TRF-204
___ 07:50AM BLOOD Folate-14.4
___ 04:10PM BLOOD VitB12-___*
___ 07:50AM BLOOD 25VitD-18*
___ 07:35AM BLOOD 25VitD-19*
Thyroid Trend:
___ 07:20AM BLOOD TSH-3.5
___ 07:57AM BLOOD TSH-5.4*
___ 06:55AM BLOOD TSH-5.9*
___ 04:10PM BLOOD TSH-8.6*
___ 06:55AM BLOOD Free T4-0.9*
Brief Hospital Course:
___ with no known PMHx who presented to the ED with reported
constipation, noted to have severe toxic/metabolic
encephalopathy with agitation, due to sepsis from E coli
bacteremia and urinary tract infection likely caused by Urinary
retention. She had a prolonged hospitalization (101 days) to
complete conser___, obtain ___ and confirm long
term placement. During her prolonged hospitalization she was
treated for chronic constipation and new onset hypothyroidism
but the majority of her course was uncomplicated without acute
medical issues.
# Acute encephalopathy with behavioral disturbances
# Urinary tract infection:
Mental status significantly improved with treatment of
underlying infection, although collateral information suggests
that she has been deteriorating cognitively for quite some time
now. She was initially treated ceftriaxone, then broadened to
cefepime, then narrowed to ciprofloxacin when sensitivities
returned. Day one of antibiotics was ___, the date of first
negative blood cultures, and a ___nded ___. A foley
catheter was placed for urinary retention on ___, a voiding
trial was attempted ___ and patient failed. Urinary retention
was felt to be due to severe constipation and hypothyroidism.
She completed two doses of Fosfomycin on ___ and ___ for
enterococcus UTI. She was started on Synthroid and given an
aggressive bowel regimen. Thereafter she voided and stooled
normally for the duration of her prolonged hospitalization
# Dementia:
# Social Situation:
While patient had acute encephalopathy in the setting of acute
illness, there are concerns for the patient's ability to care
for herself at home. She has limited social supports, is quite
physically frail, is thin/malnourished, extremely hard of
hearing and vision impaired limiting communication. Her
encephalopathy resolved following completion of antibiotics and
she appointed a health care proxy and signed a MOLST form.
During acute encephalopathy she was agitated requiring
haloperidol / zyprexa, and restraints PRN agitation for patient
safety and to avoid interfering with necessary medical care.
However, after acute medical illness resolved she remained
pleasant, appropriate and without delirium for the duration of
her prolonged hospitalization. She believed her hospital room
was her apartment and greeted visitors pleasantly, slept well
and ambulated hallways without difficulty. She remained in the
hospital for 101 days to obtain conservatorship. After a
prolonged period a conservator was obtained, court appointed and
___ application filed by conservator, see below for name,
she was discharged to long term care facility given inability to
care for herself at home.
#Severe malnutrition:
BMI 17 on admission with possible mild refeeding syndrome with
Hypernatremia, hypercalcemia, hypokalemia, hypophosphatemia.
Likely due to dehydration / poor PO intake; uncertain food
security and resources as outpatient. Electrolytes were
repleted PRN and she was given IV fluids. Nutrition was
consulted and supplements provided. She was started on thiamine
and multivitamin daily. For the duration of her hospitalization
she ate a regular diet without issues and maintained adequate
nutrition.
#Hypothyroidism:
Noted on last admission years ago but was never followed up
On admission, TSH was elevated at 8.6 and FT4 low at 0.7*,
started low dose
levothyroxine 12.5mcg on ___ which was then increased to 25mcg
on ___ as weight based dosing would suggest patient's chronic
dose should be 60mcg. TSH on ___ remained elevated and her dose
was increased to 37.5 and repeat TSH on ___ was therapeutic.
She was discharged on 37.5mcg and to have repeat TSH check on
___
# Conjunctivitis:
Caused by patient performing manual disimpaction at home with
poor hand hygiene. She completed a 7 day course of erythromycin
ointment at the beginning of her hospitalization.
# Vitamin D deficiency:
Vitamin D deficiency: started on 50,000 units weekly for 8 weeks
which was completed while in house.
TRANSITIONAL ISSUES:
# Needs repeat TSH in 6 weeks (___).
# Please monitor for chronic constipation
# CONTACT: ___ (friend, HCP) ___
# ___ is her conservator
# DNR/DNI/DNH, MOLST form completed
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 325-650 mg PO Q6H:PRN pain
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Fleet Enema ___AILY:PRN constipation
4. Lactulose 30 mL PO DAILY:PRN constipation
5. Levothyroxine Sodium 37.5 mcg PO DAILY
6. Milk of Magnesia 30 mL PO Q6H:PRN constipation
7. Multivitamins 1 TAB PO DAILY
8. Polyethylene Glycol 17 g PO DAILY
9. Senna 17.2 mg PO BID
10. TraZODone 25 mg PO QHS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary: E coli bacteremia, E coli urinary tract infection,
metabolic encephalopathy, dementia
Secondary: Urinary retention, Severe constipation,
Hypothyroidism
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were hospitalized for confusion due to a urinary tract
infection and blood stream infection. You were treated with
antibiotics and your constipation was relieved. You also have
low functioning thyroid which needs to be supplemented. You
stayed in the hospital while it was arranged for someone to
legally help you manage your affairs.
It was a pleasure caring for you,
Your ___ Doctors
___ take your medications as directed and follow up as noted
below.
Followup Instructions:
___
|
10681061-DS-7
| 10,681,061 | 28,208,612 |
DS
| 7 |
2201-02-25 00:00:00
|
2201-02-25 22:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Darvocet-N 100 / Vicodin
Attending: ___.
Chief Complaint:
============================
HMED History and Physical
============================
CC: ___ Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ year old female with PMH of CLL, TIIDM, A.
fib on Warfarin, and HTN who presented with 4 days of LLQ ABD
pain that started on ___. She had eaten some food, and was
washing dishes when she noted she felt weak in her knees. She
laid down for 3 hours. Her abdomen felt bloated and was painful
and persisted over the weekend. On presentation the pain was
improved but not resolved. She had no diarrhea, though was
having normal BMs. No recent bloody stool or melena. She did not
have any fevers, nause or vomiting.
In the ED. Labs showed a WBC of 90. Creatinine was 1.7 (baseling
1.3 from ___. CT showed diverticulitis and concern for
thickening of her colon at the splenic flexture that could be
consistent with malignancy.
This was discussed with the patient, her daughter, and GI. GI
will arrange for a colonoscopy in ___ weeks.
ROS per above, all other systems negative. Patient was feeling
well and tolerating PO on the floor.
Past Medical History:
ADULT ONSET DIABETES MELLITUS
ATRIAL FIBRILLATION
CHOLECYSTECTOMY
CHRONIC LYMPHOCYTIC LEUKEMIA
COLONIC POLYPS
HEMATURIA
HIP REPLACEMENT
HYPERTENSION
MITRAL REGURGITATION
SQUAMOUS CELL CARCINOMA
TONSILLECTOMY
AORTIC STENOSIS
H/O DIVERTICULITIS
Social History:
___
Family History:
Family history of hypertension
Physical Exam:
PE:
VS: afebrile, BP 150s/80s
Gen: elderly, NAD
HEENT: MMM, anicteric
Pulm: CTAB
CV: Irregularly irregular, III/VI SEM
GI: Soft, mild TTP no rebound or guarding in the LLQ
Skin: No rashes
Psych: mood appropriate
Pertinent Results:
Admission Labs:
___ 09:45PM BLOOD WBC-90.7*# RBC-3.29* Hgb-9.9* Hct-29.5*
MCV-90 MCH-30.1 MCHC-33.5 RDW-15.7* Plt ___
___ 09:45PM BLOOD Neuts-2* Bands-0 Lymphs-96* Monos-0 Eos-0
Baso-1 Atyps-1* ___ Myelos-0
___ 10:25PM BLOOD ___ PTT-29.2 ___
___ 09:45PM BLOOD Glucose-100 UreaN-65* Creat-1.7* Na-139
K-4.5 Cl-102 HCO3-26 AnGap-16
___ 09:45PM BLOOD ALT-17 AST-22 AlkPhos-85 TotBili-0.2
___ 09:45PM BLOOD Albumin-3.9
Imaging:
IMPRESSION:
Preliminary Report
1. New 4.5 cm segment of colon in the hepatic flexure with
concentric wall thickening and minimal stranding raises concern
for colonic neoplasm versus focal colitis. There is no adjacent
lymphadenopathy. Further assessment with colonoscopy versus
repeat CT after resolution of diverticulitis is recommended.
2. Minimal wall thickening with adjacent stranding about the
proximal sigmoid colon may represent mild uncomplicated
diverticulitis.
3. Prominent endometrial canal with probable fluid is noteworthy
in a patient of this age group. Further assessment with pelvic
ultrasound should be performed on a nonemergent basis.
4. Mild common bile duct dilatation as well as prominence of the
central intrahepatic biliary ducts are likely the result of
prior cholecystectomy.
5. High-grade stenosis at the origin of the celiac artery with
immediate reconstitution of flow.
Brief Hospital Course:
___ year old with HTN, CKD, CLL, atrial fibrillation on warfarin
who presents with diverticulitis.
1. Diverticulitis:
- uncomplicated
- mild symptoms with abdominal pain, no diarrhea, nausea,
vomiting. No documented fever.
- Started treatment with Cipro/Flagyl x 2 weeks
2. CT findings concerning for neoplasm with some associated
inflammation.
- Discussed with patient and daughter. ___ if they would want
further testing. Will discuss further with their PCP in
___.
- Discussed with GI, C-scope should take place after
inflammation improves and treatment is completed. Likely ___
weeks. They will arrange and notify the patient.
- She will be arranged for outpatient colonoscopy to evaluate
- I will notify her PCP of findings.
3. CKD:
- Baseline creatinine ~1.3, 1.7 on admit with most recent from
___. Improved to 1.5 on discharge with minimal
intervention.
4. HTN:
- Held ___, HCTZ on admission, resumed losartan on discharge,
and held HCTZ to be resumed as an outpatient.
5. A-fib:
- On warfarin
- continued rate control with metoprolol
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Losartan Potassium 100 mg PO DAILY
3. Metoprolol Tartrate 12.5 mg PO BID
4. Warfarin 4 mg PO DAILY16
5. Acetaminophen 1250 mg PO BID:PRN pain
6. Ascorbic Acid ___ mg PO DAILY
7. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral BID
8. Cyanocobalamin 100 mcg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Fish Oil (Omega 3) 1000 mg PO BID
Discharge Medications:
1. Metoprolol Tartrate 12.5 mg PO BID
2. Acetaminophen 1250 mg PO BID:PRN pain
3. Ascorbic Acid ___ mg PO DAILY
4. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral BID
5. Cyanocobalamin 100 mcg PO DAILY
6. Fish Oil (Omega 3) 1000 mg PO BID
7. Losartan Potassium 100 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Warfarin 4 mg PO DAILY16
10. Ciprofloxacin HCl 500 mg PO Q24H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth once a day
Disp #*13 Tablet Refills:*0
11. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*41 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Diverticulitis
Concern for malignancy of the colon
Atrial fibrillation
Hypertension
Chronic Kidney Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___-
You were admitted for an infection in your colon called
diverticulitis. Your abdominal pain was improving and you were
started on antibiotics. You did not have any fever, diarrhea,
nausea or vomiting.
You had a CT scan done which showed a thickening of your bowel,
which could be consistent with inflammation, infection, or
cancer. I discussed this with you and your daughter. Our
gastroenterologists are going to arrange for a colonoscopy in
___ weeks if you decide that you do want to have the procedure.
You will receive two weeks of antibiotics.
If you develop any worsening fever, chills, abdominal pain,
nausea vomiting, abdominal distension or severe constipation
please notify your physicians or return to the hospital.
Followup Instructions:
___
|
10681072-DS-10
| 10,681,072 | 20,638,505 |
DS
| 10 |
2177-05-23 00:00:00
|
2177-05-25 14:34:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ yoF with cholangiocarcinoma s/p Whipple on
___ gemcitabine who presents with fevers. She developed a
fever 4 days ago to 100.6. She also has had a few transient
(___) episodes of vertigo triggered by head movement last
episode day prior to arrival. Has had a slight sore throat, no
cough, SOB, CP. No ear pain. Had slight dysuria over the past
weekend. No abdominal pain or diarrhea. She was seen in ___
clinic yesterday and had an unremarkable UA. Today she again had
fevers and the onset of bladder pressure. She discussed her
symptoms with the heme/onc fellow who called her in Augmentin
(for GPC ___ in urine culture), of which she took one dose.
She then developed rigors and fever to 104 and presented to the
ED.
Of note, she is on cycle 3 of gemcitabine and on past cycles she
has had a fever on day 15.
In the ED, initial vitals were 104.4 117 138/80 16 98% RA. The
patient received 100mg acetminophen. CT abdomen pelvis
completed. Wet read not suggestive of infection. CXR also not
suggetive of infection. On transfer, the patient's vitals were
101.1 102 119/79 16 99%.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies blurry vision, diplopia, loss of vision,
photophobia. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations, lower
extremity edema. Denies cough, shortness of breath, or wheezes.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
melena, hematemesis, hematochezia. Denies dysuria, stool or
urine incontinence. Denies arthralgias or myalgias. Denies
rashes or skin breakdown. No numbness/tingling in extremities.
All other systems negative.
Past Medical History:
1) DIET CONTROLLED DIABETES MELLITUS
2) COLONIC ADENOMA ___ and in ___ by Dr. ___
3) H/O ABNORMAL PAP SMEAR ___ - CIN I. Colposcopy in ___ at
___, biopsy benign per patient's report. Pap normal since ___
4) H/O GASTRITIS ___- EGD showed gastritis, bx c/w chemical
gastritis. EGD o/w WNL. Dr. ___.
5) H/O BREAST LUMP ___ - Mammogram done at ___, BIRADS 1
in ___
ONCOLOGIC HISTORY:
Diagnosed with a 6mm moderately differentiated, pT3N0
extrahepatic cholangiocarcinoma with ___ LN and negative
margins (+ perineural invasion) after work-up for abdominal pain
and jaundice. She underwent an ERCP ___ that demonstrated a
single tight stricture of malignant appearance at the lower
third of the common bile duct. CBD brushings were suspicious for
malignancy. Imaging did not identify a defined mass, although
there was significant proximal intrahepatic and extrahepatic
biliary ductal dilatation with distal stricture. Minimally
elevated ___ pre-op (35). S/p whipple with Dr. ___
___. Started adjuvant chemotherapy (gemcitabine) ___.
Now on C3D15.
Social History:
___
Family History:
Father died of CVA. An uncle has a history of colon cancer.
Mother with breast CA. No FH of pancreatic / biliary cancer.
Physical Exam:
VITALS: 99.5, 110/71, 94, 16, 100% RA
GENERAL: NAD, comfortable
HEENT: NCAT, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
MMM NECK: supple, no LAD, no JVD
CARDIAC: RRR, S1/S2, no m/r/g
LUNG: CTAB, no w/r/r, no accessory muscle use
ABDOMEN: mildly tender LLQ, +BS, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: WWP, no c/c/e, 2+ DP pulses bilaterally
NEURO: CN II-XII intact, moving all extremities
VITALS: 99.1, 127/82, 88, 18, 100% RA
GENERAL: NAD, comfortable
HEENT: NCAT, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
MMM , Tympanic membranes clear, no evidence of infection
NECK: supple, no LAD, no JVD
CARDIAC: RRR, S1/S2, no m/r/g
LUNG: CTAB, no w/r/r, no accessory muscle use
ABDOMEN: mildly tender LLQ, +BS, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: WWP, no c/c/e, 2+ DP pulses bilaterally
NEURO: CN II-XII intact, moving all extremities
Pertinent Results:
Admission:
___ 01:48AM LACTATE-2.1*
___ 01:35AM ALT(SGPT)-32 AST(SGOT)-26 ALK PHOS-71 TOT
BILI-0.4
___ 01:35AM GLUCOSE-174* UREA N-13 CREAT-0.7 SODIUM-136
POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-27 ANION GAP-13
___ 01:35AM ALBUMIN-4.2 CALCIUM-8.8 PHOSPHATE-3.0
MAGNESIUM-1.7
___ 01:35AM WBC-5.7# RBC-3.93* HGB-11.6* HCT-34.6* MCV-88
MCH-29.5 MCHC-33.5 RDW-15.9*
___ 01:35AM NEUTS-85.8* LYMPHS-7.0* MONOS-6.7 EOS-0.2
BASOS-0.2
___ 01:35AM PLT COUNT-137*
___ 01:35AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 01:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 01:35AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 01:35AM URINE Color-Straw Appear-Clear Sp ___
Discharge:
___ 07:20AM BLOOD WBC-3.9* RBC-4.25 Hgb-12.2 Hct-37.1
MCV-87 MCH-28.6 MCHC-32.9 RDW-16.5* Plt ___
___ 07:20AM BLOOD Glucose-148* UreaN-9 Creat-0.5 Na-145
K-4.1 Cl-107 HCO3-28 AnGap-14
___ 10:03AM URINE Color-Yellow Appear-Clear Sp ___
Micro:
___ BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
___ BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
___ BLOOD CULTURE Blood Culture,
Routine-PENDING
___ 10:03 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 1:53 am URINE Site: NOT SPECIFIED
HEME S# 50Z UCU ADDED ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 12:00 pm STOOL CONSISTENCY: SOFT Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
Radiology Report CT ABD & PELVIS WITH CONTRAST Study Date of
___ 2:59 AM
IMPRESSION:
1. No acute findings to explain the patient's abdominal pain or
fever.
2. Expected postoperative appearance status post
pancreaticoduodenectomy with hepaticojejunostomy and
pancreaticojejunostomy as well as pylorus preservation with
anastomosis to small bowel.
3. Normal appendix.
4. Fibroid uterus containing IUD, similar to pelvic ultrasound
of ___.
5. Fluid-filled structure in the right lower quadrant
compatible with
hydrosalpinx also seen and similar to appearance from ___.
Radiology Report CHEST (PA & LAT) Study Date of ___ 12:57
AM
FINDINGS: The lungs are slightly under inflated, which
accentuates
bronchovascular markings. There is no focal consolidation
concerning for
pneumonia. No pleural effusion or pneumothorax is detected.
The pulmonary vasculature is not engorged. The cardiac
silhouette is normal in size. The mediastinal and hilar
contours are within normal limits. The trachea is midline. A
left subclavian approach Port-A-Cath is unchanged in position
with the tip terminating in the mid-to-distal SVC. Surgical
clips projecting in the right upper quadrant of the abdomen are
compatible with prior cholecystectomy.
IMPRESSION: No acute cardiopulmonary process and no change from
___.
Brief Hospital Course:
The patient is a ___ yoF with cholangiocarcinoma on C3D15
gemcitabine who presented with fevers and possible urinary tract
infection.
1. Fever: Patient presented with fevers to 104 at home. She has
had recurrent fevers with first two cycles of chemotherapy that
typically occur during the week following treatment. She is now
on cycle three, however fever occured prior to day 15
gemcitabine instead of after. She was seen in clinic 2 days
prior to arrival. The patient had a recent outpatient urine
culture that grew 10,000-100,000 Gram positive, alpha strep or
lactobillus and she was started on Augmentin, of which she only
took one dose prior to arrival. On admission her UA was
unremarkable. She also had new lef lower quadrant pain, however
no findings on abdominal CT to account for pain and fever. Only
other localizing symptoms was diarrhea that started morning of
arrival. Stool studies including C difficile were sent and
negative. Diarrhea subsequently resolved. Augmentin
discontinued in setting of clean UA, and patient monitored for
fever/infection to declare itself. She had a brief episode of
ear pain, but ___ were normal. Patient is not neutropenic,
although given her diagnois, likely still immunosuppressed to
some extent. She continued to have discomfort with urination
and UA with few bacteria and only 3 WBCS; Augmentin was
restarted prior to discharge for presumed UTI. Blood cultures
negative to date and pending on discharge.
2. Cholangiocarcinoma: Patient has cholangiocarcinoma s/p
Whipple, on gemcitabine chemotherapy C3D15 on arrival. She was
due to receive gemcitabine on day of arrival however, this was
deferred as patient febrile. She was continued on symptomatic
treatment of chemotherapy side effects with prochlorperazine,
ondansetron, Ativan, Peridex. She will follow up on ___ in
___ clinic to resume chemotherapy.
Transitional Issues:
- Blood cultures pending on discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
2. Lorazepam 0.5 mg PO Q4H:PRN nausea, insomnia, anxiety
3. Ondansetron 8 mg PO Q8H:PRN nausea
4. Prochlorperazine 10 mg PO Q6H:PRN nausea
5. Peridex *NF* (chlorhexidine gluconate) 0.12 % Mucous Membrane
BID
6. Acyclovir Ointment 5% 1 Appl TP ASDIR
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*13 Tablet Refills:*0
2. Lorazepam 0.5 mg PO Q4H:PRN nausea, insomnia, anxiety
3. Ondansetron 8 mg PO Q8H:PRN nausea
4. Prochlorperazine 10 mg PO Q6H:PRN nausea
5. Acyclovir Ointment 5% 1 Appl TP ASDIR
6. Peridex *NF* (chlorhexidine gluconate) 0.12 % Mucous Membrane
BID
7. Phenazopyridine 100 mg PO TID Duration: 3 Days
RX *phenazopyridine 100 mg 1 tablet(s) by mouth three times a
day Disp #*6 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: fever, urinary tract infection
Secondary: cholangiocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. ___,
___ was a pleasure taking care of you at ___
___. You were admitted with a fever and had a CT scan
of your abdomen which did not show any signs of infection. You
also had blood and urine cultures. The fever may have been due
to a urinary tract infection so we will start you on antibiotics
to treat this.
Medication Changes:
Please start Augmentin 875 mg every 12 hours for 7 days
Please use pyridium (phenazopyridine) 95 mg three times a day
for three days to help with urinary pain
Followup Instructions:
___
|
10681517-DS-13
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2147-06-14 00:00:00
|
2147-06-15 09:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
hypertensive urgency
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with delayed development, hypertension, chronic kidney
disease presents with hypertension. Patient was recently
admitted due to hypertensive emergency last week and discharged.
Per ED dash, the patient was seen by visiting nurse today and
she noted blood pressure was eleveated and was tachycardic. ___
recommended she come in for further evaluation. Patient denies
any chest pain, headache, changes in vision, fevers, chills,
cough, difficulty with urination or abdominal pain. She
otherwise feels well.
In the ED intial vitals were: 98.7 ___ 18 97% RA. She
was given home medications labetalol and minoxidil. She was
readmitted for HTN. Vitals on transfer: 98.4 107 164/95 18 96%
RA
On the floor, pt had a little dizziness that felt okay when she
was laying down. She otherwise had no acute complaints.
Past Medical History:
-IDDM, followed by ___. C/b retinopathy
-CKD, stage 3
-Asthma
-Reported sleep apnea
-Developmental delay
-S/p ankle surgery
-HL
-HTN
Social History:
___
Family History:
Mother decreased, h/o CAD and lung cancer. Sister with anemia
Father - DM
Physical ___:
ADMISSION EXAM
Vitals- 98.1 128/47 108 20 94 RA 111.7kg
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Tachycardic, reg rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE VITALS
Vitals- 98.4 ___ 98 20 98% RA
remainder of exam unchanged.
Pertinent Results:
ADMISSION LABS
___ 08:29PM BLOOD WBC-14.2*# RBC-4.75 Hgb-12.3 Hct-39.3
MCV-83 MCH-25.9* MCHC-31.3 RDW-14.4 Plt ___
___ 08:29PM BLOOD Neuts-79.3* Lymphs-13.2* Monos-4.7
Eos-2.4 Baso-0.4
___ 05:11PM BLOOD UreaN-40* Creat-2.0* Na-139 K-4.0 Cl-100
HCO3-29 AnGap-14
___ 04:00PM BLOOD Calcium-8.6 Phos-4.8* Mg-2.1
___ 08:29PM URINE Blood-TR Nitrite-NEG Protein-300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 08:29PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
DISCHARGE LABS
___ 08:40AM BLOOD WBC-10.3 RBC-4.14* Hgb-10.7* Hct-34.4*
MCV-83 MCH-25.9* MCHC-31.2 RDW-14.5 Plt ___
___ 08:40AM BLOOD Glucose-135* UreaN-41* Creat-2.2* Na-137
K-4.3 Cl-102 HCO3-25 AnGap-14
___ 08:40AM BLOOD Calcium-9.2 Phos-5.1* Mg-2.2
PERTINENT STUDIES
CXR ___
New mild-to-moderate pulmonary edema and new small left pleural
effusion.
Brief Hospital Course:
___ with delayed development, hypertension, chronic kidney
disease presents with hypertension.
ACUTE CARE
# Hypertensive urgency - Pt initially with BPs in the low 200s
though asymptomatic. Her BP came down with administration of
home medications. The pt reports taking all prescribed
medications at home, however, similar to the admission last
month, the patient's blood pressure easily responds to
medications when they are given. She actually has become
hypotensive both this admission and during the prior admission.
It stands to reason that she is not taking her medications at
home. She reports that her VNAs do not watch her take her
medications- they often trust her report that she has taken
them. Thus, we started her on a ___ plan in which the patient is
observed taking her medications.
Due to the hypotension which occurred when she did receive her
home medications, her minoxidil was stopped, clonidine patch was
decreased from 0.3 to 0.1mg weekly and her labetolol was
decreased from 600mg BID to ___ BID. Her blood pressure was in
the 130s systolic consistently on this regimen for about 24
hours prior to discharge. She should be on an ___ due to
concomittant DM but this was not started currently due to acute
on chronic kidney disease.
# Leukocytosis -resolved. WBC from 14 to 10. UA neg; CXR not
clearly infectious.
CHRONIC CARE
# IDDM - Complicated by retinopathy, nephropathy followed by
___. Held home metformin while in-house. She is on lantus and
aspart, but put on lantus and humalog while in-house as aspart
is non-formulary.
# CKD - Stage 3. Currently at baseline.
# Asthma: cont albuterol nebs, and fluticasone-salmeterol diskus
# HL - cont fenofibrate, rosuvastatin
TRANSITIONS IN CARE
# Code: Full (presumed)
# Emergency Contact: ___ (sister) ___,
___
# ISSUES TO DISCUSS AT FOLLOW UP:
- start the patient on an ___
# PENDING STUDIES: none
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze
3. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QFRI
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Aspart 12 Units Breakfast
Aspart 12 Units Lunch
Aspart 15 Units Dinner
Glargine 45 Units Bedtime
6. Labetalol 600 mg PO BID
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Minoxidil 5 mg PO Q6H
9. Rosuvastatin Calcium 40 mg PO DAILY
10. Spironolactone 100 mg PO DAILY
11. Albuterol Inhaler 2 PUFF IH Q4H:PRN qheeze
12. ammonium lactate 12 % topical daily
13. Clotrimazole Cream 1 Appl TP BID
14. fenofibrate 54 mg oral qhs
15. Lactaid (lactase) 3,000 unit oral TID w/ meals
16. Victoza 3-Pak (liraglutide) 0.6 mg/0.1 mL (18 mg/3 mL)
subcutaneous daily
17. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Aspart 12 Units Breakfast
Aspart 12 Units Lunch
Aspart 15 Units Dinner
Glargine 45 Units Bedtime
5. Labetalol 200 mg PO BID
RX *labetalol 200 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
6. Rosuvastatin Calcium 40 mg PO DAILY
7. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QWED
RX *clonidine 0.1 mg/24 hour apply to skin weekly Disp #*3 Unit
Refills:*0
8. Albuterol Inhaler 2 PUFF IH Q4H:PRN qheeze
9. ammonium lactate 12 % topical daily
10. Clotrimazole Cream 1 Appl TP BID
11. fenofibrate 54 mg oral qhs
12. Lactaid (lactase) 3,000 unit oral TID w/ meals
13. MetFORMIN (Glucophage) 500 mg PO BID
14. Victoza 3-Pak (liraglutide) 0.6 mg/0.1 mL (18 mg/3 mL)
subcutaneous daily
15. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
16. Outpatient Lab Work
Please check your chemistry: potassium, sodium, creatinine,
chloride, BUN, glucose. Please fax the results to ___,
___: ___ Fax: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
primary diagnosis:
hypertensive urgency
hypotension
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 high blood pressure. Please take your
blood pressure medications. Please note the changes to your
medications.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. We wish you all the best. Take care.
Followup Instructions:
___
|
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2152-01-11 00:00:00
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2152-01-11 19:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Toviaz
Attending: ___.
Chief Complaint:
Shortness of breath, hypertensive urgency
Major Surgical or Invasive Procedure:
Tunneled HD line placement ___, replaced ___
History of Present Illness:
Ms. ___ is a ___ year-old female with past medical history
significant for severe hypertension, OSA not on bipap, DM2, CKD
Stage IV, and HFpEF who presents with hypertension urgency.
Patient initially presented pre-operatively for placement of a
an AV fistula for planned initiation of dialysis. During
placement of an IV, patient was having pain and started
hyperventilating. She then began to feel acutely short of
breath. She was provided with an albuterol neb, but continued to
feel short of breath. She was then transferred to the ___ ED
for further evaluation. Notes that her symptoms improved with
rest.
Of note, patient has a history of severe hypertension with
history of non-adherence to medication regimen. She has
difficulty remembering to take her morning medication per review
of outpatient notes and takes most of her anti-hypertensives in
the morning. She was recently seen by cardiology who recommended
increasing her hydralazine dose to 100mg twice daily. In
addition, she was evaluated by sleep medicine in ___ and was
wound to have OSA and concern for possible central sleep apnea.
However, she was unable to tolerate CPAP at home, so has not
been wearing it.
In ED initial VS: ___ 25 99% Non-Rebreather
Labs significant for:
11.5
10.3 >----< 334
36.6
136|102|72
----------< 325
4.4|18|5.8
CK 1121 Trop T 0.10
BNP 4345
Patient was given:
+ Nitroglycerin SL x 3
+ Lorazepam 1mg PO
+ Nitro ggt
She was placed on BiPAP for presumed flash pulmonary edema.
Imaging notable for:
Low lung volumes. Relative increase in opacity projecting over
the lung bases, right greater than left, could relate to
overlying soft tissue, but consolidation due to pneumonia is
difficult to exclude, particularly at the right lung base. PA
and lateral views of the chest should be helpful for further
assessment, if/when patient able.
Consults: None
VS prior to transfer: ___ 20 100% Bipap
On arrival to the MICU, patient is sitting comfortably.
Complains of headache, but notes that it feels like her chronic
headache. She denies dyspnea, chest pain, palpitations. Denies
abdominal pain, nausea/vomiting.
Past Medical History:
HTN
HLD
Stage 4 CKD
OSA
Intellectual disability
Morbid obesity
HFpEF
Social History:
___
Family History:
Mother with history of CAD, stroke, and lung cancer.
Physical Exam:
PHYSICAL EXAM:
GENERAL: Lying comfortably in bed.
HEENT: EOMI, MMM, oropharynx clear
NECK: enlarged, JVP difficult to appreciate.
LUNGS: Good air movement throughout. No wheezes, rales, or
rhonchi.
CV: Tachycardic. No no murmurs, rubs, gallops.
ABD: Soft, obese, non-tender, non-distended, no rebound
tenderness or guarding
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Acanthosis nigricans rash on posterior neck. No other
rashes or lesions.
NEURO: CNII-XII intact. Strength ___ in upper and lover
extremities.
DISCHARGE PHYSICAL EXAM:
VS: ___ 0728 Temp: 99.1 PO BP: 145/80 L Sitting HR: 97 RR:
18 O2 sat: 98% O2 delivery: Ra FSBG: 182
General: Well-developed, obese female
HEENT: NC/AT, Sclera anicteric
Neck: supple, JVP not able to be assessed due to body habitus
Lungs: CTAB, no wheezes, rales, or rhonchi
CV: Distant heart sounds, 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, 1+ bilateral lower
extremity
edema to knees b/l, no clubbing, cyanosis.
Skin: No erythema or tenderness to palpation. Skin otherwise
warm, dry, no rashes. No evidence of bleeding at sites of pulled
catheters.
Neuro: Alert and interactive. Knows she is at ___ and why she
is here, though uncertain of the date/year.
Pertinent Results:
ADMISSION LABS
==============
___ 12:55PM BLOOD WBC-10.3* RBC-4.35 Hgb-11.5 Hct-36.6
MCV-84 MCH-26.4 MCHC-31.4* RDW-15.7* RDWSD-43.3 Plt ___
___ 12:55PM BLOOD Neuts-79.2* Lymphs-12.3* Monos-6.3
Eos-1.6 Baso-0.2 Im ___ AbsNeut-8.16* AbsLymp-1.27
AbsMono-0.65 AbsEos-0.17 AbsBaso-0.02
___ 01:10PM BLOOD ___ PTT-34.7 ___
___ 12:55PM BLOOD Glucose-325* UreaN-72* Creat-5.8* Na-136
Cl-102 HCO3-18* AnGap-16
___ 12:55PM BLOOD CK(CPK)-1121*
___ 12:55PM BLOOD CK-MB-10 MB Indx-0.9 cTropnT-0.10*
proBNP-4345*
___ 11:17PM BLOOD Calcium-8.5 Phos-5.3* Mg-2.1
___ 11:17PM BLOOD TSH-2.4
___ 01:04PM BLOOD Lactate-1.4 K-4.4
INTERVAL LABS
=============
___ 11:17PM BLOOD CK(CPK)-727*
___ 10:42AM BLOOD CK(CPK)-419*
___ 11:17PM BLOOD CK-MB-7 cTropnT-0.10*
___ 05:00AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
___ 05:00AM BLOOD HCV Ab-NEG
DISCHARGE LABS
==============
___ 04:45AM BLOOD WBC-10.7* RBC-3.85* Hgb-10.3* Hct-32.3*
MCV-84 MCH-26.8 MCHC-31.9* RDW-13.2 RDWSD-39.8 Plt ___
___ 04:45AM BLOOD Glucose-175* UreaN-79* Creat-7.2* Na-140
K-5.6* Cl-101 HCO3-21* AnGap-18
___ 04:45AM BLOOD Calcium-9.3 Phos-7.3* Mg-2.5
MICROBIOLOGY
============
Urine culture ___ - MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES),
CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.
Blood culture ___ - NO GROWTH.
Blood cultures ___ - NGTD
Urine legionella antigen ___ - NEGATIVE
IMAGING
=======
CXR ___
Low lung volumes. Relative increase in opacity projecting over
the lung
bases, right greater than left, could relate to overlying soft
tissue, but
consolidation due to pneumonia is difficult to exclude,
particularly at the right lung base. PA and lateral views of
the chest should be helpful for further assessment, if/when
patient able.
CXR ___
Low lung volumes with mild pulmonary edema. Opacity at the
right lung base does not appear appreciably changed and is
concerning for pneumonia.
Brief Hospital Course:
*** Patient scheduled for AV fistula creation at ___ on ___.
The transplant coordinator will be in contact with your facility
with more information regarding time and exact location. If you
do not hear from them by noon on ___, please call ___.
She should be NPO at midnight on ___ in preparation for
surgery. ***
Ms. ___ is a ___ year-old woman with a history of severe
hypertension, OSA not on BiPAP, DM2, CKD Stage IV, and HFpEF,
who initially presented with tachypnea and concern for
hypertensive urgency while getting AV-fistula placement
requiring brief MICU stay for antihypertensive drip and quickly
weaned and called out to regular floor. Hospital course was
complicated by labile BPs, uncontrolled blood glucose,
community-acquired pneumonia, end-stage renal disease requiring
hemodialysis initiation, and altered mental status.
ACUTE ISSUES
# Acute respiratory distress
Patient initially referred to hospital from outpatient procedure
for AV fistula placement with acute respiratory distress.
Differential included hypertensive emergency vs. flash pulmonary
edema vs. reactive airway disease. She was admitted to the MICU
for parenteral hypertension control (see below) and her
respiratory distress resoled without acute intervention.
# Hypertensive urgency
Patient noted to be hypertensive to 225/133 upon presentation
consistent with hypertensive urgency. She was admitted to the
MICU and initiated on a nitroglycerin drip with significant
improvement in her hypertension. She was transitioned to her
outpatient PO antihypertensive regimen and called out to the
floor. While on the floor, patient was noted to be hypotensive
to the ___ systolic. Given this response to restarting her
home regimen, it is strongly suspected that the patient's
hypertension in the outpatient setting was in large part due to
medication noncompliance. Ultimately, her antihypertensive
regimen was reduced to labetalol 300mg PO with a goal SBP ~140.
# ESRD on dialysis
Patient presented with CKD stage 4 and was being followed by
nephrology on an outpatient basis for consideration of RRT vs.
transplant. While inpatient, her azotemia progressed and
requiring initiation of hemodialysis. She had a right chest HD
line placed on ___ with initiation of dialysis on the same day.
She received her second session on ___, but accidentally pulled
out her HD line on ___ prior to her third HD session. Her
HD line was replaced by ___ on ___ (unfortunately the right IJ
was completely occluded requiring placement in the left IJ) and
she underwent her third session of HD on ___. At time of
discharge she was scheduled to continue her intermittent HD as
an outpatient. She was continued on her calcitriol 3x weekly and
calcium acetate.
# Possible community-acquired pneumonia
Patient was noted to have a new leukocytosis and opacification
seen on CXR on ___ concerning for community-acquired pneumonia.
Given these concerns and her multiple comorbidities, the
decision was made to treat with a 5 day course of levofloxacin,
which she completed on ___.
# Altered mental status
Throughout her hospitalization patient was noted to have altered
mental status that waxed and waned, sometimes being so sleepy
that she could not hold a conversation and other times being
awake and alert. This was likely multifactorial with
contributions from uremia, hospital-acquired delirium, and
toxic-metabolic encephalopathy iso possible CAP. Her mental
status was significantly improved by the time of discharge.
# Insulin dependent DMII
Very labile blood glucose measurements ranging from >400 to <60.
Notably, the patient came in on a regimen of U500. It is likely
that her outpatient diet is not consistent with a diabetic diet,
prompting her widely variable blood sugars once her diet was
carbohydrate controlled. Ultimately, ___ was consulted and
recommended a basal-bolus regimen with standing glargine and
Humalog in addition to a Humalog sliding scale. This regimen
will most likely need to be adjusted on an outpatient basis when
she resumes her normal diet. The patient was scheduled to follow
up with ___ after discharge in order to help address these
concerns.
# Elevated CK
Elevated on admission to 1121. Unclear etiology. Patient's
rosuvastatin was held and her CK downtrended to 419. Outpatient
providers can make further decisions regarding restarting statin
therapy.
CHRONIC ISSUES
# HFpEF
Patient with history of HFpEF and mild pulmonary congestion on
initial CXR. Her volume exam was quite difficult as she has
long-standing ___ edema and her body habitus made JVD assessment
difficult. She did not require supplemental oxygen after her
initial presentation, despite holding her home torsemide. Plan
for volume management going forward was through intermittent HD.
Resuming diuretic can be considered on an outpatient basis.
# OSA
Patient with OSA and possible central sleep apnea, though
noncompliant with CPAP at home. This should continue to be
addressed by her outpatient providers.
TRANSITIONAL ISSUES
[ ] Statin - held in the setting of elevated CK, as above. Can
be restarted at the discretion of her outpatient provdiers.
[ ] CPAP - noncompliant with CPAP as an outpatient. Should
continue to be addressed.
[ ] HTN regimen - Her outpatient regimen was significantly
deescalated while hospitalized secondary to hypotension. We
acknowledge that she is likely noncompliant with diet and
medications as an outpatient, and her regimen will likely need
ongoing titration.
[ ] DMII regimen - Also significantly modified while she was
inpatient in the setting of several episodes of hypoglycemia.
___ was consulted and helped establish a glargine/Humalog
regimen that the patient will be discharged on. She has follow
up scheduled with ___ for ongoing management as an
outpatient.
[ ] Diuretics - her home torsemide was held in the setting of
labile BPs. After initiation of dialysis, plan was to manage her
volume status with intermittent HD. Consideration of restarting
her diuretic can be made on an outpatient basis.
*** Patient scheduled for AV fistula creation at ___ on ___.
The transplant coordinator will be in contact with your facility
with more information regarding time and exact location. If you
do not hear from them by noon on ___, please call ___.
She should be NPO at midnight on ___ in preparation for
surgery. ***
*** ABSOLUTELY NO BLOOD DRAWS, PERIPHERAL IVS, OR BLOOD
PRESSURES ARE TO BE PERFORMED ON THE PATIENT'S LEFT SIDE ***
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Doxazosin 8 mg PO HS
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
3. Losartan Potassium 50 mg PO DAILY
4. trospium 20 mg oral BID
5. Ketoconazole Shampoo 1 Appl TP ASDIR
6. Metoprolol Succinate XL 400 mg PO DAILY
7. Docusate Sodium 200 mg PO QHS
8. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QMON
9. Cyclobenzaprine ___ mg PO HS:PRN back pain
10. Lactaid (lactase) 3,000 unit oral TID W/MEALS
11. amLODIPine 10 mg PO DAILY
12. HydrALAZINE 75 mg PO BID
13. Rosuvastatin Calcium 40 mg PO QPM
14. Torsemide 60 mg PO DAILY
15. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
16. Aspirin 81 mg PO DAILY
17. Loratadine 10 mg PO DAILY:PRN allergies
18. FoLIC Acid .4 mg PO DAILY
19. Calcitriol 0.25 mcg PO 3X/WEEK (___)
20. U-500 Conc 80 Units Breakfast
U-500 Conc 60 Units Lunch
U-500 Conc 60 Units Dinner
21. Calcium Acetate 667 mg PO QIDWMHS
22. Esomeprazole 20 mg Other DAILY
23. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
24. Cyanocobalamin 500 mcg PO DAILY
25. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - First Line
2. Bisacodyl ___AILY:PRN Constipation - First Line
Reason for PRN duplicate override: Alternating agents for
similar severity
3. Oxymetazoline 1 SPRY NU BID:PRN Epistaxis Duration: 3 Days
4. Polyethylene Glycol 17 g PO DAILY
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
Reason for PRN duplicate override: Alternating agents for
similar severity
6. FoLIC Acid 1 mg PO DAILY
7. Glargine 20 Units Dinner
Humalog 2 Units Breakfast
Humalog 2 Units Lunch
Humalog 2 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
8. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
10. Aspirin 81 mg PO DAILY
11. Calcitriol 0.25 mcg PO 3X/WEEK (___)
12. Calcium Acetate 667 mg PO QIDWMHS
13. Cyanocobalamin 500 mcg PO DAILY
14. Cyclobenzaprine ___ mg PO HS:PRN back pain
15. Docusate Sodium 200 mg PO QHS
16. Esomeprazole 20 mg Other DAILY
17. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
18. Ketoconazole Shampoo 1 Appl TP ASDIR
19. Lactaid (lactase) 3,000 unit oral TID W/MEALS
20. Loratadine 10 mg PO DAILY:PRN allergies
21. trospium 20 mg oral BID
22. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
===================
Acute respiratory distress
Hypertensive urgency
Secondary Diagnoses
====================
ESRD requiring HD
Community acquired pneumonia
Uncontrolled diabetes
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ from ___.
WHY WAS I ADMITTED?
========================
- You were admitted because you became short of breath prior to
your procedure to have a fistula created in your arm for
dialysis.
- Your blood pressure was very high, which required you to be
hospitalized.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
===========================================
- You were briefly admitted to the Intensive Care Unit for
management of your high blood pressure.
- We adjusted your blood pressure medications to get better
control.
- We had difficulty controlling your blood sugars, so our
diabetes experts at ___ helped us develop a better insulin
regimen.
- You were treated for pneumonia.
- You had a catheter placed in your chest and began hemodialysis
through this catheter.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
=============================================
- You have surgery scheduled for ___ for creation of
your AV fistula. The transplant coordinator will contact your
rehab facility to notify them of time and place, in addition to
any other specific instructions. If you have not heard from them
by noon on ___, please call ___.
- Take all of your medications, as prescribed. We suspect that
your blood pressure has been so high recently because you were
not always taking your medications.
- Follow up with your primary care doctor and your kidney doctor
after you leave rehab.
- Follow up with your new diabetes doctors at ___ as
scheduled.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
It was a pleasure caring for you!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10681517-DS-15
| 10,681,517 | 25,590,198 |
DS
| 15 |
2152-08-10 00:00:00
|
2152-08-13 13:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Toviaz
Attending: ___
Chief Complaint:
___ F w/ ESRD on HD presents with L hemibody weakness since
around the morning/afternoon on ___ at church.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
She states that she was in church yesterday and around 10 am or
perhaps the afternoon, she noted that she began to have L sided
facial droop, L sided weakness. She denies having these symptoms
in the past and denies having had previous strokes. She had told
nursing the symptoms began after awaking from a nap during
church, though she does not volunteer this information to me.
She
states this persisted throughout the day yesterday. Today when
she woke up the symptoms were worse, so she presented for
evaluation. She denies any recent infectious symptoms. She
states that she had some trouble putting clothes on yesterday
morning but denied unilateral weakness at that time. She also
noted
walking was harder yesterday. She has dialysis MWF, and had her
last dialysis ___. She has not had her ___ yet, because
she is here.
ROS:
On neurological review of systems, the patient denies headache,
confusion, difficulties producing or comprehending speech, loss
of vision, blurred vision, diplopia, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the patient denies recent fever,
chills, night sweats, or recent weight changes. Denies cough,
shortness of breath, chest pain or tightness, palpitations.
Denies nausea, vomiting, diarrhea, constipation or abdominal
pain. Denies dysuria, or recent change in bowel or bladder
habits. Denies arthralgias, myalgias, or rash.
Past Medical History:
HTN
HLD
Stage 4 CKD
OSA
Intellectual disability
Morbid obesity
HFpEF
Social History:
___
Family History:
Mother with history of CAD, stroke, and lung cancer.
Physical Exam:
On admission
Vitals: T98.3 HR90 BP:136/80 RR:20 98% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history.
Attentive, able to name ___ backward without difficulty.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors. Able to name
both high and low frequency objects. Able to read without
difficulty. There is some guttural dysarthria. Able to follow
both midline and appendicular commands. There was no evidence of
apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation and finger
count. Did not blink to threat bilaterally.
V: Facial sensation intact to light touch.
VII: L face activates more slowly.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk and tone throughout. No pronator drift. No
adventitious movements, such as tremor or asterixis noted.
[___]
L 4 5- 4 4 4 ___ 4 4 5 5
R 5 5 5 5 5 ___ 5 5 5 5
L arm and leg drift down and are lower than the other side.
-Sensory: No deficits to light touch, pinprick, temperature,
vibration, or proprioception throughout. No extinction to DSS.
Romberg absent.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF or HKS bilaterally.
-Gait: deferred
Discharge Physical Exam
========================
Physical Exam:
Vitals: 24 HR Data (last updated ___ @ 1549)
Temp: 98.9 (Tm 99.2), BP: 142/82 (142-165/82-96), HR: 90
(87-98), RR: 17 (___), O2 sat: 96% (96-100), O2 delivery: Ra
General: Awake, cooperative, obese woman sitting up in a chair
in
NAD.
HEENT: NC/AT, no scleral icterus noted, MMM
Pulmonary: Breathing comfortably, no tachypnea nor increased WOB
Cardiac: skin warm, well-perfused.
Abdomen: soft, ND
Extremities: Symmetric, no edema. pain to palpation of left
calf,
no edema, mild pain to palpation of foot, no ulceration or cuts
seen on left foot
Neurologic:
-Mental Status: Alert. Attentive, able to name ___ backward
without difficulty. Language is fluent with intact and
comprehension to cross body commands on second effort.
Repetition
correct of four word phrases but not grammatically complex
phrases. There were no paraphasic errors. Naming intact to high
and medium, but not low frequency objects.
-Cranial Nerves: PERRL 4mm and minimally reactive. No rAPD. EOMI
but unable to follow finger unless told to look in various
directions, no BTT bilaterally, left facial droop but with
encouragement can activate left side. Hearing intact to
conversation. Palate elevates symmetrically. Tongue protrudes in
midline and moves briskly to each side. Mild labial dysarthria.
-Motor: Normal bulk, tone throughout. No adventitious movements,
such as tremor, noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA
L 2 4 4+ 3+ 4+ ___ 4 4+
R 5 ___ ___ 5 5 5
-Sensory: deferred
Pertinent Results:
Admission Labs
===============
___ 10:00AM BLOOD WBC-9.2 RBC-4.06 Hgb-10.9* Hct-34.8
MCV-86 MCH-26.8 MCHC-31.3* RDW-13.7 RDWSD-41.7 Plt ___
___ 10:00AM BLOOD Glucose-243* UreaN-83* Creat-8.1*# Na-135
K-5.3 Cl-97 HCO3-21* AnGap-17
___ 10:00AM BLOOD Albumin-4.7 Calcium-9.9 Phos-6.3* Mg-2.0
Important interval labs
========================
___ 05:20AM BLOOD %HbA1c-9.2* eAG-217*
___ 05:20AM BLOOD Triglyc-215* HDL-26* CHOL/HD-4.3
LDLcalc-44
___ 05:20AM BLOOD TSH-2.2
Discharge Labs
===============
___ 06:30AM BLOOD WBC-7.4 RBC-3.73* Hgb-10.1* Hct-32.0*
MCV-86 MCH-27.1 MCHC-31.6* RDW-13.4 RDWSD-41.9 Plt ___
___ 06:30AM BLOOD Glucose-173* UreaN-47* Creat-7.1* Na-144
K-4.7 Cl-102 HCO3-25 AnGap-17
___ 05:20AM BLOOD ALT-6 AST-11 LD(LDH)-198 AlkPhos-94
TotBili-0.4
IMAGING
========
-CTA HEAD and NECK ___
1. Sequela of chronic bilateral occipital lobe (left greater
than right), left
parietal lobe, and right corona radiata and posterior limb of
the right
internal capsule infarcts. However, these findings are new
compared to CT
head on ___.
2. No evidence of recent infarct, hemorrhage or intracranial
mass.
3. No new infarct identified on the perfusion images. Perfusion
abnormalities
correspond to the sequela of prior infarctions.
4. Patent cervical and intracranial vasculature without
evidence of
dissection, stenosis, occlusion or aneurysm formation greater
than 3 mm.
5. Incidental note is made of fetal type posterior cerebral
arteries.
-MR HEAD on ___
1. Recent infarcts in the left parieto-occipital lobe, in a
region adjacent to prior infarction, and in the right globus
pallidus/posterior limb of the internal capsule and right medial
temporal lobe. No evidence of hemorrhagic transformation.
2. Sequela of prior infarction in the left parieto-occipital
region and right occipital lobes.
3. Superficial siderosis in the region of encephalomalacia in
the left
parietooccipital lobe and additional microhemorrhages in the
left globus
pallidus and left insular region.
4. Old lacunar infarct in the left centrum semiovale.
5. Nonspecific scattered white matter changes in the cerebral
hemispheres
bilaterally likely reflect chronic small vessel ischemic changes
which are
more than expected for patient's age.
-Duplex L lower extremity vein ___
No evidence of deep venous thrombosis in the left lower
extremity veins
-TTE **
Brief Hospital Course:
Ms. ___ came into the ED at ___ on ___ due to L
hemibody weakness and dysarthria. She underwent a CTA head and
neck which showed Sequela of chronic bilateral occipital lobe
(left greater than right), left parietal lobe, and right corona
radiata and posterior limb of the right internal capsule
infarcts.
#Right anterior choroidal infarct: CT head with hypodensity in
right coronal radiate and posterior limb of internal capsule.
CTA without evidence of large vessel occlusion. Therefore given
unclear last known well and evidence of possibly completed
infarct on CT without LVO she was not candidate for thrombectomy
or tpa. MRI showed multiple chronic infarcts, notably several
large territory infarctions in the territories of bilateral
PCAs. Of note she does have bilateral fetal PCAs. MRI also
showed new right anterior choroidal artery distribution infarct,
responsible for her presentation. Given pattern of chronic
infarcts and current anterior choroidal artery infarct, highest
suspicion is for cardioembolic etiology vs atheroembolic though
there was not a large amount of extracranial atherosclerotid
disease on CTA. She has multiple vascular risk factors and
evidence of white matter disease on MRI therefore, small vessel
disease cannot be excluded. She was started on aspirin and
Plavix. TTE was showed moderate symmetric LVH but no
cardioembolic source. Risk factors were notable for HgbA1c 9.2
and LDL 44. She was continued on her home rosuvastatin.
She was discharged with zio patch for outpatient telemetry
monitoring.
#ESRD, on HD ___: she was continued on her home ESRD
medications and followed by renal. She received HD on ___ on
admission, ___. She was continued on her home torsemide during
admission.
#Chronic back pain: her pain was managed with tylenol and
lidocaine patch.
#Calf pain: during admission she developed new left calf pain to
palpation. Lower extremity ultrasound was negative for DVT.
#Diabetes: ___ was consulted to assist with management of
diabetes. HgbA1C 9.2. Her home insulin 70/30 was increased
slightly to 34 units BID.
#HTN: iso acute stroke her blood pressure was allowed to
autoregulate and her home antihypertensive medications were
held. She was continued on her home Carvedilol but at half dose.
amlodipine 10/valsartan 320 daily**
#GERD: her home esomeprazole was replaced with pantoprazole due
to interaction with Plavix.
Transitional Issues
====================
[] insulin increased slightly to 34 units BID per ___ for
better BG control
[] She was discharged with outpatient telemetry with Zio patch
to monitor for A fib
[] Neurology: Discharged on DAPT (aspirin, Plavix) for 3 months,
will continue aspirin thereafter
[] HD ___
[] Follow up with Neurology
[] Neurology: Noted to have fetal PCAs on CTA
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No. If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
() Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL = 44 ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharm___
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - () No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - If no, why not (I.e.
bleeding risk, etc.) (x) N/A
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. amlodipine-valsartan ___ mg oral Daily
3. Calcitriol 0.25 mcg PO 3X/WEEK (___)
4. CARVedilol 12.5 mg PO BID
5. Esomeprazole 20 mg Other Daily
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. Polyethylene Glycol 17 g PO DAILY
8. Rosuvastatin Calcium 40 mg PO QPM
9. trospium 20 mg oral BID
10. Aspirin 325 mg PO DAILY
11. Cyanocobalamin 500 mcg PO DAILY
12. Loratadine 10 mg PO DAILY
13. Senna 8.6 mg PO BID
14. Torsemide 80 mg PO 3X/WEEK (___)
15. Torsemide 60 mg PO 4X/WEEK (___)
16. sevelamer CARBONATE 1600 mg PO TID W/MEALS
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
2. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
3. Docusate Sodium 100 mg PO BID
4. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
5. Glucose Gel 15 g PO PRN hypoglycemia protocol
6. 70/30 34 Units Breakfast
70/30 34 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
7. Lidocaine 5% Patch 1 PTCH TD QPM
8. Pantoprazole 40 mg PO Q24H
9. Aspirin 81 mg PO DAILY
10. CARVedilol 6.25 mg PO BID
11. Loratadine 10 mg PO EVERY OTHER DAY
12. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
13. amlodipine-valsartan ___ mg oral Daily
14. Calcitriol 0.25 mcg PO 3X/WEEK (___)
15. Cyanocobalamin 500 mcg PO DAILY
16. Esomeprazole 20 mg Other DAILY
17. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
18. FoLIC Acid 0.4 mg PO DAILY
19. Polyethylene Glycol 17 g PO DAILY
20. Rosuvastatin Calcium 40 mg PO QPM
21. Senna 8.6 mg PO BID
22. sevelamer CARBONATE 1600 mg PO TID W/MEALS
23. Torsemide 80 mg PO 3X/WEEK (___)
24. Torsemide 60 mg PO 4X/WEEK (___)
25. trospium 20 mg oral BID
26. Vitamin D2 (ergocalciferol (vitamin D2)) 50,000 unit oral
Once a week
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute ischemic stroke
End stage renal disease on hemodialysis
type 2 diabetes mellitus
hypertension
hyperlipidemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of left weakness
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
-high blood pressure
-high cholesterol
-uncontrolled diabetes
-chronic kidney disease
-obstructive sleep apnea
-obesity
We are changing your medications as follows:
-Take Plavix in addition to Aspirin for the next three months.
Keep take aspirin only after this
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911).
In particular, since stroke can recur, please pay attention to
the sudden onset and persistence of these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10681659-DS-21
| 10,681,659 | 23,796,132 |
DS
| 21 |
2127-05-28 00:00:00
|
2127-05-28 23:56:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
___ yo presents with 4 days of worsening stabbing RLQ pain and
nausea. Slowly progressive. No radiation. No emesis. Has been
having several weeks of postprandial nausea, adbominal pain and
occasional regurgitation. CT a/p done in ED showed possible
walled off cecal perforation and possible mass. She was seen by
surgery who recommended IV abx and Gi was consulted for
colonoscopy.
Past Medical History:
asthma
Social History:
___
Family History:
dather with diabetes
Physical Exam:
General: Doing well, ambulating, pain controlled with PO
medications
Neuro: A&OX3
Cardio/pulm: no sob or chest pain
Abd: soft, incisions intact
Ext: no edema
Pertinent Results:
___ 07:40PM GLUCOSE-97 UREA N-12 CREAT-0.7 SODIUM-137
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-24 ANION GAP-16
___ 07:40PM ALT(SGPT)-15 AST(SGOT)-21 ALK PHOS-90 TOT
BILI-0.4
___ 07:40PM LIPASE-31
___ 07:40PM ALBUMIN-4.2
___ 07:15AM IRON-25*
___ 07:15AM calTIBC-255* FERRITIN-55 TRF-196*
___ 07:15AM WBC-7.7 RBC-3.67* HGB-10.6* HCT-32.4* MCV-88
MCH-28.9 MCHC-32.7 RDW-13.3
___ 07:15AM NEUTS-77.7* LYMPHS-16.3* MONOS-5.2 EOS-0.4
BASOS-0.3
___ 07:15AM PLT COUNT-283
___ 07:15AM RET AUT-1.5
CT Abd/pel IMPRESSION: Findings most concerning for a cecal mass
and worrisome for malignancy. A severe atypical infectious
process is unlikely given the apparent solid irregular
enhancement of the cecal wall in this region. No evidence of
frank bowel perforation although ulceration may be present with
bulging of the wall focally. Hyperenhancing nodes in the right
lower quadrant are suspicious for involvement. Recommend further
evaluation with colonoscopy.
No liver lesion.
Brief Hospital Course:
___ yo with asthma presents with new finding of cecal mass
concerning for malignancy. Final CT read without perforation. GI
to call colorectal surgery as they want to request ___ or
___ specifically. ACS was following, and decision was made
to forgo colonoscopy given high risk of perforation with
insufflation. She remained on clear liquids on the days
preceding her surgery, bowel prep performed on ___, and went
to the OR on ___. The procedure went well without
complications. She was extubated in the operaitng room and
transferred to the post anesthesia care unit. She remained in
stable in the PACU and was later transferred to the floor. She
was given sips of clear liquids which she tolerated well. The
epidural was in place and controlled the pain well. On the
second day after surgery, she reported feeling hungry however
tolerated only a small amount of sips. Her diet was advanced and
she could pick and choose what she would eat. The Foley catheter
came out and she was able to void without issues. Redness was
noticed along the incision for which 5 day course of antibiotic
was initiated. On postoperative day three, the epidural was
removed without issue. She was tolerating a regular diet, her
pain was well controlled with oral pain medication.
On ___, the patient was discharged to home. At discharge,
she was tolerating a regular diet, voiding, and ambulating
independently. She will follow-up in the clinic in ___ weeks.
This information was communicated to the patient directly prior
to discharge.
Post-Surgical Complications During Inpatient Admission:
[ ] Post-Operative Ileus resolving w/o NGT
[ ] Post-Operative Ileus requiring management with NGT
[ ] UTI
[x] 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:
The Preadmission Medication list is accurate and complete.
1. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN SOB
Discharge Medications:
1. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN SOB
2. Acetaminophen 1000 mg PO Q8H:PRN pain
do not take more than 3000mg of tylenol in 24 hours or drink
alcohol while taking
RX *acetaminophen 500 mg ___ tablet(s) by mouth every eight (8)
hours Disp #*50 Tablet Refills:*0
3. Cephalexin 500 mg PO Q6H
please take your entire prescription, last day ___
RX *cephalexin [Keflex] 500 mg 1 capsule(s) by mouth every six
(6) hours Disp #*23 Capsule Refills:*0
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
do not drink alcohol or drive a car while taking this medication
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*50 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Colonic mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after a Right Sided Colectomy
for surgical management of your Colon Mass. 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, passing gas and your pain is
controlled with pain medications by mouth. You may return home
to finish your recovery.
Please monitor 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 your 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 your bowel function closely. If you are
passing 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 does 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
constipation.
You have a long vertical incision on your abdomen that is closed
with staples. Your incision was slightly red and you were
started on antibiotics which you will continue to take to
complete a 7 day course of antibiotics. This incision can be
left open to air or covered with a dry sterile gauze dressing if
the staples become irritated from clothing. The staples will
stay in place until your first post-operative visit at which
time they can be removed in the clinic, most likely by the
office nurse. Please monitor the incision for signs and symptoms
of infection including: increasing redness at the incision,
opening of the incision, increased pain at the incision line,
draining of white/green/yellow/foul smelling drainage, or if you
develop a fever. Please call the office if you develop these
symptoms or go to the emergency room if the symptoms are severe.
You may shower, let the warm water run over the incision line
and pat the area dry with a towel, do not rub.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. ___ Dr. ___. You may
gradually increase your activity as tolerated but clear heavy
exercise with you surgeon.
You will be prescribed a small amount of the pain medication
Oxycodone. Please take this medication exactly as prescribed.
You may take Tylenol as recommended for pain. Please do not take
more than 3000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car while taking narcotic pain medication.
Thank 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:
___
|
10681689-DS-10
| 10,681,689 | 24,534,868 |
DS
| 10 |
2169-03-25 00:00:00
|
2169-03-26 20:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
==============
___ 03:00AM BLOOD WBC-14.5* RBC-3.02* Hgb-9.1* Hct-28.8*
MCV-95 MCH-30.1 MCHC-31.6* RDW-15.1 RDWSD-51.0* Plt ___
___ 03:00AM BLOOD Neuts-81.2* Lymphs-6.3* Monos-9.4
Eos-0.3* Baso-0.9 Im ___ AbsNeut-11.77* AbsLymp-0.92*
AbsMono-1.36* AbsEos-0.04 AbsBaso-0.13*
___ 03:00AM BLOOD ___ PTT-26.8 ___
___ 03:00AM BLOOD Glucose-128* UreaN-18 Creat-1.5* Na-140
K-4.4 Cl-106 HCO3-20* AnGap-14
___ 03:00AM BLOOD ALT-91* AST-58* AlkPhos-190* TotBili-0.3
___ 03:00AM BLOOD Lipase-68*
___ 03:00AM BLOOD Albumin-3.9 Calcium-9.6 Phos-3.5 Mg-1.6
___ 03:02AM BLOOD Lactate-1.7
___ 01:47PM BLOOD Lactate-1.1
DISCHARGE LABS:
==============
___ 12:00AM BLOOD WBC-12.5* RBC-2.81* Hgb-8.6* Hct-27.2*
MCV-97 MCH-30.6 MCHC-31.6* RDW-15.5 RDWSD-52.8* Plt ___
___ 12:00AM BLOOD Neuts-76.8* Lymphs-8.2* Monos-11.5
Eos-0.7* Baso-0.6 NRBC-0.2* Im ___ AbsNeut-9.62*
AbsLymp-1.03* AbsMono-1.44* AbsEos-0.09 AbsBaso-0.08
___ 12:00AM BLOOD Plt ___
___ 12:00AM BLOOD Glucose-112* UreaN-17 Creat-1.6* Na-142
K-4.2 Cl-105 HCO3-25 AnGap-12
___ 12:00AM BLOOD ALT-30 AST-16 LD(LDH)-175 AlkPhos-139*
TotBili-<0.2
___ 12:00AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.9 UricAcd-4.4
MICROBIOLOGY:
============
___ 11:15 am URINE Source: Kidney.
URINE CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000 CFU/mL.
Oxacillin RESISTANT Staphylococci MUST be reported as also
RESISTANT to other penicillins, cephalosporins, carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
COAG NEG STAPH does NOT require contact precautions, regardless
of resistance.
STAPHYLOCOCCUS, COAGULASE NEGATIVE |
GENTAMICIN------------ <=0.5 S
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 1 S
___ 3:36 am BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
___ 3:00 am BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGES:
=======
___:
CT ABD & PELVIS WITH CO
IMPRESSION:
1. Cortical hypoenhancement in the mid to lower left kidney is
concerning for
pyelonephritis.
2. Left nephrostomy tube appears appropriately positioned
without
hydronephrosis.
3. Chronic severe right hydroureteronephrosis with severe
thinning of the
right renal parenchyma. Obstruction of the right distal ureter
at the level of
the presacral soft tissue thickening is similar to prior.
4. Residual presacral soft tissue thickening with residual gas
component is
unchanged.
___:
CXR
IMPRESSION:
No radiographic evidence of pneumonia.
Brief Hospital Course:
Patient Summary:
=================
Ms. ___ is a ___ year-old woman with Hodgkin Lymphoma (diagnosed
___ s/p C1D1 BV-AVD on ___, C2D1 AVD + Brentuximab on
___, unknown cancer in ___ in ___ (perhaps both
uterine and colon cancer, status-post TAH/BSO with partial
colectomy, followed by vaginal brachytherapy, without
chemotherapy c/b ___ and vesicovaginal fistulae), CKD,
chronic
hydronephrosis, ureteral stones, urosepsis in ___ requiring
left percutaneous nephrostomy placement and recent admission in
___ for pyelonephritis and likely right-sided nephrolithiasis
(resolved with cipro). She p/w abdominal pain, vomiting, fever,
hypotension c/f urosepsis ___ pyelonephritis. Patient was on
vanc/cefepime with good response. She was transitioned to
cefpodoxime on ___. She was also given IVF for her tachycardia
and ___.
Transitional Issues:
===================
[] Please call urology and follow up within ___ weeks of
discharge.
[] Please continue to drink at least ___ of water per day. This
will help hydrate your kidneys and prevent your heart from
beating too fast.
[] If tachycardia persists despite fluids, may consider CTA.
[] Please follow up with hematology/oncology on ___ for next
chemotherapy dose.
Acute Issues:
=====================
#Sepsis
#Pyelonephritis
#Chronic Hydronephrosis
#Hx of Colovaginal and vesicovaginal fistulae
Patient has a complicated urological history. She presented with
fever at home, abdominal pain, R flank pain, and vomiting. She
was tachycardic to the 120-130's with elevated white counts. Had
dirty u/a, CT A/P redemonstrated unchanged right-sided
hydronephrosis and concerns for L pyelonephritis. s/p IVF, Vanc,
Zosyn in the ED. L nephrostomy tube exchanged ___. As early as
1
day after abx, pt's symptoms resolved. She was transitioned to
cefpodoxime with good response. Urology was consulted and they
deferred right PCN as patient was responding well to antibiotics
and the risks>benefits. She was treated with tylenol for pain.
At the time of discharge, she was afebrile and improved
clinically.
#Tachycardia
Likely ___ urosepsis. Baseline HR's in the 110's. Other DDx
includes MI, PNA, pulmonary embolism. CXR and EKG reassuring.
Wells Score is 2.5 points (16.2% chance of PE in an ED
population). Tachycardia improving from 120's to 100/110's with
fluids.
#Hodgkin Lymphoma: s/p C1D1 BV-AVD on ___ and C2D1 AVD +
Brentuximab on ___. Next dose in cycle is on ___
-Continued ppx with acyclovir/allopurinol
#Anemia:
Presents with Hg of 9.1-->8.1. Slightly worse than baseline (Hg
___, related to recent receipt of chemotherapy. No evidence of
active bleeding. At time of discharge, patient's Hg was 8.4 and
stable throughout hospitalization.
___ ON CKD:
Pt presented with Cr 1.9 with baseline Cr 1.4-1.5 iso chronic
hydronephrosis, UTI, and pylenephritis. Improved with IVF. At
time of discharge, Cr was at baseline.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. Allopurinol ___ mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. LORazepam 0.5 mg PO Q6H:PRN nausea
5. Multivitamins 1 TAB PO DAILY
6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
7. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
8. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Medications:
1. Cefpodoxime Proxetil 200 mg PO Q12H
RX *cefpodoxime 200 mg 1 tablet(s) by mouth one tablet every
twelve (12) hours Disp #*20 Tablet Refills:*0
2. Acyclovir 400 mg PO Q12H
3. Allopurinol ___ mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. LORazepam 0.5 mg PO Q6H:PRN nausea
6. Multivitamins 1 TAB PO DAILY
7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
8. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
9. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Disposition:
Home
Discharge Diagnosis:
Final diagnosis:
================
Urosepsis
Pyelonephritis
Secondary diagnosis:
====================
Chronic Hydronephrosis
Hodgkin Lymphoma
Anemia
Acute kidney infection
Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___!
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you had a fever,
abdominal and back pain. You were found to have a kidney
infection.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were given IV antibiotics with good response. We
transitioned you to oral antibiotics, which you also tolerated
well.
- You were seen by our urology doctors who advised against a
percutaneous nephrostomy tube for your right kidney. They would
like to follow up with you outpatient.
- You were given fluids.
WHAT SHOULD I DO WHEN I GO HOME?
- Please take all your medications as prescribed.
- Please follow-up with your doctor as noted in your discharge
paperwork.
We wish you the best,
Your ___ care team
Followup Instructions:
___
|
10682002-DS-7
| 10,682,002 | 20,035,892 |
DS
| 7 |
2132-12-11 00:00:00
|
2132-12-11 18:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___
Chief Complaint:
Chief Complaint: Altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old man with ETOH abuse w/ history
of DT & recent history of AMS apparently undergoing outpatient
work-up, who is presenting as a transfer from ___ for
altered mental status.
He has a history of long standing heavy alcohol use, worsening
cognition with word finding difficulty over last ___ years,
urinary incontinence, personality changes and memory impairment
(not recognizing siblings) over last ___ months. He became
acutely agitated towards his family and he assaulted his wife.
911 was called and brought the patient to ___.
At ___, he was noted to be alert but not able to answer
questions, smelling of alcohol, without focal neurologic
abnormality. VS were notable for tachycardia, labs were notable
for Cr 0.99, WBC of 13.5, negative trop, EKG showing sinus
tachycardia. He received 2L NS, phenobarbital 130mg IV x 1,
diazepam 20mg IV x 1, haloperidol 5mg IM x 2, lorazepam 1mg IM x
2, 2mg IM x 1, thiamine 500mg, folate. A NCHCT was negative for
acute changes but showed moderate white matter disease and
volume loss, atrophy esp in anterior left temporal, with ?left
temporal variant frontotemporal dementia. He was transferred to
___.
In ___ ED, initial vital signs were: 97.9 90 135/79 20 98% RA
- Exam notable for:
Somnolent, rousable, protecting airway. Was noted to be
intermittently agitated, pulling at lines, biting at restraints
- Labs were notable for chem7 with K of 6.5 (hemolyzed, repeat
3.6) bicarb 21, LFTs with AST 59, otherwise WNL. Trop negative x
1, urine tox screen negative aside from pos barbs (s/p pheno
dose at OSH)
CBC with WBC 13.5, H/H 13.2/39.7, Plts 283 (81.5 PMN, 8.2 lymph,
9.2 M), Serum tox negative, UA with 6 WBC, few bact, 0 epis, neg
nitr, UCx pending
- Studies performed include EKG which was NSR at 83, normal
axis. sub-mm STE in v3.
- Patient was given thiamine 500mg, folic acid 1mg, phenobarb
180mg loading dose, Haldol 2mg IV x 2.
Patient was initially admitted to the medicine floor. On arrival
to the floor, the patient has poor attention, and refuses to
answer most questions. He is able to say his first and last name
(___) and notes his home address as the place he
believes he is. He does not tell us the year. RN notes that
marijuana was found in his possession. He was tremulous and
required four point restraints.
REVIEW OF SYSTEMS: Unable to obtain
Past Medical History:
EtOH abuse
History of withdrawal seizure
Possible dementia, work up ongoing
Social History:
___
Family History:
His mother and aunt both died of Alzheimer's disease at ___ and
___. They did drink alcohol, but not as much as patient. Father
had senile dementia, died at ___. No history of heart disease or
cancer.
Physical Exam:
Admission exam:
VITALS: 98.4 74 161/86 17 100% RA
GENERAL: drowsy but arousable, quickly falls asleep
HEENT: Sclera anicteric, dry OM, PERRL
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: warm, dry, no obvious lesions
NEURO: drowsy but arousable, quickly falls, asleep, face
symmetric, no increased ___ when agitated
Discharge exam:
98.0 ___ R ___
sitting in bed, very rarely saying anything but at rare times
saying "open the zipper" (on restraint bed when food arrived)
but otherwise not talking to medical providers
___, no droop
RRR
CTAB
sntnd
wwp, neg edema, no cords
MAEE, normal gait, face symmetric, will not engage with
orientation questions
impulsive at times but non-violent
Pertinent Results:
Admission labs:
===========================
___ 04:17AM BLOOD WBC-13.5* RBC-4.37* Hgb-13.2* Hct-39.7*
MCV-91 MCH-30.2 MCHC-33.2 RDW-14.7 RDWSD-49.1* Plt ___
___ 04:17AM BLOOD Neuts-81.5* Lymphs-8.2* Monos-9.2
Eos-0.1* Baso-0.6 Im ___ AbsNeut-11.04* AbsLymp-1.11*
AbsMono-1.25* AbsEos-0.01* AbsBaso-0.08
___ 04:29AM BLOOD ___ PTT-27.2 ___
___ 04:17AM BLOOD Glucose-115* UreaN-14 Creat-0.7 Na-139
K-6.5* Cl-107 HCO3-21* AnGap-11
___ 04:17AM BLOOD ALT-13 AST-59* AlkPhos-41 TotBili-0.4
___ 06:35PM BLOOD ALT-14 AST-45* LD(LDH)-305* AlkPhos-64
TotBili-0.8
___ 04:17AM BLOOD Lipase-43
___ 04:17AM BLOOD cTropnT-<0.01
___ 04:17AM BLOOD Albumin-4.0 Calcium-8.5 Phos-3.0 Mg-2.2
___ 04:17AM BLOOD VitB12-316 Folate->20
___ 04:17AM BLOOD TSH-2.1
___ 06:35PM BLOOD HIV Ab-NEG
___ 04:17AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:29AM BLOOD ___ pO2-67* pCO2-42 pH-7.39
calTCO2-26 Base XS-0
___ 07:14PM BLOOD Lactate-1.4
___ 04:29AM BLOOD K-3.6
___ 06:05AM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 06:05AM URINE Color-Straw Appear-Clear Sp ___
___ 06:05AM URINE bnzodzp-NEG barbitr-POS* opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
INTERVAL LABS
=============
___ 06:35AM BLOOD WBC-10.7* RBC-4.49* Hgb-13.5* Hct-40.4
MCV-90 MCH-30.1 MCHC-33.4 RDW-14.5 RDWSD-47.0* Plt ___
___ 06:35AM BLOOD Glucose-120* UreaN-15 Creat-0.6 Na-141
K-4.1 Cl-100 HCO3-26 AnGap-15
___ 03:20AM BLOOD ALT-15 AST-29 LD(LDH)-188 AlkPhos-59
TotBili-0.4
___ 12:55PM BLOOD D-Dimer-2757*
MICROBIOLOGY:
=============
___ 4:17 am SEROLOGY/BLOOD Grossly Hemolyzed Specimen.
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
REPORTS:
========
RUQ U/S:
IMPRESSION: No significant sonographic abnormality.
DISCHARGE LABS:
___ 06:35AM BLOOD WBC-10.7* RBC-4.49* Hgb-13.5* Hct-40.4
MCV-90 MCH-30.1 MCHC-33.4 RDW-14.5 RDWSD-47.0* Plt ___
___ 06:35AM BLOOD Glucose-120* UreaN-15 Creat-0.6 Na-141
K-4.1 Cl-100 HCO3-26 AnGap-15
___ 03:20AM BLOOD ALT-15 AST-29 LD(___)-188 AlkPhos-59
TotBili-0.4
___ 06:35AM BLOOD Calcium-9.1 Phos-3.1 Mg-1.9
Brief Hospital Course:
***Patient left against medical advice***
AMA Discharge: Patient had persistent tachycardia despite
improvement in agitation and withdrawal symptoms. Wells score
___ and d-dimer obtained which was 2757. Recommended CTA or V/Q
scan, however, patient's wife and HCP refused. She understands
the risks of PE including death. She states that she is
concerned that the test will agitate him further and she does
not want to subject him to further testing.
Mr. ___ is a ___ male with history of
significant EtOH abuse with likely frontotemporal dementia and
chronic progressive cognitive decline who presents as a transfer
from ___ for altered mental status concerning for
complicated EtOH withdrawal on top of baseline cognitive
disorder. He was eventually transferred from MICU to the general
medicine floor on ___ and tapered off of anti-psychotics for
severe agitation.
# Encephalopathy with agitation
# Likely EtOH withdrawal
# Likely Frontotemporal dementia - Patient initially presented
with altered mental status to ___ with initial concern
for complicated EtOH withdrawal. He has a history of significant
EtOH use and per family has had progressive cognitive decline
over the last ___ years. Of note, he has also had progressive
expressive aphasia over the last 3 months, with no clear acute
worsening of mental status prior to presentation per his wife.
Given initial concern for complicated EtOH withdrawal, he was
initially phenobarbital loaded. Phenobarbital was subsequently
discontinued given concern for supratherapeutic dosing given
brain atrophy. Patient demonstrated no signs of active
withdrawal throughout hospital course and was started on
thiamine and folic acid supplementation.
Encephalopathy is likely multifactorial in nature. Progressive
decline likely secondary to chronic EtOH use in the background
of baseline cognitive disorder. CT Head imaging at OSH was
consistent with frontotemporal dementia. Of note, also with
family history of early Alzheimer's dementia in mother, aunt,
and sister. ___ workup including TSH, B12, folate
were normal, and also had negative HIV, RPR and ethanol level
was normal on arrival. Although had leukocytosis per below,
there was no other infectious signs or symptoms to suggest
infectious etiology of presentation. Hospital course was
complicated by severe agitation in the ICU requiring upwards of
haloperidol 60 mg PO QD. Psychiatry was consulted and also
assisted with haloperidol taper down to off, which he tolerated
well. At time of discharge, patient was discharged off of
haloperidol.
At time of discharge patient opens eyes to voice, tracks,
however does not appropriately answer questions and is minimally
verbal, which appears to be new baseline. He was evaluated by
social work, physical therapy and occupational therapy and was
determined to require significant high level ___ care. Multiple
discussions were had with family regarding care needs. Per wife,
she would like to provide care to husband with assistance from
son at home. Family is understanding of his high level of care
needs and is willing to provide them at this time. They
demonstrated clear understanding of his care needs and are
currently pursuing guardianship. They expressed understanding
that if patient develops worsening agitation, or is a safety
concern to self or others will contact law enforcement and
re-present to the Emergency Department. At time of discharge,
family is requesting ___ with new PCP within ___ health
system and will also arrange for outpatient ___ with
neurology.
# Tachycardia - Patient with persistent tachycardia, initially
thought to be secondary to EtOH withdrawal in addition to severe
agitation. He continued to have low-grade sinus tachycardia,
despite being out of the EtOH withdrawal window with improved
agitation. Given prolonged immobilization in restraints due to
agitation, has risk factors for PE with Wells Score ___. D-dimer
was obtained which was elevated at 2757. Recommended CTA or V/Q
scan, however, patient's wife and HCP refused. She understands
the risks of PE including death. She states that she is
concerned that the test will agitate him further and she does
not want to subject him to further testing.
# Leukocytosis - Patient initially presented with WBC 13.5 on
admission with peak of 19.8 without focal infectious signs.
There was no meningismus, fevers or pain to suggest meningitis.
CXR without acute process per report. UA was bland, UCx with
skin contamination, blood cultures were negative, and lactate
WNL. Leukocytosis possibly related to stress reaction from acute
agitation and withdrawal syndrome as no fevers or localizing
symptoms. Down-trended to normal and antibiotics were deferred.
For billing purposes only: >30 minutes spent on patient care and
coordination on day of discharge.
TRANSITIONAL ISSUES
==================
[ ] NEW/CHANGED MEDCIATIONS
- Started folic acid 1mg PO QD for nutrition optimization
- Started multivitamins 1 TAB PO QD for nutrition optimization
- Started thiamine 100mg PO QD for nutrition optimization
[ ] Consider outpatient CTA Chest to rule out PE
[ ] Needs close PCP ___ regarding home services, family
coping, and meeting patient care needs at home
[ ] Continue to monitor agitation and potential safety concerns
[ ] Consider outpatient substance use referral for chronic EtOH
use
[ ] Abnormal labs on discharge
- D dimer 2757
#CONTACT INFORMATION
Name of health care proxy: ___
Relationship: Wife
Phone number: ___
#FULL CODE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
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. Multivitamins 1 TAB PO DAILY
RX *multivitamin [Daily Multi-Vitamin] 1 tablet(s) by mouth
Daily Disp #*30 Tablet Refills:*0
3. 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 DIAGNOSIS
#Metabolic myopathy with agitation
#Likely EtOH withdrawal
#Likely frontotemporal dementia
#Sinus tachycardia
SECONDARY DIAGNOSIS
#EtOH Abuse
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
You initially came to ___ because of worsening
confusion and you were transferred to ___ due to
concern for alcohol withdrawal.
What happened during your hospitalization?
- You were initially given medication in order to assist with
alcohol withdrawal, which was later discontinued.
- A CAT scan of your head at ___ showed chronic brain
changes likely related to dementia
- You were given thiamine, folic acid, and multivitamins in
order to improve your nutritional status
- You were given a medication called haloperidol because of
agitation which was subsequently discontinued
- You continued to have an elevated heart rate concerning for
possible blood clot in your lung, and recommended additional
imaging, however you subsequently signed out against medical
advice
What should you do when you leave the hospital?
- Continue to take all of your medications as prescribed
- ___ with your primary care physician ___ 1 week
- Please keep all of your other scheduled healthcare
appointments as listed below
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10682162-DS-5
| 10,682,162 | 25,843,020 |
DS
| 5 |
2123-09-02 00:00:00
|
2123-09-02 15:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Orthostatic hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ y/o male with a past medical history of
Parkinsons, Afib on Coumadin, CVA, seizure d/o, CKD, recent fall
1 month who was noted to have a large flank hematoma ~ 1 week
who presents from nursing home for orthostatic hypotension.
History is limited as patient presents with minimal
documentation from rehab facility and unable to contact wife and
patient cannot recount all history.
Patient has been at a rehab facility and has had episodes of
orthostatic hypotension with SBPs ___ when standing. Over the
past 5 days he was also found to have a Hgb drop from 11.7 to
8.5 while at his rehab facility. There is also documentation
that the patient's INR was supratherapeutic at the rehab to ~ 4
during this period and his Coumadin was held. The rehab facility
started the patient initially on fludrocort and then on
midodrine for his low blood pressure on ___ and ___
respectively. On ___ he noted excessive weakness and dizziness
and was sent for evalutation at ___ on ___. He initially
presented to ___. H/H was 9.1/27.8 (H/H on ___ was
14.6/43.0 at ___. A FAST exam was performed and was
negative at ___. CT was done and showed a left hip
hematoma that was stable from prior. Patient was guiac negative.
He was transferred to ___ for further management and possible
___ intervention.
In the ED, initial vitals were: T 98.6, HR 64, BP 115/71, RR
18, 99% RA. Labs were notable for Hb 8.4/Hct 25.9, Cr 1.2, INR
1.7. He was admitted to medicine for management of orthostatic
hypotension and flank hematoma.
On the floor, patients sleeping in bed and easily arousable.
VSS. He states that he feels lousy. He knows that he is in a
hospital and he knows the date, however he does not clarify any
of the history other than stating that he has pain and brusing
on his L flank which he points to.
Past Medical History:
- Parkinsons
- CVA
- Afib on Coumadin
- s/p CCY
- DM
- CKD
- seizure d/o
- HTN
Social History:
___
Family History:
- DM, heart disease, arthritis
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================================
Vital Signs: 98; 122/50; 74; 18; 98RA
General: Alert, oriented to hospital, date, president, no acute
distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding. L flank with large 20cm
visible hematoma. TTP
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
DISCHARGE PHYSICAL EXAM:
=========================================
Vitals: Tm 98.2, Tc 98.2, BP 95-110/44-60, Standing BP (87/49,
and asymptomatic), HR 61-99, Standing HR 90, RR ___, O2
92-100%
in: 1.5L out: 1.7L
Exam:
GENERAL - Alert, well-appearing in NAD
HEENT - sclerae anicteric, MMM, OP clear
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - Stable, nontender ecchymosis over L flank and hip,
WWP, no edema
NEURO - Sleepy, AOx3, CNs II-XII grossly intact, moving all
extremities; ambulated with assistance - gait with small steps
Pertinent Results:
ADMISSION LABS:
================================
___ 10:30PM BLOOD WBC-9.6 RBC-2.65* Hgb-8.4* Hct-25.9*
MCV-98 MCH-31.7 MCHC-32.4 RDW-14.1 RDWSD-47.8* Plt ___
___ 10:30PM BLOOD ___ PTT-32.0 ___
___ 10:30PM BLOOD Glucose-124* UreaN-27* Creat-1.2 Na-134
K-4.2 Cl-102 HCO3-23 AnGap-13
___ 05:55AM BLOOD Calcium-8.3* Phos-1.9* Mg-2.2 Iron-75
___ 05:55AM BLOOD calTIBC-246* Hapto-<10* Ferritn-878*
TRF-189*
___ 06:55AM BLOOD Cortsol-17.7
___ 01:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
___ 01:00PM URINE Color-Yellow Appear-Clear Sp ___
INTERVAL IMAGING STUDIES:
=================================
___ MRI HEAD W/O CONTRAST
1. No evidence of acute infarct.
2. Geographic T2/FLAIR hyperintensities extending to the cortex
within the
left frontal and left temporoparietal regions, likely
representing chronic
infarcts.
3. Lateral ventricular prominence and dilated temporal horns
along with
prominence of sulci are suggestive of brain and medial temporal
atrophy. The appearance is not typical for normal pressure
hydrocephalus.
___
HIP X-RAY
Frontal view the pelvis and two views of the left hip show no
fracture,
subluxation, or dislocation. Hip joints are well mineralized.
Mild
eburnation of the acetabular articulating surfaces is symmetric.
There is no appreciable hip joint space narrowing. Pelvic ring
is intact.
RELEVANT INTERVAL LABS:
==================================
___ 05:42AM BLOOD ___ PTT-28.4 ___
___ 05:54AM BLOOD ___ PTT-31.5 ___
___ 06:11AM BLOOD ___ PTT-32.5 ___
___ 05:45AM BLOOD ___ PTT-34.4 ___
OUTSTANDING LABS:
==================================
___ 05:54AM BLOOD METHYLMALONIC ACID-PND
DISCHARGE LABS:
==================================
___ 05:45AM BLOOD WBC-8.1 RBC-2.87* Hgb-9.0* Hct-28.4*
MCV-99* MCH-31.4 MCHC-31.7* RDW-15.8* RDWSD-55.7* Plt ___
___ 05:45AM BLOOD ___ PTT-34.4 ___
___ 05:45AM BLOOD Glucose-89 UreaN-23* Creat-1.1 Na-139
K-3.9 Cl-106 HCO3-24 AnGap-13
Brief Hospital Course:
Mr. ___ is an ___ year old man with a PMHx of AF
(on warfarin), TIA, seizure disorder, early ___ disease
(not on treatment) and fall (___), who presented from nursing
home for orthostatic hypotension as well as drop in Hgb/flank
hematoma in the setting of a supratherapeutic INR.
ACTIVE ISSUES
## ORTHOSTATIC HYPOTENSION: patient evaluated for etiology.
Morning cortisol within normal limits. IV hydration given with
minimal improvement. Patient diabetic, but A1C 6.5%. ___
disease very mild, likely not contributing to OH. Medications
likely not contributing. Vitamin B12 level 370, which could
indicate occult B12 deficiency. MMA level sent, but pending at
discharge. Orthostatic vital signs improved with addition &
uptitration of fludrocortisone & midodrine. Neurology/Autonomics
consulted for concern for possible ___ contribution
to orthostatics, but this was not felt to be the case. Per
neurology, deconditioning likely contributing to OH and
recommended 3L fluid intake per day. NaCl tabs 1g TID started,
in addition to fludrocortisone & midodrine. Abdominal binder
also provided, as well as compression stockings, though patient
poorly tolerant of these.
- Follow up pending methylmalonic acid (MMA) level, pending on
discharge
## LEFT FLANK BLEEDING, ## ACUTE BLOOD LOSS ANEMIA: likely from
supratherapeutic INR. Outside CT demonstrated possible L greater
trochanter nondisplaced fracture. Hip XR here did not
redemonstrate this. Evaluated by orthopedics, who didn't
recommend any interventions. Patient without pain. Warfarin
held, and Hgb stabilized. Warfarin restarted, as below. FAST
exam and stool Guaiac negative at outside hospital.
## CONCERN FOR NORMAL PRESSURE HYDROCEPHALUS: noted magnetic
gait on neurology evaluation, however patient largely
deconditioned. MRI head performed, with results above. Not
typical for NPH, however, ventricular dilatation with
transependymal flow identified.
- Follow up with outpatient neurology arranged; will need to
keep this appointment for further evaluation & determination of
need for treatment
CHRONIC ISSUES
## ATRIAL FIBRILLATION: warfarin initially held in setting of
supratherapeutic INR and left flank bleeding. Restarted in house
once Hgb stable, without heparin gtt bridging.
*** TRANSITIONAL ISSUES ***
## ANTICOAGULATION: please refer to anticoagulation sheet on
discharge. In brief, fludrocortisone may decrease efficacy of
warfarin. Monitor INR closely. ___ given 5 mg. Would give
5 mg on ___, and then decrease to 3 mg daily, following daily
INRs as possible.
## ORTHOSTATIC HYPOTENSION: encourage abdominal binder and 3L
fluid intake per day. Stay out of bed for 10 hours per day.
Elevate head of bed by 6 inches. Physical therapy.
## CONCERN FOR NORMAL PRESSURE HYDROCEPHALUS: patient scheduled
to see ___ Neurology as outpatient. Imaging perhaps
suggestive. ___ need further testing (ie LP, with measured/timed
walk) and even surgical intervention. Would refer to
neurosurgery if suggestive.
ADDENDUM:
Neurology appt at ___ conveyed to ___ by team after discharge
via phone call.
Elevated MMA level followed up on via telephone to ___ (see OMR
note).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clotrimazole Cream 1 Appl TP BID
2. LevETIRAcetam 500 mg PO QHS
3. Digoxin 0.25 mg PO DAILY
4. Simvastatin 20 mg PO QPM
5. Atenolol 25 mg PO DAILY
6. LevETIRAcetam 250 mg PO BID
7. TraMADol 25 mg PO Q6H:PRN pain
8. Fenofibrate 200 mg PO DAILY
9. Acetaminophen 650 mg PO Q4H:PRN pain
10. Vitamin D 1000 UNIT PO DAILY
11. Warfarin 5 mg PO MON, THURS Afib
12. Warfarin 2.5 mg PO T, W, F, SA, ___ Afib
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Digoxin 0.25 mg PO DAILY
3. Fenofibrate 200 mg PO DAILY
4. LevETIRAcetam 500 mg PO QHS
5. LevETIRAcetam 250 mg PO BID
6. Simvastatin 20 mg PO QPM
7. Vitamin D 1000 UNIT PO DAILY
8. Warfarin 2.5 mg PO T, W, F, SA, ___ Afib
9. Atenolol 25 mg PO DAILY
10. Clotrimazole Cream 1 Appl TP BID
11. TraMADol 25 mg PO Q6H:PRN pain
12. Warfarin 5 mg PO ___, ___ Afib
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses: Orthostatic Hypotension, Left flank hematoma
in setting of supratherapeutic INR
Secondary diagnoses: diabetes mellitus, ___ disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
to our hospital for having a low blood pressure when you stand,
and for having a low blood count.
To increase your blood pressure, we gave you fluids and started
two new medications called fludrocortisone and midrodrine. We
also started salt tabs to help raise your blood pressure. There
are also a list of things for you to do to help raise your blood
pressure. These include:
1. Drink more water
2. Eat more salt
3. Spend as much time out of bed as possible
4. Perform leg exercise in bed
5. Wear the Velcro binder over your belly
We think your blood count was low because your Coumadin (blood
thinner) level was too high and it caused you to bleed into your
hip and back. After we made sure your Coumadin was no longer too
high and your blood level was returning to normal, we restarted
your Coumadin to treat your atrial fibrillation ("a fib," or
irregular heart rhythm).
While you were here we also evaluated your hip. You had a X-ray
of your hip which did not show any fractures. The orthopedic
doctors also ___ and ___ that your hip did not need
any additional treatment.
When you are discharged, you will return to rehab to work on
your walking. You should also follow up with your primary care
doctor and tell them you were hospitalized.
It was a pleasure caring for you!
- Your team at ___
Followup Instructions:
___
|
10682162-DS-6
| 10,682,162 | 26,844,965 |
DS
| 6 |
2123-10-20 00:00:00
|
2123-10-20 12:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
failure to thrive, lethargy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ man w/ ___ disease, AF on Coumadin, prior
stroke, seizure disorder, CKD, and a recent admission for
orthostatic hypotension who was brought to ___ ED by EMS after
he was found to be more lethargic by home ___ for evaluation of
failure to thrive.
Patient was unable to provide any history. Upon speaking w/ the
patient's wife ___, it seems that the pt was in his usual state
of health until about 2 days ago when it took her 2 hours to get
him out of the bed. He normally enjoys eating but didn't want to
eat and when ___ came to work w/ him, they thought he looked
dehydrated; he seemed to get a little better after drinking some
water. The next day he wouldn't drink water, didn't want any
breakfast or other food later in the day. He just went to bed
and
stayed there until the medics came after they called ___. The pt
was previously having conversations until early this week and
generally loved history and politics so it is very unusual for
him not to know the president or what country he's in, per the
wife. The wife also noticed that he jumped if anyone would touch
his feet which is new. He has not mentioned to her any chest
pain, shortness of breath, abdominal pain, diarrhea, headache,
pain in his extremities other than his feet when touched. He has
been urinating more. There's no dysuria. There's been no falls
recently, and he normally uses a cane to get around. Of note, he
refused all his medications yesterday.
Of note, he was recently admitted from ___ when he was
admitted from his nursing home w/ orthostatic hypotension, flank
hematoma w/ concurrent drop in hgb in the setting of a
supratherapeutic INR to ~4. Pt was discharged to ___ and
returned home on ___. Of note, he was found to be deficient in
B12 and started on vitamin B12 supplements.
In the ED it was confirmed that the patient is DNR/DNI per his
MOLST. His HCP is his daughter, ___.
ED Course (labs, imaging, interventions, consults):
- Initial Vitals: 98.7 67 158/70 16 100% RA.
- EKG: Atrial fibrillation, no significant ST T changes.
- Exam: cardiopulmonary benign, abdomen benign, neuro exam CNs
intact, strength full in extremities, sensations intact, not
oriented to place or time. Feet painful to touch, no edema.
- Received 40 mEq potassium for K of 3.0.
- UA w/ neg nitrites and leuks, 15 RBCs, few bacteria and 10
ketones
- ___: 36.6 PTT: 39.1 INR: 3.3 , WBC 10.3 w/out bands, hgb
14.5,
lactate 1.8
- CT w/out contrast showed no acute intracranial process. Stable
left frontal and parietal encephalomalacia, likely sequela of
chronic
infarct.
- CXR showed mild bibasilar opacities that likely reflect
atelectasis.
Pt was admitted for work up of altered mental status. On arrival
to the floor patient is oriented to himself, but not to date,
city, state or country. He knows he's in a hospital but is
unsure
why he is here, aside from saying that his wife was concerned
about him. He denies any pain anywhere, no CP, abdominal pain,
headaches. Denies any SOB, diarrhea, nausea or vomiting.
Endorses
feeling sleepy and that all he wants to do lately is sleep.
Endorses possible dysuria, but it is unclear if that's really
what he means. Denies any fevers, chills, cough.
ROS: Full 10 pt review of systems negative except for above.
Past Medical History:
# ___ disease
- orhtostatic hypotension
# HTN/HLD
# DM2
# afib on coumadin
# h/o CVA (L frontal, parietal)
# Seizure d/o on Keppra
# CKD Stage 1
# PVD
# GERD
# mild cognitive impairment
Social History:
___
Family History:
- DM, heart disease, arthritis
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.6 PO 153 / 75 60 18 99 RA
General: Alert, oriented to self and hospital but not date or
city/state/country
HEENT: Sclera anicteric, mucous membranes dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD, PERRL, EOMI
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: At the time of exam RRR, 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, pt jumps when his feet are touched
Skin: WWP, no rashes or cyanosis
Neuro: Alert but oriented only to self and hospital, not name of
hospital, not to city, state, country, or president, could not
start to say months of year backwards, could follow 2 step
command ___ times, speech is clear but pt is slow to respond to
questions
Sensation- to light touch intact on all 4 extremities
CN ___ intact
Strength ___ in elbow, hip and ankle flexors and extensors,
however pt is resisting bending is knees, knee extensors fire
bilaterally
Finger to nose performed very slowly
Cogwheel rigidity present in bilateral upper extremities
Pertinent Results:
ADMISSION LABS:
___ 09:34PM PLT COUNT-245
___ 09:34PM ___ PTT-39.1* ___
___ 09:34PM NEUTS-67.0 ___ MONOS-10.4 EOS-1.0
BASOS-0.7 IM ___ AbsNeut-6.93* AbsLymp-2.09 AbsMono-1.08*
AbsEos-0.10 AbsBaso-0.07
___ 09:34PM WBC-10.3* RBC-4.51*# HGB-14.5# HCT-42.3#
MCV-94 MCH-32.2* MCHC-34.3 RDW-12.5 RDWSD-43.0
___ 09:34PM LACTATE-1.8
___ 09:34PM DIGOXIN-1.5
___ 09:34PM CRP-55.5*
___ 09:34PM CRP-55.5*
___ 09:34PM TSH-3.0
___ 09:34PM ALBUMIN-4.1
___ 09:34PM ALT(SGPT)-13 AST(SGOT)-27 ALK PHOS-55 TOT
BILI-1.1
___ 09:34PM GLUCOSE-98 UREA N-11 CREAT-1.1 SODIUM-140
POTASSIUM-3.0* CHLORIDE-96 TOTAL CO2-31 ANION GAP-16
___ 02:42AM URINE RBC-15* WBC-3 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 02:42AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-2* PH-6.5 LEUK-NEG
___ 02:42AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 01:15PM PLT COUNT-227
___ 01:15PM WBC-8.7 RBC-4.52* HGB-14.5 HCT-42.6 MCV-94
MCH-32.1* MCHC-34.0 RDW-12.8 RDWSD-44.1
___ 01:15PM CK-MB-<1 cTropnT-<0.01
___ 01:15PM CK(CPK)-46*
___ 01:15PM GLUCOSE-123* UREA N-12 CREAT-0.9 SODIUM-138
POTASSIUM-3.0* CHLORIDE-95* TOTAL CO2-35* ANION GAP-11
(___): WBC 10.3, K 3.0, HCO3 31, Dig 1.5, TSH 3.0, Trop<0.01,
ESR 11, CRP 55.5
.
OTHER DATA:
# EEG (___): Abnormal portable EEG due to a very disorganized
and mildly slow background with frequent bursts of generalized
delta slowing. These findings indicate a widespread
encephalopathy. Most cortical and subcortical structures.
Medications, metabolic disturbances, and infection are among the
most common causes. There were no areas of prominent focal
slowing, but encephalopathies may obscure focal findings. There
were no epileptiform features.
# Head CT (___): 1. No acute intracranial process or
hemorrhage.
2. Stable left frontal and parietal encephalomalacia, likely
sequela of chronic infarct.
# LP (___): opening pressure 18, WBC 2, RBC 454, TP 50, Gluc 71,
HSV PCR, EBV PCR pending
# MRI Brain (___): 1. No acute infarction. Unchanged areas of
chronic infarcts in the left frontal and left temporoparietal
regions. 2. Chronic small vessel ischemic disease.
# Port CXR (___): There bilateral lower lobe airspace opacities
which have progressed compared to the prior exam and focally
obscure both hemidiaphragms. While some of this could be due to
volume loss, the appearance particularly on the right is
concerning for an infectious infiltrate. There small bilateral
pleural effusions. The heart size is upper limits of normal.
The aorta is tortuous IMPRESSION: right lower lobe pneumonia
with possible left lower lobe infiltrate as well
# EEG (___): pending on date of discharge
# Bedside swallow eval (___): no evidence of aspiration
Brief Hospital Course:
___ h/o ___ disease, AF on Coumadin, stroke, seizure
disorder, CKD, and a recent admission for orthostatic
hypotension who was brought to ___ ED by EMS for acute onset
of altered mental status.
# Encephalopathy: Mr. ___ was admitted with progressive
cognitive dysfunction over the past 2 months - subacutely over
the past 2 weeks. Gait instability and urinary incontinence
were also noted. To further evaluate the etiology of this
deterioration, neurology was consulted and extensive workup was
performed. Metabolic etiologies w/up were largely negative.
CBC, U/A, RPR, trop/CPK, CXR (on admit), TSH, head CT were also
negative. Dig level was at 1.5. EEG with disorganized, slow
background (c/w met encephalopathy) and no epileptimform
features. An LP was performed with results showing the
following: LP WBC 2, RBC 454, TP 50, Gluc 71. Ultimately
additional tests were unremarkable: HSV, EBV PCR negative; CSF
cytology negative. Brain MRI did not show any signs of acute
CVA.
In the beginning, a broad differential was entertained:
medication effect (Keppra, digoxin, oxybutynin), NPH, herpes
encephalitis, acute CVA. For this reason, modifications were
made to medications: most notable discontinuation of oxybutynin
and decrease of digoxin to 0.125 from 0.25 mg daily. He was
temporarily placed on acyclovir IV, but this was discontinued
once the HSV PCR returned negative. Brain MRI (as noted above)
returned negative and thus made acute CVA less likely. NPH was
also entertained by the primary team; however felt less likely.
This was considered given some dramatic improvement in his
cognitive function after 28 cc of CSF fluid was removed via LP
on ___. However, after much consideration, there was
significant concern for risk of additional large volume CSF taps
given brain atrophy, anticoagulation - with risk of bridging
vessel rupture and significant SDH. Furthermore, given his
brain atrophy and poor substrate, he would not be considered a
good surgical candidate for CP shunt - and thus the ultimate
endpoint for such repeat LP was non-existent.
Ultimately, Mr. ___ has ___ and likely
vascular dementia (given microvascular small vessel changes seen
on CT and MRI) which accounts for the underlying
cognitive/degenerative changes. There did not seem to be any
evidence of other degenerative conditions (PSP, ___ Body
based on history and exam). The family was made aware that it
is possible that this is his new baseline. We hope that
increased ___, rehab may help overcome an underlying metabolic
disorder not identified during this admission.
# RLL, possibly LLL PNA: Of note, during this admission, as
further workup of ongoing delirium. A CXR was obtained -
showing RLL and possibly LLL pneumonia. (Note: no pneumonia was
noted on admission/presentation). This was concerning for
aspiration PNA. He was treated with vanco/cefepime (___) and
switched to Levoflox on ___. The last day of abx can be ___ to
complete a ___ day course. He was placed on aspiration
precaution. Speech path was consulted: and there was no evidence
of aspiration at the bedside. As a result, he was placed on
regular diet, thin liquids.
# CV: HTN/HLD, afib (CHA2DS2-VASc score 6), h/o CVA: continued
on warfarin, digoxin, fenofibrate, statin. As noted, digoxin
was decreased to 0.125 mg daily (especially in setting of
hypokalemia from Fludrocortisone). INR was monitored daily with
goal 2.0-3.0
# Parkinsonism, h/o orthostatic hypotension: possible component
of rapidly deteriorating degenerative d/o (? PSP - although no
evidence of such). He was continued on fludrocortisone, NaCl,
midodrine (to be given 8AM,noon,4PM to avoid nighttime effects).
He was not on any treatment for ___ symptoms.
monitoring. Neuro consulted.
# Seizure disorder- EEG without signs of epileptiform
discharges. he was continued on home Keppra.
# OTHER ISSUES AS OUTLINED.
.
#FEN: [] IVF [X] Oral [] NPO [] Tube Feeds []
Parenteral
#DVT PROPHYLAXIS: on coumadin
#LINES/DRAINS: [X] Peripheral [] PICC [] CVL [] Foley
#PRECAUTIONS: Fall
#COMMUNICATION: pt, wife, HCP daughter, ___
___.
#CONSULTS: Neuro
#CODE STATUS: DNR/DNI per his MOLST which is in the paper chart
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Digoxin 0.25 mg PO DAILY
2. Fenofibrate 200 mg PO DAILY
3. LevETIRAcetam 500 mg PO QHS
4. LevETIRAcetam 250 mg PO QAM
5. Simvastatin 20 mg PO QPM
6. Warfarin 5 mg PO 3X/WEEK (___) Afib
7. Fludrocortisone Acetate 0.2 mg PO DAILY
8. Midodrine 5 mg PO TID
9. Polyethylene Glycol 17 g PO DAILY:PRN constipatoin
10. Sodium Chloride 1 gm PO TID
11. Warfarin 2.5 mg PO 4X/WEEK (___)
12. Oxybutynin 5 mg PO DAILY
13. Cyanocobalamin 1000 mcg PO DAILY
Discharge Medications:
1. Cyanocobalamin 1000 mcg PO DAILY
2. Digoxin 0.125 mg PO DAILY
3. Fenofibrate 200 mg PO DAILY
4. Fludrocortisone Acetate 0.2 mg PO DAILY
5. LevETIRAcetam 500 mg PO QHS
6. LevETIRAcetam 250 mg PO QAM
7. Midodrine 10 mg PO QAM
8. Midodrine 10 mg PO NOON
9. Midodrine 10 mg PO EVERY 4 ___
10. Polyethylene Glycol 17 g PO DAILY:PRN constipatoin
11. Simvastatin 20 mg PO QPM
12. Sodium Chloride 1 gm PO TID
13. ___ MD to order daily dose PO DAILY16
14. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever
15. Docusate Sodium 100 mg PO BID
16. Levofloxacin 750 mg PO Q48H Duration: 3 Days
Last dose ___ (dose given on ___
17. Senna 8.6 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Encephalopathy, progressive dementia
___
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure looking after you, Mr. ___. As you may
know, you were admitted with increasing confusion, gait
imbalance. Extensive workup was performed here - neurology
experts were also consulted. The workup included lumbar
puncture, brain imaging (CT scan, MRI), multiple blood tests,
and EEG to assess for existence of seizure. Despite this
workup, we did not identify any reversible causes - and our
recommendation is to undergo physical therapy to ensure
maintenance of physical strength and hope for some return of
cognitive function (memory, daily functional skills, etc..).
You were found to have a pneumonia during this
hospitalization (not seen on admission) and are being treated
with antibiotics. This can be completed on ___. We also
made change to your digoxin dose from 0.25 mg daily to 0.125 mg
daily. Oxybutinin was discontinued (due to side effects
associated with confusion). Otherwise, there were no major
changes to your medications
Followup Instructions:
___
|
10682231-DS-23
| 10,682,231 | 27,806,495 |
DS
| 23 |
2131-08-29 00:00:00
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2131-08-29 17:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Keflex
Attending: ___.
Chief Complaint:
Left hallux necrosis
Major Surgical or Invasive Procedure:
___
1. Ultrasound-guided access to right common femoral artery with
placement of ___ sheath.
2. Selective catheterization of superficial femoral artery
third-order vessel.
3. Abdominal aortogram with CO2.
4. Left lower extremity imaging with CO2 and contrast.
___
1. Left below-knee popliteal to posterior tibial artery bypass
with non-reversed greater saphenous vein.
2. Angioscopy with valve lysis.
3. Left hallux amputation.
History of Present Illness:
___ who is referred by podiatrist to see vascular surgery and Dr
___ non healing ulcerations left great toe over past
week. She reports that her toe has been infected for the past
three weeks, and it now more black than it was before. She has
been following with podiatry who prescribed her keflex for the
past week and drained an abscess on the toe today. She denies
any pain in the foot and reports that she cannot feel anything
in the toe. She denies fevers, chills, headaches, dizziness or
vomiting though she does report some nausea which she associates
with taking the Keflex over the past week.
Past Medical History:
DM(since ___ c/b neuropathy, hypercholesterolemia, HTN
Past Surgical History:
___ right ___ toe amputation for nonhealing ulcer,
___ Right hallux distal phalanx and third toe amputation,
Right ankle surgery for fracture at ___ years of age
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission,
98.3 106 142/76 16 97% RA
NAD, AAO
RRR
CTA b/l
soft, ND, NT abdomen
RLE: well healed RLE TMA site, warm and well perfused without
edema or erythema
LLE: mild erythema over foot, dry necrosis on great toe with
fluctuant area on toe pad, no drainage
Pulses:
FEM POP DP ___
R P P D D
L P P D D
On discharge,
98.6 81 122/65 20 97% RA
GEN: AAOx3, NAD
CV: RRR, S1S2
PULM: CTAB
GI: soft, NT, ND
EXT: warm, well perfused, medial LLE incisions with staples in
place appear clean, dry and intact with minimal overlying
erythema. Left hallux TMA site with dry blood, otherwise with
sutures in place.
Pulses:
FEM POP DP ___
R P P D D
L P P D D
Pertinent Results:
___ 10:09PM WBC-14.5*# RBC-3.71* HGB-10.7* HCT-33.5*
MCV-90 MCH-29.0 MCHC-32.1 RDW-13.3
___ 10:09PM NEUTS-76.1* LYMPHS-17.3* MONOS-4.8 EOS-1.6
BASOS-0.3
___ 10:09PM PLT COUNT-399#
___ 10:09PM ___ PTT-27.5 ___
___ 10:09PM LACTATE-1.4
___ 10:09PM GLUCOSE-310* UREA N-38* CREAT-2.0* SODIUM-133
POTASSIUM-5.9* CHLORIDE-99 TOTAL CO2-21* ANION GAP-19
___ 10:09PM CALCIUM-9.1 PHOSPHATE-3.7 MAGNESIUM-2.3
Left foot X-ray ___
Soft tissue swelling and minimal bone fragmentation medial to
the head of the first metatarsal, at the metatarsophalangeal
joint. Focal subcortical demineralization could represent early
osteomyelitis. There is no periosteal reaction and no gas in the
soft tissue. MRI scanning is much more reliable in
distinguishing early infection from demineralization due to
hyperemia from adjacent soft tissue infection and would be
useful to assess demineralization in the distal fourth
metatarsal. Valgus deformity of the fifth metatarsophalangeal
joint is not accompanied by degenerative changes.
Right foot X-ray ___
Three views of the right foot show extension of earlier
amputation involving the phalanges of the first, second, and
fourth rays. There is a deep ulceration between the first and
second metatarsal heads. No subcutaneous emphysema is present,
and there are no areas of demineralization suspicious for active
osteomyelitis.
Bilateral vein mapping ___
Patent GSV and LSV bilaterally
Brief Hospital Course:
The patient is a ___ year old female who was admitted to the
Vascular Surgery service with left hallux necrosis. She was
started on vanc/cipro/flagyl, and a culture was obtained. She
was followed by podiatry, who recommended a left foot x-ray,
which showed no signs of osteomyelitis. On ___, she
underwent a left lower extremity angiogram (please see procedure
note for more details). Findings consisted of left common
femoral, profunda, and SFA patent with 40-50% stenosis in its
distal portion. The left popliteal artery was patent with some
mild irregularities and one-vessel runoff through the peroneal
artery. The ___ reconstituted distally at the level of the ankle.
On ___, she underwent vein mapping, which showed patient GSV
and LSV bilaterally. Cultures obtained on admission grew staph
aureus coag positive. Vanco and flagyl were discontinued, and
cipro was continued for the foot infection and UTI. On ___,
she underwent a ___ bypass graft and left hallux
amputation (please see operative note for more details). She
tolerated the procedure well and was transferred to the VICU for
further care. On ___, she was kept on bedrest, and she was
started on regular diabetic diet, which she tolerated well.
Vancomycin was restarted due to erythema at the amputation site.
She was also given one dose of fluconazole due to yeast growing
on her urine culture. Cipro was discontinued. Her HbA1C was 9.2,
for which ___ diabetes service was consulted. They made
adjustments to her insulin regimen and blood sugars remained
stable. Vancomycin was discontinued, and oral regimen with
dicloxacillin was started. She was up out of bed to chair with
left leg elevation. She spiked a temp 101.2 in evening. On
___, her WBC was elevated to 15. CXR and urinalysis were
obtained, and blood cultures were sent. CXR showed increase in
fluid, but no PNA. Anticipating discharge, she was evaluated by
physical therapy with recommendation for touch-down weight
bearing on LLE and ambulation of essential distances only. She
made great progress and was deemed suitable to go home with ___
and ___ services for wound care. White blood cell count trended
downwards the last couple of days and urinalysis remained
questionable for UTI, even after obtaining a sample through
straight catheterization. She remained afebrile and
asymptomatic, for which reason no further antibiotics were
given.
At the time of discharge Mrs. ___ was doing well, pain was
well controlled with oral medication, ambulating essential
distances with assistance, tolerating regular diet, and voiding
without problems. Discharge teaching and follow-up instructions
were given with verbalized understanding and agreement on the
discharge plan. She would follow-up with Dr ___ in one
week.
Medications on Admission:
Insulin (lantus 40u qhs and humalog ISS), plavix 75mg qday,
aspirin 81mg qday, simvastatin 5mg qday
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain/headache
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet
extended release(s) by mouth every 8 hours Disp #*30 Tablet
Refills:*0
2. Aspirin EC 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet,delayed
release (___) by mouth daily Disp #*30 Tablet Refills:*0
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
RX *bisacodyl 5 mg 1 tablet,delayed release (___) by mouth
daily Disp #*30 Tablet Refills:*0
4. Clopidogrel 75 mg PO DAILY
RX *clopidogrel [Plavix] 75 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily Disp #*30 Capsule Refills:*0
6. Glargine 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone [Oxecta] 5 mg ___ tablet, oral only(s) by mouth
every ___ hours Disp #*30 Tablet Refills:*0
8. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [___] 8.6 mg 1 tablet by mouth once or twice
daily Disp #*25 Tablet Refills:*0
9. Simvastatin 5 mg PO DAILY
10. Amitriptyline 50 mg PO HS
11. DiCLOXacillin 250 mg PO Q6H Duration: 7 Days
RX *dicloxacillin 250 mg 1 capsule(s) by mouth every 6 hours
Disp #*28 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left hallux necrosis
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:
Mrs. ___,
___ was a pleasure taking care of you here at ___
___. You were admitted to the Vascular
Surgery service with an infection of the left big toe. You
underwent a left lower extremity angiogram and then a left
___ bypass graft and toe amputation. You are now ready
to complete your recovery at home. Please follow the
instructions below:
Division of Vascular and Endovascular Surgery
Discharge Instructions
WHAT TO EXPECT:
1. It is normal to feel tired, this will last for ___ weeks
You should get up out of bed every day and gradually increase
your activity each day
Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
Elevate your leg above the level of your heart (use ___ pillows
or a recliner) every ___ hours throughout the day and at night
Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
You will probably lose your taste for food and lose some weight
Eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
MEDICATION:
Take aspirin as instructed
Follow your discharge medication instructions
ACTIVITIES:
No driving until post-op visit and you are no longer taking
pain medications
You should ambulate essential distances only, as instructed by
your physical therapist
You should keep the amputation site elevated when ever
possible.
You may use the opposite foot for transfers and pivots.
No heavy lifting greater than 20 pounds for the next 3 weeks.
BATHING/SHOWERING:
You may shower when you get home
No tub baths or pools / do not soak your foot for 4 weeks from
your date of surgery
WOUND CARE:
An appointment will be made for you to return for removal of
your staples and sutures in your incisions.
When the sutures are removed the doctor may or may not place
pieces of tape called steri-strips over the incision. These will
stay on about a week and you may shower with them on. If these
do not fall off after 10 days, you may peel them off with warm
water and soap in the shower.
CAUTIONS:
If you smoke, please make every attempt to quit. Your primary
care physician can help with this. Smoking causes narrowing of
your blood vessels which in turn decreases circulation.
DIET:
Low fat, low cholesterol / if you are diabetic follow your
dietary restrictions as before
Followup Instructions:
___
|
10682269-DS-6
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DS
| 6 |
2113-11-07 00:00:00
|
2113-11-07 18:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
LOC, Head strike, HA, skull fractures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ transferred from ___ with small SAH and skull
fractures. She has a history of both seizure disorder and
presumed vasovagal syncope and sustained a fall from standing
today. She is a nursing student and today was her first day of
clinical rotations; she was with patients at the time and
recalls
feeling "tunnel vision" for at least a minute prior to
unconsciousness. Per witnesses, she fell from standing position
backward, hitting her head on the floor. She also lost urinary
continence. No convulsions or loss of bowel function were
reported. She awoke after a few minutes complaining of
headache,
but alert and oriented. She was transported to ___ ED. On
arrival, she had nausea and vomited x3. CT scan at ___
demonstrated right SAH and left sided skull fractures. She was
transferred to ___ for further care.
Notably she has had seizures in the past - around age ___ she had
several episodes (sometimes multiple per day) of "rapid
oscillating eye movements" lasting several seconds. EEG at that
time confirmed seizure activity and she was treated with
depakote
and eventually added lamictal. She was treated with these two
anti-epileptic medications with success for ___ years, when she
weaned off these meds per her primary neurologist's advice.
Since that time, she had two episodes of what appear to be
syncope - tunnel vision leading to loss of consciousness, which
are NOT similar to her prior seizures. Per ___ mother,
she
was worked up at ___ for these episodes and the presumed
diagnosis was vasovagal syncope as she did NOT demonstrate
evidence of seizures on EEG testing. It has been ___ years since
the last such event, until today's episode.
Currently in the ED she is quite somnolent but arousable; she
complains of severe headache. ROS is positive for nausea and
emesis today, and for URI symptoms (runny nose, dry cough) for
the past 2 weeks; othewise ROS is negative except as noted.
Past Medical History:
seizure disorder
Social History:
___
Family History:
no seizure history
Physical Exam:
EXAM:
T: 97.4 P: 76 R: 16 BP: 106/69 SaO2: 97% RA
___: somnolent but arousable, A&O x3
HEENT: nontender, full ROM; ___ clear and intact ___
Cardiac: RRR
Abdomen: soft, NT/ND
Ext: WWP
Neuro:
- CN ___ intact
- strength / sensation equal and intact in UEs and ___
DISCHARGE EXAM:
NEUROLOGICALY INTACT
Pertinent Results:
___ 10:10AM BLOOD WBC-11.2* RBC-3.93* Hgb-12.1 Hct-36.8
MCV-94 MCH-30.8 MCHC-32.9 RDW-12.4 Plt ___
___ 10:55AM BLOOD WBC-7.1 RBC-3.69* Hgb-11.7* Hct-34.7*
MCV-94 MCH-31.8 MCHC-33.8 RDW-12.0 Plt ___
___ 10:10AM BLOOD Glucose-113* UreaN-7 Creat-0.7 Na-136
K-3.8 Cl-100 HCO3-24 AnGap-16
___ 10:10AM BLOOD Calcium-8.6 Phos-2.9 Mg-1.7
CT head ___. Compared to the prior CT peformed 6 hour prior, the right
frontal contusion is more defined. Right temporal and posterior
frontal contusions and subarachnoid hemorrhage are unchanged.
Right subdural hemorrhage layering along the tentorium is also
unchanged.
2. Left parietal bone fracture extends through the occipital
bone, left temporal bone and into the left sphenoid sinus. The
fracture abuts the cavernous portion of the left carotid canal.
CTA is recommended to further evaluation of the cerebral
vasculature.
3. Left parietotemporal scalp hematoma and subcutaneous air.
4. Complete opacification of the left sphenoid sinus is likely
related to hemorrhage. Partial opacification of the ethmoid air
cells, maxillary sinuses, right sphenoid sinus and left mastoid
air cells also likely represent hemorrhage.
___ EEG
Abnormal extended routine EEG due to the prominent right
hemispheric slowing, consistent with the report of a structural
abnormality in the right hemisphere. The background was normal
elsewhere, and there were no definite epileptiform features.
___ CT Orbits, sella, IAC; CTA head
1. No dissection, occlusion, flow-limiting stenosis, or aneurysm
of the
cranial vasculature.
2. Lack of opacification of the left sigmoid sinus is concerning
for dural
venous thrombosis.
3. Unchanged right parietal and temporal contusion and
subarachnoid
hemorrhages. No new hemorrhage identified.
___ MRV
Loss of flow related enhancement within the left distal
transverse and left sigmoid sinuses as well as the portion of
the left internal jugular vein included on the field of view
compatible with venous thrombosis.
___ MR head with and without contrast
Post-traumatic venous sinus thrombosis in the left transverse
sigmoid sinus extending into the proximal IJV. Areas of
hemorrhagic contusion as above. No evidence for large
territorial infarction.
___ MRV Head (prelim)
Redemonstration of absent flow related enhancement within the
left transverse
and sigmoid sinuses, as well as the proximal left internal
jugular vein, as
detailed above compatible with venous thrombosis.
___ MRV- Read pending
Brief Hospital Course:
Mrs. ___ was transferred to ___ from ___
after sustaining a head strike from vasovagal syncope on
___. Her head CT upon arrival showed little change from OSH
CT exam. Her initial exam was positive for headache but she was
neurologically intact CN2-12 and moving all extremities well.
She was admitted to the Neurosurgical team and started on Keppra
as well as PO and IV analgesia. Her diet was advanced to
regular diet on ___.
On ___, the patient was transferred to ___ ED. CT scan:
SAH/IPH, parietal-temporal-Sphenoid synus fx w/ mastoid air cell
opacities. On ___, her diet was advanced. ENT was consulted
and recommended CSF leak precautions (___ elevation, stool
softeners, sneeze with mouth open, no nose blowing), and
audiogram. CTA and Dedicated Temporal CT ordered. An EEG was
completed and revealed epileptiform features.
On ___, a MRV and CTA were concerning for a sigmoid venous
sinus thrombosis, and the jugular is also not well visualized.
The transverse sinus has low flow but this is felt to be the
congenitally smaller sinus. An MRI and repeat MRV with contrast
to further look for thrombus are requested. The patient is
hydrated with IVF, neuro exam was intact.
Mrs. ___ underwent a repeat MRV on ___ and on ___ ,
which again revealed an absent flow enhancement of the patient's
left sigmoid and transverse sinus; she was started on ASA 325
and she was discharged home with follow up on ___.
Medications on Admission:
OCP daily, fish oil daily
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN
pain/headaches
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 10 Days
END date ___
3. Aspirin 325 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
6. LeVETiracetam 500 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Subarachnoid hemorrhage, Intraparenchymal Hemorrhage,
Parieto-Temporal skull Fractures.
Venus thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Augmentin 875 mg PO BID x 10 days.
CSF leak precautions: (___ elevation, stool softeners, sneeze
with mouth open, no nose blowing), no straws
Followup Instructions:
___
|
10682294-DS-14
| 10,682,294 | 24,954,610 |
DS
| 14 |
2133-10-03 00:00:00
|
2133-10-03 20:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Augmentin / Influenza Virus Vaccine
Attending: ___
Chief Complaint:
Cough, fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with sickle cell disease (HbSS with
persistent fetal hemoglobin) who presents with ___ days of cough
and fever.
Patient reports that 1 day prior to admission she was feeling
generally unwell with myalgias, subjective fevers, chills, cough
and sputum production. Her symptoms worsened on the day of
admission so she presented to her PCP (at ___)
who recommended that she go to the ED for evaluation.
In the ED, she was febrile to 102.9, but vitals were otherwise
stable. She was placed on 2L NC, but had been 98-100% on RA.
Influenza swab was performed for a research study which came
back POSITIVE. However, the official lab influenza swab came
back negative. Labs otherwise notable for H/H 7.0/21.1, which
was at baseline. Chest x-ray showed no acute process. She was
NOT given Tamiflu. She received 1L of NS, acetaminophen 1000mg x
2, levofloxacin 750mg IV, benzonatate 100mg PO, ibuprofen 600mg
PO. She was admitted for further management.
Past Medical History:
- G1P1 with NSVD ___, course complicated by dilutional
anemia, severe postpartum preeclampsia
- Sickle cell disease - no pain crises, no hydroxyurea,
transfusions in ___ in setting of severe epistaxis, and ___
in the peripartum period
Social History:
___
Family History:
Both parents have sickle cell trait, and she believes that her
mother may have concurrent thalessemia as well.
She has two sisters, twins aged ___, both of whom also have SCD.
One sister is receiving exchange transfusions and may soon start
hydroxyurea. The other sister has had pain crises.
Physical Exam:
ADMISSION EXAM:
Vital signs: T 102.5, BP 111/70, P 94, RR 18, O2 98% RA
Gen: Well appearing, in no apparent distress
HEENT: NCAT, oropharynx clear
Lymph: no cervical lymphadenopathy
CV: No JVD present, regular rate and rhythm, ___ SEM loudest at
LUSB, no rubs or gallops
Resp: CTA bilaterally in anterior and posterior lung fields, no
increased work of breathing
GI: soft, non-tender, non-distended. No hepatosplenomegaly
appreciated.
GU: No suprapubic tenderness
Extremities: no clubbing, cyanosis, or edema
Neuro: no focal neurologic deficits appreciated. Moves all 4
extremities purposefully and without incident, no facial droop.
Psych: Euthymic, speech non-tangential, appropriate
DISCHARGE EXAM
98.4
PO 108 / 69 63 18 100 Ra
HEENT: PERRL, Anicteric, eyes conjugate,pallor present, MMM, no
JVD; no erythema in oropharynx, no LAD, no tonsilar exudates
Cardiovascular: RRR no MRG, nl. S1 and S2
Pulmonary: no rales today
Gastroinestinal: Soft, non-tender, non-distended, bowel sounds
present, no HSM
MSK: No edema
Skin: No rashes or ulcerations evident
Neurological: Alert, interactive, speech fluent, face symmetric,
moving all extremities, strength in extremities is full and
symmetric throught upper and lower extremities.
Psychiatric: pleasant, appropriate affect
Access: there is no urinary catheter present.
Pertinent Results:
LAB RESULTS:
CBC:
8.9 > 7.0/21.2 < 165
Ret-Aut: 13.4
Abs-Ret: 0.34
BMP:
135 | 98 | 5
----------------< 80
3.9 | 23 | 0.5
Ca: 8.7 Mg: 1.6 P: 2.8
ALT: 21
AST: 38
___: 12.5 PTT: 42.4 INR: 1.2
UCG: Negative
Research influenza swab: POSITIVE (normal swab, but done for a
study of statins in influenza)
Regular influenza swab: NEGATIVE
IMAGING:
CXR (___):
1. Low lung volumes. No focal pneumonia.
2. Top-normal heart size.
CXR ___
IMPRESSION:
Bilateral peribronchial opacities in the lower lobes, right
greater than left,
most consistent with infection.
DISCHARGE LABS
___ 06:52AM BLOOD WBC-6.7 RBC-2.34* Hgb-6.4* Hct-19.4*
MCV-83 MCH-27.4 MCHC-33.0 RDW-18.3* RDWSD-55.5* Plt Ct-88*
___ 03:25PM BLOOD WBC-7.0 RBC-2.54* Hgb-6.9* Hct-21.0*
MCV-83 MCH-27.2 MCHC-32.9 RDW-18.4* RDWSD-53.6* Plt Ct-87*
___ 03:25PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-2+
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL
Ovalocy-OCCASIONAL Target-OCCASIONAL Sickle-OCCASIONAL Tear
Dr-OCCASIONAL
___ 06:52AM BLOOD Plt Ct-88*
___ 06:52AM BLOOD Glucose-77 UreaN-8 Creat-0.5 Na-136 K-4.0
Cl-101 HCO3-24 AnGap-15
___ 07:10AM BLOOD LD(LDH)-439*
Brief Hospital Course:
___ yo with HbSS dx but with persistence of Fetal Hb per OMR
notes, who presented to the ED with ___ dd of fever, cough,
malaise, found to have positive (research) swab for flu study
being done in the ED, but negative ___ clinical swab (actually
the same swab and same processing). Admitted, oseltamivir
started as symptoms c/w flu and one swab positive. On HD 3
developed bibasilar rales, so cxr repeated, and found to have
has bibasilar infiltrates c/f: influenza pna v. bacterial pna v.
acute chest syndrome (less likely the latter). Sats normal,
vss, no cp or sob. Hb is in the 6.4-7 range. Plts are approx.
70-80k. Noted that she has had marked thrombocytopenia in the
past with hospitalizations.
Influenza, w fever, cough, st, now with bibasilar lt greater
than
rt rales that do not clear, concerning for pneumonia (viral,
secondary bacterial), or acute chest syndrome (doubt latter as
no
hypoxemia or pain however): continued oseltamivir. Repeated
cxr, found rt greater than lt infiltrates seen on CXR c/f
pneumonia. Obtained blood cultures and sputum, started
levofloxacin, monitored saturations closely and now being
discharged on course of levaquin for total of 7 days.
No fever, normal WBC, no oxygen requirement, imporved lung exam
has been noted.
Given b/l infiltrates considered early acute chest syndrome and
aggressive fluids were given but patient never had any pain,
difficulty breathing. Clinically low suspicion for
vaso-occlusive crisis.
Sickle Cell Disease, without asplenia, with persistence of fetal
Hb: baseline runs around 7, was noted to drop to 6, but repeat
hb-6.9. On discharge day hb is 6.4. Heme/onc was consulted given
low counts. Repeat Hb electrophoresis was ordered and currently
pending. Patient runs low and tends to tolerate low Hb and is
asymptomatic. Her usual thresolh for transfusion is less than 6,
after discussing with patient and hematology since patient was
asymtomatic , trasnfusion was deferred. She will need f/u CBC
when she sees her PCP and asked to follow up with hematology
outpatient. Continue folic acid and iron supplements.
Thrombocytopenia - likely due to mild hypersplenism, influenza,
has been noted previously. Monitored and remained stable.
Anxiety: continued lorazepam prn
#PPX (DVT): gave teds/pneumatic boots, ambulation (ordered), as
pt. refused sc heparin, and wanted to avoid heparin at any rate
d/t low platelets.
Stable to be discharged.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyanocobalamin 1000 mcg PO DAILY
2. Ferrous Sulfate 325 mg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Loratadine 10 mg PO DAILY
6. Vitamin D 400 UNIT PO DAILY
7. acetaminophen-codeine 300-30 mg oral Q8H:PRN hip pain
8. LORazepam 0.5-1 mg PO BID:PRN anxiety
9. norelgestromin-ethin.estradiol 150-35 mcg/24 hr transdermal
PER INST
10. DiphenhydrAMINE 25 mg PO Q8H:PRN allergy symptoms
11. Ketorolac 0.5% Ophth Soln 1 DROP BOTH EYES BID:PRN allergy
symptoms
Discharge Medications:
1. Levofloxacin 750 mg PO DAILY
RX *levofloxacin [Levaquin] 750 mg 1 tab tablet(s) by mouth qday
Disp #*4 Tablet Refills:*0
2. OSELTAMivir 75 mg PO Q12H
RX *oseltamivir [Tamiflu] 75 mg 1 tab capsule(s) by mouth twice
a day Disp #*4 Capsule Refills:*0
3. acetaminophen-codeine 300-30 mg oral Q8H:PRN hip pain
4. Cyanocobalamin 1000 mcg PO DAILY
5. DiphenhydrAMINE 25 mg PO Q8H:PRN allergy symptoms
6. Ferrous Sulfate 325 mg PO DAILY
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY
8. FoLIC Acid 1 mg PO DAILY
9. ketotifen fumarate 0.025 % (0.035 %) ophthalmic BID:PRN
allergies
10. Loratadine 10 mg PO DAILY
11. LORazepam 0.5-1 mg PO BID:PRN anxiety
12. norelgestromin-ethin.estradiol 150-35 mcg/24 hr transdermal
PER INST
13. Vitamin D 400 UNIT PO DAILY
14.Return to work form
Patient was admitted to ___ for medical issues from ___ to
___. She may return to work on ___
Discharge Disposition:
Home
Discharge Diagnosis:
Influenza, pneumonia,anemia
thrombocytopenia
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 flu and pneumonia. We also had hematology
see you while you were in the hospital. You have improved. Keep
youself hydrated. F/u with your PCP closely and you will need
follow up CBC when you see your PCP.
Good luck
Followup Instructions:
___
|
10682488-DS-16
| 10,682,488 | 22,073,138 |
DS
| 16 |
2186-10-21 00:00:00
|
2186-10-22 06:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
FLUID OVERLOAD
Major Surgical or Invasive Procedure:
___ ___ paracentesis: 1.75L removed, no e/o SBP.
History of Present Illness:
Mr. ___ is a ___ year old man with alcoholic and HCV
cirrhosis decompensated by ascites with a history of SBP,
hepatic
encephalopathy, and variceal bleeding s/p banding who presented
to clinic today for follow-up and was referred to the ED for
admission for IV diuresis + albumin, expedited inpatient
transplant workup and feeding tube placement. He says he last
had
a therapeutic paracentesis last ___ where 5L were removed.
He denies fevers and chills at home. He has had some pain at
the
access site for his paracentesis and has noted some occasional
fluid and blood leaking from this area. He has back pain
chronically which he feels is secondary to fluid overload. He
does state that he is short of breath with exertion. He denies
chest pain, nausea, vomiting. Denies recent alcohol or drug use.
He was first seen in our multidisciplinary transplant clinic
about 3 weeks ago at which point his urine tox screen was
positive for opiates which was felt to be a mistake by his wife
(accidentally gave him a Vicodin instead of a potassium pill
from
her own pillbox). He has since denied further narcotic use. He
has been abstinent since ___ from alcohol and has been
engaged with a therapist weekly on the outpatient setting.
In the ED initial vitals: Temperature 97.2, heart rate 97, blood
pressure 130/66, respiratory rate 20, 100% on room air
- Exam notable for: Not documented
- Labs notable for:
CBC: White blood cell count of 6.4, hemoglobin 9.4, platelets 61
Chem7: Sodium of 129, potassium 5.5, chloride 102, bicarb 18,
BUN
18, creatinine 0.9
LFTs: Bilirubin 3.7, AST 81, ALT 36, alk phos 170, albumin 3.0
Coags: INR 1.4
- Imaging notable for: RUQUS shows Cirrhotic liver with patent
main portal vein with hepatopetal flow. Large volume ascites.
Splenomegaly. Please refer to same-day MRI of the abdomen for
further details.
- Patient was given: Nothing
- ED Course: Bedside ultrasound showed no tap-able pocket for
paracentesis.
On arrival to the floor the patient notes he has back pain
related to fluid overload. Breathing is comfortable. he is
compliant with his medications. No chest pain. Swelling in the
legs is slowly increasing over he past few months. Abdomen is
distended and has some pain at the site of last week's
paracentesis.
Past Medical History:
- Hepatitis C/ETOH cirrhosis complicated by varices s/p banding,
ascites (untreated HCV)
- History of alcohol use disorder
- Subdural hematoma s/p evacuation in ___
- Peptic ulcer disease
Social History:
___
Family History:
Adopted and family history unknown.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS:
24 HR Data (last updated ___ @ 2144)
Temp: 97.9 (Tm 97.9), BP: 121/76, HR: 95, RR: 20, O2 sat:
100%, O2 delivery: RA, Wt: 227.7 lb/103.28 kg
Gen: Frail appearing with temporal wasting and muscle wasting on
his arms. He is alert oriented x3 has no asterixis.
HEENT: scleral icterus, moist mucous membranes. No oral lesions.
CV: RRR, no r/m/g.
Pulm: Clear bilaterally.
Abdomen: Soft, nontender, distended with large ascites as well
as
a umbilical hernia without any strangulation.
Extremities: 3+ edema, warm.
Neuro: Alert and oriented x 3. No asterixis.
Skin: No lesions.
DISCHARGE PHYSICAL EXAMINATION:
24 HR Data (last updated ___ @ 2342)
Temp: 98.7 (Tm 99.1), BP: 120/59 (103-123/54-77), HR: 87
(87-98), RR: 20 (___), O2 sat: 96% (95-97), O2 delivery: Ra,
Wt: 219.3 lb/99.47 kg
Gen: NAD.
CV: RRR, no r/m/g.
Pulm: Decreased RLL breath sounds.
Abdomen: Soft, nontender, distended. +umbilical hernia
Extremities: Warm, trace-1+ b/l ___.
Neuro: Alert and oriented x 4. No asterixis.
Skin: Mildly jaundiced.
Pertinent Results:
ADMISSION LABS
___ 04:36PM BLOOD WBC-6.4 RBC-3.12* Hgb-9.4* Hct-29.9*
MCV-96 MCH-30.1 MCHC-31.4* RDW-18.2* RDWSD-64.6* Plt Ct-61*
___ 04:36PM BLOOD Neuts-55.6 ___ Monos-14.2*
Eos-8.5* Baso-0.6 Im ___ AbsNeut-3.55 AbsLymp-1.33
AbsMono-0.91* AbsEos-0.54 AbsBaso-0.04
___ 04:36PM BLOOD ___ PTT-32.9 ___
___ 04:36PM BLOOD Glucose-75 UreaN-18 Creat-0.9 Na-129*
K-5.5* Cl-102 HCO3-18* AnGap-9*
___ 04:36PM BLOOD ALT-36 AST-81* AlkPhos-170* TotBili-3.7*
___ 04:36PM BLOOD Albumin-3.0* Calcium-8.5 Phos-4.2 Mg-2.0
DISCHARGE LABS
___ 04:45AM BLOOD WBC-5.6 RBC-2.73* Hgb-8.4* Hct-25.9*
MCV-95 MCH-30.8 MCHC-32.4 RDW-18.3* RDWSD-63.1* Plt Ct-44*
___ 06:07AM BLOOD ___
___ 04:45AM BLOOD Glucose-90 UreaN-21* Creat-1.0 Na-134*
K-3.4* Cl-96 HCO3-28 AnGap-10
___ 04:45AM BLOOD ALT-25 AST-59* LD(LDH)-223 AlkPhos-207*
TotBili-2.5*
___ 04:45AM BLOOD Albumin-3.0* Calcium-7.9* Phos-4.3 Mg-1.9
MICRODATA
___ 4:36 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 12:56 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
REPORTS
___ LIVER MRI:
1. Cirrhotic liver morphology with stigmata of portal
hypertension including
varices, splenomegaly, and moderate to large amount of ascites.
No concerning
focal liver lesion is identified. The calculated liver volume:
1389.1 cc
2. An enlarged 1.5 cm perigastric lymph node is noted, possibly
reactive.
___ RUQUS:
Cirrhotic liver with patent main portal vein with hepatopetal
flow. Large
volume ascites. Splenomegaly. Please refer to same-day MRI of
the abdomen
for further details.
___ CXR:
Small posterior pleural effusion.
___ DIAGNOSTIC/THERAPEUTIC PARA:
1. Technically successful ultrasound guided diagnostic and
therapeutic
paracentesis.
2. 1.75 L of fluid were removed and sent for requested analysis.
___ TTE: SEE ATTACHED REPORT
___ STRESS TEST
___ CARDIAC PERFUSION TEST
Brief Hospital Course:
Mr. ___ is a ___ year old man with Child C alcoholic and HCV
cirrhosis decompensated by ascites w/ a history of SBP, hepatic
encephalopathy, and variceal bleeding s/p banding who was
admitted for fluid overload, malnutrition, and expedited
transplant work-up. diuresis and initiation of enteral feeding.
He was actively diuresed with IV Lasix and switched to PO
torsemide 40 BID prior to discharge. ___ ___ guided para was
performed with removal of 1.75L fluid. Dobhoff was placed on
___ and tube feeds were initiated on ___.
#CIRRHOSIS
#ANASARCA
#ASCITES
Patient presenting with anasarca and refractory ascites. No
clear
reason for decompensation at this time. Reports compliance with
medication, no signs of bleeding, RUQUS showed cirrhotic liver
and large volume ascites. ___ guided paracentesis on ___ was
performed with 1.75L removed - no e/o SBP at that time, but he
was continued on home cipro. He was diuresed with IV Lasix 40
and switched to PO torsemide 40mg BID with discharge weight of
220 lbs.
#MALNUTRITION.
___ was placed ___ and tube feeds were started, with plan
to continue at home.
#LIVER TRANSPLANT EVALUATION.
Per outpatient provider, liver transplant eval was expedited
during admission. He is hepatitis C positive and is untreated
and has higher chance to receive an organ with a lower meld
score if there is a positive hep C organ offer. Most of his
work-up was completed during this admission. Labs ordered, but
pending at discharge include: LMK antibody, IGRA. Studies to be
performed include: DEXA which could not be done as inpatient,
and EGD which he preferred to get done as outpatient.
# CODE: Presumed FULL
# CONTACT: Name of health care proxy: ___
___: wife
Phone number: ___
Cell phone: ___
TRANSITIONAL ISSUES
====================
[]Will need to complete DEXA, EGD for transplant work-up.
[]Will need ___ antibody, IGRA.
[]Monitor for fluid overload. Discharge Weight: 220 lbs,
Discharge Cr: 1.0
[]Should have weekly MELD labs
[]Should continue to have therapeutic paracenteses as needed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lactulose 15 mL PO BID
2. HydrOXYzine 25 mg PO Q6H:PRN Itching
3. Furosemide 40 mg PO BID
4. aMILoride 5 mg PO BID
5. Omeprazole 20 mg PO DAILY
6. Ciprofloxacin HCl 500 mg PO Q24H
7. magnesium chloride 71.5 mg oral DAILY
8. Potassium Chloride 20 mEq PO BID
9. rifAXIMin 550 mg PO BID
10. Venlafaxine XR 75 mg PO DAILY
11. Thiamine 100 mg PO DAILY
12. Vitamin D ___ UNIT PO DAILY
13. Vitamin D ___ UNIT PO 1X/WEEK (___)
14. Cholestyramine 2 gm PO DAILY
Discharge Medications:
1. Torsemide 40 mg PO BID
RX *torsemide 20 mg 2 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
2. aMILoride 5 mg PO BID
3. Cholestyramine 2 gm PO DAILY
4. Ciprofloxacin HCl 500 mg PO Q24H
5. HydrOXYzine 25 mg PO Q6H:PRN Itching
RX *hydroxyzine HCl 25 mg 1 tablet(s) by mouth q6 Disp #*28
Tablet Refills:*0
6. Lactulose 15 mL PO BID
7. magnesium chloride 71.5 mg oral DAILY
8. Omeprazole 20 mg PO DAILY
9. Potassium Chloride 20 mEq PO BID
Hold for K >5
10. rifAXIMin 550 mg PO BID
11. Thiamine 100 mg PO DAILY
12. Venlafaxine XR 75 mg PO DAILY
13. Vitamin D ___ UNIT PO DAILY
14. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
#Decompensated cirrhosis
Secondary diagnoses:
Anasarca
Ascites
Malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you had too much fluid
in your body.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- We removed fluid from your abdomen (called "paracentesis").
We took off 1.75 liters of fluid from your abdomen on ___.
- We gave you IV medications to remove excess fluid from your
body.
- Before you left the hospital, we switched to an oral
medication to keep fluid off your body.
- We continued studies for your liver transplant.
- We placed a feeding tube to help with nutrition
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Keep your follow up appointments with your doctors
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight changes by more
than 3 pounds
- Please stick to a low salt diet and monitor your fluid intake
- If you experience any of the danger signs listed below please
call your primary care doctor or come to the emergency
department immediately.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team
Followup Instructions:
___
|
10682617-DS-20
| 10,682,617 | 27,183,004 |
DS
| 20 |
2128-10-29 00:00:00
|
2128-11-01 18:53:00
|
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:
EGD
History of Present Illness:
___ with history of hysterectomy (___), asthma, who presents
with 5 day history of worsening RLQ abdominal pain, with
postprandial vomiting.
She began having this RLQ abdominal pain on ___ when she was
sitting down. It is constant with intermittent worsening ___
up to ___, and sharp). She has not been able to eat anything.
Eating any type of food has caused her to vomit. Her last bowel
movement was on ___ morning. She has not passed gas since a
couple of days ago. Notes pain for the past month, but at a much
lower level.
She went to ___ on ___ and was discharged
yesterday. CT imaging was negative for any findings per
patient's
report with no stone or torsion. She was discharged with pain
medications. However, she comes in to the ___ ED due to
worsening pain. Putting a pillow between her legs helps
alleviate
the pain. Walking or flexing her hips aggravates the pain. Not
pleuritic
She has a history of kidney stones and pain from endometriosis.
However she does not believe the pain quality is similar. She
notes thinking that eating garlic and onion at OSH worsened the
pain, and believes she might have an allergy to this.
Patient notes multiple episodes of lightheadedness/falling over
the past month or so, feels blurry vision coming on and feels
faint, with +LOC multiple times, every other day or so for the
past month. Unsure if head strike.
In the ED, initial VS were 97.4 78 ___ 100% RA Pain ___
Exam notable for Vitals within normal limits. ___ pain. PEx.
CTAB. RRR. - Rovsing sign. + Psoas sign. Tenderness to
percussion
in RLQ. Abdomen otherwise feels bloated to palpation.
Labs showed lactate 1.8. Chem7 notable for bicarb of 18,
otherwise WNL. CBC WNL. UCG negative. UA normal,
Imaging showed CT abd & pelvis w contrast:
1. No bowel obstruction. Normal appendix.
2. Trace bilateral pleural effusions with overlying minor
atelectasis.
3. Small amount of pelvic free fluid is nonspecific, but may be
within
physiologic range.
4. Right mid to lower abdominal lymph nodes are not
pathologically enlarged, but are nonspecific.
5. 2 hypodense lesions with peripheral nodular enhancement in
the
liver segment 7 are not fully characterized but are most
commonly
hemangiomas.
Received toradol IV 30mg, 1L NS, Zofran 4mg IV, and morphine 4mg
IV.
Patient was admitted due to inability to tolerate PO meds
Transfer VS were 98.7 80 ___ 98% RA pain ___
On arrival to the floor, patient reports ongoing abd pain. No
fevers, but notes some chills. No hematemesis but noted some
bleeding from nose and saw specks in the vomit. No
hematochezia/melena. Notes eating much less the past few days
Past Medical History:
Past Medical History:
- Asthma
- Environmental allergies
- Chronic back pain
- Migraines with aura
- Endometriosis
Past Surgical History:
- Sinus surgery
- Knee cartilage surgery
- ACL reconstruction (___)
- s/p R rib fractures from MVA
- ACL reconstruction (___)
- Diagnostic laparoscopies for endometriosis (___) at ___
- Laparoscopic left salpingectomy (___) for ruptured ectopic
pregnancy, with second laparoscopy for hemoperitoneum ("ruptured
sutures") - ___
- Total laparoscopic hysterectomy (___) at ___
Social History:
___
Family History:
- Mother: history of MI, HTN
- Paternal uncle and father with leukemia
- No family history of endometriosis
- Denies family history of Breast ca, Gyn Ca, or Colon Ca
- Denies family history of bleeding/clotting disorders
- No family history of inflammatory bowel disease or GI cancers
Physical Exam:
ADMISSION EXAM:
VS: T 97.7 BP 109/73 HR 68 RR 18 O2 Sat 99% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, soft. Very tender to light touch,
especially on the right side. no rebound/guarding.
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
Vitals: T 97.7 BP 96/64 HR 67 RR 16 O2 Sat 97 on RA
GENERAL: lying in bed in NAD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, soft. Very tender to mild palpation/light
touch, especially in RLQ. Winces and complains of referred
"pressure" in RLQ when pressing on LLQ. No rebound or guarding.
No peritoneal signs.
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, complains of "pulling pain" in RLQ when flexing at
R hip. Strength ___ in bilateral LEs, sensation to light touch
intact and symmetric on both feet
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSIONS LABS:
___ 05:00PM BLOOD WBC-4.3 RBC-4.54 Hgb-12.4 Hct-39.2 MCV-86
MCH-27.3 MCHC-31.6* RDW-12.4 RDWSD-39.5 Plt ___
___ 05:00PM BLOOD Neuts-56.9 ___ Monos-8.8 Eos-1.4
Baso-0.0 AbsNeut-2.47 AbsLymp-1.43 AbsMono-0.38 AbsEos-0.06
AbsBaso-0.00*
___ 05:00PM BLOOD Glucose-75 UreaN-7 Creat-0.7 Na-138 K-4.5
Cl-101 HCO3-18* AnGap-19*
___ 05:15PM BLOOD Lactate-1.8
___ 06:45AM BLOOD Albumin-3.6 Calcium-8.5 Phos-3.7 Mg-1.6
___ 05:00PM BLOOD Amylase-61
___ 05:00PM BLOOD Lipase-34
___ 06:45AM BLOOD ALT-10 AST-17 LD(LDH)-157 AlkPhos-60
TotBili-0.5
___ 05:05PM BLOOD CRP-18.1*
___ 05:05PM BLOOD tTG-IgA-4
___ 05:05PM BLOOD SED RATE-11
___ 04:48PM URINE Color-Straw Appear-Clear Sp ___
___ 04:48PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-150* Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 04:48PM URINE UCG-NEGATIVE
DISCHARGE LABS:
___ 06:25AM BLOOD WBC-4.0 RBC-4.21 Hgb-11.8 Hct-35.9 MCV-85
MCH-28.0 MCHC-32.9 RDW-13.0 RDWSD-40.3 Plt ___
___ 06:25AM BLOOD Glucose-84 UreaN-10 Creat-0.7 Na-141
K-3.6 Cl-104 HCO3-20* AnGap-17*
___ 07:00AM BLOOD ALT-40 AST-46* LD(LDH)-175 AlkPhos-69
TotBili-0.3
___ 06:25AM BLOOD Albumin-4.0 Calcium-8.8 Phos-4.1 Mg-1.9
MICROBIOLOGY:
___ 5:00 pm SEROLOGY/BLOOD
**FINAL REPORT ___
HELICOBACTER PYLORI ANTIBODY TEST (Final ___:
POSITIVE BY EIA.
(Reference Range-Negative).
___ 4:48 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
IMAGING:
MR PELVIS W&W/O CONTRAST ___:
FINDINGS:
UTERUS AND ADNEXA:
Postsurgical changes from hysterectomy are present. There is no
intrinsic T1 hyperintensity seen in the pelvis to suggest
endometriosis.
The right ovary is visualized and appears within normal limits.
The left ovary is visualized and appears within normal limits.
There is a small amount of free fluid in the pelvis, within
normal physiologic limits.
LYMPH NODES: There are no pathologically enlarged pelvic
sidewall or inguinal lymph nodes.
BLADDER AND DISTAL URETERS: The bladder is partially distended
and unremarkable. Distal ureters are normal.
RECTUM AND INTRAPELVIC BOWEL: Pelvic small and large bowel is
unremarkable. Appendix is visualized, without wall thickening
for hyperenhancement.
VASCULATURE: Pelvic vasculature is patent.
OSSEOUS STRUCTURES AND SOFT TISSUES: There are no suspicious
bony lesions. There is mild subchondral edema in the sacroiliac
joints. No bony erosion identified. There is no superficial
soft tissue abnormality.
IMPRESSION:
1. Post hysterectomy.
2. Small amount of pelvic free fluid, within physiologic limits.
3. No MR evidence of endometriosis.
4. Mild subchondral edema in the bilateral sacroiliac joints
without bony
erosion, findings likely degenerative.
ECG ___:
Clinical indication for EKG: ___.___ - Other long term (current)
drug therapy
Sinus rhythm. Non-specific slight ST segment elevation could be
early repolarization. The T wave inversion in lead V2 is due to
placement close to lead V1. No previous tracing available for
comparison.
PELVIS U/S, TRANSVAGINAL ___:
FINDINGS:
Patient has had a partial hysterectomy. The left ovary appears
normal, measuring 3.8 x 4.7 x 1.5 cm, and contains multiple
follicles. The right ovary appears normal in size, measuring
3.0 x 2.0 x 1.9 cm, with multiple follicles.
There is a small amount of free fluid.
IMPRESSION:
1. Normal appearing ovaries with multiple right ovarian
follicles. Patient is status post partial hysterectomy.
2. Small amount of free fluid noted.
CT ABD & PELVIS WITH CO
FINDINGS:
LOWER CHEST: There is trace bilateral ascites with overlying
minor atelectasis. No pericardial effusion is seen.
ABDOMEN:
HEPATOBILIARY: 2 hypodense lesions with peripheral nodular
enhancement are identified in segment 7. The lesions measure 20
mm and 10 mm respectively.
These are not fully characterized, but likely hemangiomas. 7 mm
hypodensity in central liver segment 4A (02:15) is too small to
be fully characterized.
Intra and extra hepatic bile ducts are not dilated. Gallbladder
is
unremarkable.
PANCREAS: Pancreas demonstrates homogeneous attenuation
throughout. Pancreatic duct is not dilated.
SPLEEN: Spleen is not enlarged.
ADRENALS: Bilateral adrenal glands are unremarkable.
URINARY: Bilateral nephrograms are symmetric. No focal renal
lesion is identified. There is no hydronephrosis.
GASTROINTESTINAL: No bowel obstruction or bowel wall thickening
is seen. The appendix is normal.
PELVIS: Bladder is unremarkable. Small amount free fluid in the
pelvis is nonspecific, but may be within physiologic range.
REPRODUCTIVE ORGANS: Uterus is absent. Follicular activity is
seen in both ovaries.
LYMPH NODES: Scattered mesenteric and right mid to lower
abdominal lymph nodes are not pathologically enlarged.
VASCULAR: There is no abdominal aortic aneurysm. Minimal
atherosclerotic disease is noted. Hypodensity in the SMV is
likely mixing of IV contrast.
BONES: No suspicious bone lesion is identified.
SOFT TISSUES: No suspicious soft tissue lesion is identified.
IMPRESSION:
1. No bowel obstruction. Normal appendix.
2. Trace bilateral pleural effusions with overlying minor
atelectasis.
3. Small amount of pelvic free fluid is nonspecific, but may be
within physiologic range.
4. Right mid to lower abdominal lymph nodes are not
pathologically enlarged, but are nonspecific.
5. 2 hypodense lesions with peripheral nodular enhancement in
the liver segment 7 are not fully characterized but are most
commonly hemangiomas.
Brief Hospital Course:
___ with history of endometriosis s/p partial hysterectomy
(___) and asthma who presents with 5 day history of worsening
RLQ abdominal pain and postprandial vomiting. The patient has
had a long history of chronic abdominal pain, and
also reported poor oral intake for at least the past month. She
underwent an extensive workup here for her abdominal pain,
including a pelvic ultrasound, abdominal CT, pelvic MRI, and
EGD. None of the tests performed provided definitive evidence
for the etiology of her pain. Given her history of endometriosis
it was recommended that she follow up with her gynecologist to
discuss a trial of medical management for potential recurrence
of her endometriosis. At discharge she was
able to tolerate oral intake, although she continued to have
unchanged abdominal pain.
ACTIVE ISSUES
=============
#Nausea/Vomiting/Abdominal pain:
Patient presented with an acute 5 day worsening of her chronic
abdominal pain, alongside nausea, vomiting, and inability to
tolerate oral intake. She has had several workups at outside
facilities in the past with no clear etiology for her symptoms
including recent CTA abd/pelvis and stool cultures. She
underwent an extensive workup here for her abdominal pain,
including a pelvic ultrasound, abdominal CT, pelvic MRI, and
EGD. None of the tests performed provided definitive evidence
for the etiology of her pain. She was treated symptomatically
during her stay for both pain and nausea. Her pain was treated
initially with morphine and oxycodone, and she was transitioned
to Tylenol and ibuprofen. She had no increase in her pain after
discontinuing opiates. Her nausea was treated with Zofran and
Compazine. She had minimal improvement with these medicines, so
she was trialed on metoclopramide. Following initiation she had
some improvement in her oral intake, however will require a
longer trial to assess if this was a major contributor to
improvement in her symptoms. She was given an aggressive bowel
regimen during her hospitalization due to large stool burden on
her initial CT and lack of a bowel movement for several days
prior to hospitalization, however symptoms did not improve
despite her bowel movements. She was seen by the gynecology
service here who recommended medical management for the
consideration of possible endometriosis with a trial of
progestin only pills or Lupron. Lupron would require more
extensive counseling with the patient and can be considered by
her outpatient gynecologist. At discharge she was able to
tolerate oral intake, although she continued to have unchanged
abdominal pain. She will follow up with her gastroenterologist
as well to discuss any additional potential etiologies for her
abdominal pain and the utility of a colonoscopy given that she
had a negative colonoscopy in the last year.
#Syncope:
Patient endorsed feeling faint and passing out about once every
other day for a month prior to admission. Her falls were
preceded by a prodrome of lightheadedness and blurry vision, and
were followed by loss of consciousness multiple times.
These episodes were felt to likely be from hypovolemia and
vasovagal syncope due to poor PO intake. EKG and telemetry
during her hospitalization were unconcerning. While in the
hospital, the patient endorsed occasional lightheadedness and
BPs occasionally dipped to the high ___, prompting boluses of IV
fluids early in her course. As her oral intake improved, her SBP
stabilized in the ___ and orthostatics were consistently
negative without requiring IVF.
#Hematochezia
Patient reported one episode of hematochezia during
hospitalization. She has a history of hemorrhagic proctitis on
colonoscopy in ___, likely secondary to straining, which was
felt to be the likely source of hematochezia. Should symptoms
continue further workup can be considered as an outpatient.
CHRONIC ISSUES
=============
#Environmental allergies:
Continued Claritin and Flonase PRN.
#Asthma:
Continued Flovent PRN. Held Albuterol as patient does not
typically use.
TRANSITIONAL ISSUES
=====================
[ ] Follow up appointment with PCP
[ ] Follow up appointment with patient's gynecologist, Dr.
___
[ ] Follow up appointment with patient's gastroenterologist, Dr.
___
[ ] Follow up final results of EGD
[ ] Consider Lupron vs. Progestin only pills for trial of
___ medical management for endometriosis
[ ] Pending trial of medical management, may consider utility of
exploratory laparoscopy for evaluation of endometriosis in the
future
[ ] Consider colonoscopy for further evaluation of abdominal
pain.
[ ] Consider further ongoing symptomatic management of abdominal
pain, nausea, and vomiting
Full code
No HCP currently on file
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Loratadine 10 mg PO DAILY
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Lidocaine 5% Patch 1 PTCH TD QAM to lower right abd pain or
back pain
4. Fluticasone Propionate 110mcg 2 PUFF IH DAILY asthma
5. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath
Discharge Medications:
1. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate
RX *ibuprofen 200 mg 2 capsule(s) by mouth every eight (8) hours
Disp #*40 Capsule Refills:*0
2. Metoclopramide 10 mg PO QIDACHS Duration: 2 Weeks
RX *metoclopramide HCl 10 mg 1 tablet by mouth QIDACHS Disp #*40
Tablet Refills:*0
3. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
4. Ondansetron ODT 8 mg PO Q8H:PRN nausea, pre meals
RX *ondansetron 8 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
5. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath
6. Fluticasone Propionate 110mcg 2 PUFF IH DAILY asthma
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. Lidocaine 5% Patch 1 PTCH TD QAM to lower right abd pain or
back pain
9. Loratadine 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Abdominal pain
Endometriosis
Chronic Abdominal Pain
Inability to Tolerate Oral Intake
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of ___ at ___
___.
Why was I admitted?
- ___ were having belly pain, nausea, and vomiting
What was done while I was here?
- ___ had a CT scan of your belly
- ___ had an MRI of your pelvis
- ___ had an ultrasound of your pelvis
- ___ had a procedure called an EGD where they looked in your
belly with a camera
What should I do when I leave the hospital?
- ___ should try to eat food and drink fluids
- ___ should take Zofran as needed for your nausea
- ___ should take ibuprofen as needed for your abdominal pain
- ___ should take progesterone pills until ___ see Dr. ___
- ___ should follow up with your primary care doctor, ___.
___ GI doctor, ___ your gynecologist
Dr. ___
___ well!
- Your ___ Team
Followup Instructions:
___
|
10682622-DS-19
| 10,682,622 | 24,083,005 |
DS
| 19 |
2125-10-08 00:00:00
|
2125-10-08 17:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a pleasant ___ y/o F with a recent simultaneous
kidney pancreas transplant on ___ who is coming to the ED
due to not having had a BM or passed gas in 3 days.
She states things had been going well post op, but she developed
constipation that was refractory to bowel regimen and inability
to pass gas. Over he last 24h she also develop significant
abdominal pain and nausea. but denied any vomiting.
Of note, post op she did have a complication with thrombosis of
a
vessel that was not felt to be significantly supplying her
pancreatic graft, but was dcd on lovenox. She states she has
been
compliant with lovenox and all of her other medications.
She is going to undergo a pancreas US, CT abdomen and renal US.
Her labs are currently stable.
Review of systems:
(+) Per HPI, otherwise negative
Past Medical History:
Type 1 diabetes mellitus
ESRD ___ T1DM on HD TTS since ___ via LUE AVF
CAD s/p PCI and CABG
Arthritis
Hypothyroidism
Anxiety and depression
Hypercholesterolemia
Obesity
Past surgical history:
CABG ___, Coronary stents in ___ and ___, C-sectionx2
___, appendectomy ___
Simultaneous kidney/pancreas transplant ___
Social History:
Lives with husband. No etoh, non smoker.
Physical Exam:
Exam on Admission:
Vitals:Reviewed
General: Alert, oriented,in moderate distress due to abdominal
pain
HEENT: No pallor or icterus, conjunctiva and sclera clear
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, diffusely tender. No drain in place, surgical
scars are all dry and do not have any associated warmth,
decreased BS.
Ext: No clubbing, cyanosis or edema
Neuro: No focal deficits, normal speech
.
Exam at Discharge:
___ 1036 Temp: 98.1 PO BP: 133/77 R Lying HR: 69 RR:
18 O2 sat: 98% O2 delivery: Ra
___ Total Intake: 1154ml PO Amt: 1010ml IV Amt Infused:
144ml
___ Total Output: 1925ml Urine Amt: 1925ml
General: Alert, oriented, in no distress from pain today
HEENT: No pallor or icterus, conjunctiva and sclera clear
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non tender to palpation. Surgical scars are all
dry and do not have any associated warmth, decreased BS.
Ext: No clubbing, cyanosis or edema
Neuro: No focal deficits, normal speech
Pertinent Results:
Labs on Admission: ___
WBC-8.2 RBC-2.78* Hgb-8.8* Hct-27.8* MCV-100* MCH-31.7
MCHC-31.7* RDW-17.1* RDWSD-61.9* Plt ___ PTT-60.5* ___
Glucose-96 UreaN-11 Creat-0.9 Na-134* K-4.5 Cl-100 HCO3-21*
AnGap-13
ALT-17 AST-20 AlkPhos-92 Amylase-79 TotBili-0.3
Lipase-30
Albumin-3.6 Calcium-8.9 Phos-1.4* Mg-1.6
tacroFK-9.1
.
Labs at Discharge: ___
WBC-5.4 RBC-2.36* Hgb-7.3* Hct-23.9* MCV-101* MCH-30.9
MCHC-30.5* RDW-17.2* RDWSD-63.5* Plt ___ PTT-36.6* ___
Glucose-79 UreaN-5* Creat-1.1 Na-141 K-4.2 Cl-108 HCO3-20*
AnGap-13
ALT-10 AST-10 AlkPhos-68 Amylase-77 TotBili-<0.2
Lipase-26
Calcium-8.0* Phos-1.6* Mg-1.6
tacroFK-10.1
.
___ 10:45 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
___ w ESRD on HD & ___ s/p simultaneous kidney pancreas
transplant & takeback ___ (for increased FSBGs) now presenting
with nausea and abdominal pain.
.
On admission, ultrasounds were obtained for both the
transplanted kidney and pancreas. Vasculature of both organs was
reported was patent. No organ fluid collections were seen.
Amylase and lipase remained in normal limits and creatinine was
at baseline around 1.0.
She was kept NPO initially to give some bowel rest. She was also
receiving hydration and electrolyte repletions.
.
A CT abdomen and pelvis were obtained when she was still having
complaint of abdominal pain by HD 3.
This revealed multiple peripancreatic fluid collections
surrounding the transplant pancreas, new since ___, but
were likely already present on admission. After discussion with
___ it was determined these were too small and also not well
positioned for drainage. Antibiotics were continued and
transitioned to PO Cipro and flagyl for discharge. She remained
afebrile.
.
As well, there was notation that there is relative
___ of the transplanted pancreatic head, new since
___ is likely due to edema, rather than necrosis given
normal lipase`levels. Also, unchanged partial occlusive thrombus
within a superior arterial branch of the transplanted pancreas.
She will be continued on another month of lovenox
.
Diet was advanced as tolerated, abdominal pain was significantly
improved by hospital day 4.
She was seen by CPS who agree to continue the hydrocodone she
was taking prior to admission. Should wean as tolerated.
.
On this admission Prednisone was tapered to 15 mg daily. A DSA
was sent on ___. Myfortic was continued at 360 mg Four
times daily.
Tacro level ran high on several days, dose was held and then
adjusted down. Discharge dose is 3 mg BID with patient advised
to have labs drawn at ___ on ___.
.
Patient was ambulatory, tolerating a regular diet and had bowel
function. Abdominal pain was significantly improved, she was
discharged to home with ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. BuPROPion (Sustained Release) 150 mg PO BID
4. Citalopram 40 mg PO DAILY
5. Enoxaparin (Treatment) 80 mg SC Q12H
6. ergocalciferol (vitamin D2) 50,000 unit oral 1X/WEEK PLEASE
CLARIFY DAY OF WK WITH ___.
7. Famotidine 20 mg PO BID
8. Gabapentin 300 mg PO TID
9. Levothyroxine Sodium 75 mcg PO DAILY
10. Metoprolol Succinate XL 50 mg PO DAILY
11. Mycophenolate Sodium ___ 360 mg PO QID
12. Nystatin Oral Suspension 5 mL PO QID
13. Tacrolimus 6 mg PO Q12H
14. PredniSONE 20 mg PO DAILY
15. Phosphorus 250 mg PO TID
16. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
17. ValGANCIclovir 900 mg PO Q24H
18. Aspirin 81 mg PO DAILY
19. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO BID Duration: 14 Days
End date ___
2. HYDROcodone-acetaminophen 10 mg oral Q6H:PRN Moderate pain
No driving if taking this medication
3. MetroNIDAZOLE 500 mg PO TID
End date ___
4. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
5. PredniSONE 15 mg PO DAILY
6. Tacrolimus 3 mg PO Q12H
Get labs checked FGriday ___ at ___
7. amLODIPine 5 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 40 mg PO QPM
10. BuPROPion (Sustained Release) 150 mg PO BID
11. Citalopram 40 mg PO DAILY
12. Enoxaparin (Treatment) 80 mg SC Q12H
13. ergocalciferol (vitamin D2) 50,000 unit oral 1X/WEEK PLEASE
CLARIFY DAY OF WK WITH ___.
14. Famotidine 20 mg PO BID
15. Gabapentin 300 mg PO TID
16. Levothyroxine Sodium 75 mcg PO DAILY
17. Metoprolol Succinate XL 50 mg PO DAILY
18. Mycophenolate Sodium ___ 360 mg PO QID
19. Phosphorus 250 mg PO TID
20. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
21. ValGANCIclovir 900 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
peripancreatic fluid collections surrounding the transplant
pancreas
History of simultaneous kidney/pancreas transplant
Tacro toxicity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call the transplant clinic at ___ for fever of
101 or greater, chills, nausea, vomiting, diarrhea,
constipation, inability to tolerate food, fluids or medications,
yellowing of skin or eyes, increased abdominal pain, incisional
redness, drainage or bleeding, dizziness or weakness, decreased
urine output or dark, cloudy urine, swelling of abdomen or
ankles, weight gain of 3 pounds in a day or any other concerning
symptoms.
.
Bring your pill box and list of current medications to every
clinic visit.
.
You will need lab draw done at ___ on ___, then
resume lab draw schedule per kidney transplant coordinators
instructions.
.
You will have labwork drawn twice weekly as arranged by the
transplant clinic, with results to the transplant clinic (Fax
___ . CBC, Chem 10, AST, T Bili, Amylase, Lipase,
Trough Tacro level, Urinalysis.
.
*** On the days you have your labs drawn, do not take your
Tacrolimus until your labs are drawn. Bring your Tacrolimus with
you so you may take your medication as soon as your labwork has
been drawn.
.
Follow your medication card, keep it updated with any dosage
changes, and always bring your card with you to any clinic or
hospital visits.
.
You may shower. Allow the water to run over your incision and
pat area dry. No rubbing, no lotions or powder near the
incision. You may leave the incision open to the air.
.
No tub baths or swimming
.
No driving if taking narcotic pain medications, and not until
cleared by your surgeon
.
Avoid direct sun exposure. Wear protective clothing and a hat,
and always wear sunscreen with SPF 30 or higher when you go
outdoors.
.
Drink enough fluids to keep your urine light in color. Your
appetite will return with time. Eat small frequent meals, and
you may supplement with things like carnation instant breakfast
or Ensure.
.
Check your blood pressure at home. Report consistently elevated
values above 160 or less than 110 systolic to the transplant
clinic
.
Check blood sugars twice a day. Report results greater than 200
immediately to the transplant clinic
.
Do not increase, decrease, stop or start medications without
consultation with the transplant clinic at ___. There
are significant drug interactions with anti-rejection
medications which must be considered in medication management
following transplant.
.
Consult transplant binder, and there is always someone on call
at the transplant clinic with any questions that may arise
Followup Instructions:
___
|
10682915-DS-15
| 10,682,915 | 28,172,484 |
DS
| 15 |
2158-09-02 00:00:00
|
2158-09-07 19:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
History of Present Illness: ___ is a ___ year-old
woman with recent history of copious diarrhea presented to OSH
with right sided numbness and paresthesia, and is transferred
after syncope, bradycardia, hypotension for further evaluation
Patient endorses chronic diarrhea since ___ (constant since
___, notable for watery diarrhea ___. Outpatient workup
in
___ negative C diff, and upcoming colonoscopy scheduled
___.
She recently went to ___ for LUE numbness and
paresthesia on ___. She had LUE numbness and heaviness of the
entirety of her LUE lasting for ___ hours. She was admitted for
workup. Per OSH records, her workup included negative MRI,
CTA/MRA, TTE with bubble. A1c 5.3%, LDL 114. She initially
received ASA 81 mg and Lipitor 10 mg while awaiting results of
her hypercoagulable workup, but these were held due to concern
for overtreatment. B12 was 305, and B12 supplementation was
recommended.
She was discharged home. ___ as she worked out she became
lightheaded and nauseous, and was generally fatigued for the
following days. She woke from sleep at 4 am on ___. with
right arm numbness / heaviness and tingling in fingers and hand
heaviness. She also experienced "head heaviness" and trouble
finding words.
In the ED, she had jaw tightness and a syncopal event. Per OSH
report, her HR dropped to 32 and BP 52/40. Her BG was 67. She
was
given atropine and D50. The patient was lying down at the time,
reports her "head felt heavy" and "jaw felt tight," and she was
nauseated with a headache. She did not feel the room spinning or
darkness closing in. Reportedly she passed out for 10 seconds,
no
head strike, and awoke feeling sick, nauseous and still with a
HA. Her EKG was concerning for TWI, so OSH ED referred her to
___ for further evaluation
In the ED, initial vital signs were: T 98.6 P 64 BP 99/62 R 18
O2
sat. 100 on RA
- Exam unremarkable
- Studies performed include CXR
- Vitals on transfer: T 98.2 P 59 BP 98/57 R 17 O2 sat. 100 on
RA
Upon arrival to the floor, the patient in no acute distress. The
numbness and tingling she reported earlier has resolved. She
feels intermittently lightheaded and dizzy but only when she
stands up, no further syncope episodes. She does report a ___
bilateral frontal squeezing headache without radiation similar
in
character to previous headaches. Notably, the patient reports
dyspnea and chest tightness after ___ crossfit workout,
resolved with rest, slight recurrence while walking on ___
but otherwise has not recurred.
ROS otherwise negative in remaining systems.
Past Medical History:
None.
Social History:
___
Family History:
Notable for MI at age ___ in grandfather and in
___ in maternal aunt. ___ and HTN on mother's side but not
in mother. Sister with ___ disease and ___ cousin with UC.
No history sudden cardiac death or unexplained death.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals- 98.6PO 98/54 56 18 99 RA
GENERAL: AOx3, NAD
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. No
conjunctival pallor or injection, sclera anicteric and without
injection. Moist mucous membranes, good dentition. Oropharynx
is
clear.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No JVD.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
BACK: Skin. no spinous process tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to
deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema, no sign of
atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally.
SKIN: No evidence of ulcers, rash or lesions suspicious for
malignancy
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. No dysmetria, disdiadochokinesia. Gait is normal.
DISCHARGE PHYSICAL EXAM
=======================
Vitals: Tm: 98.6 Tc: 97.9 BP: 95-106/52-66 HR: 56-64 RR: ___
O2%: 99-100
GENERAL: AOx3, NAD
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. No
conjunctival pallor or injection, sclera anicteric and without
injection. Moist mucous membranes, good dentition. Oropharynx
is
clear.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No JVD.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
BACK: Skin. no spinous process tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to
deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema, no sign of
atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally.
SKIN: No evidence of ulcers, rash or lesions suspicious for
malignancy
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. No dysmetria, disdiadochokinesia. Gait is normal.
Pertinent Results:
ADMISSION LABS
==============
___ 11:30AM BLOOD WBC-5.1 RBC-3.89* Hgb-12.1 Hct-36.9
MCV-95 MCH-31.1 MCHC-32.8 RDW-12.3 RDWSD-42.7 Plt ___
___ 11:30AM BLOOD Neuts-71.1* ___ Monos-6.5
Eos-0.8* Baso-0.6 Im ___ AbsNeut-3.62 AbsLymp-1.05*
AbsMono-0.33 AbsEos-0.04 AbsBaso-0.03
___ 11:30AM BLOOD ___ PTT-25.6 ___
___ 11:30AM BLOOD Plt ___
___ 11:30AM BLOOD Glucose-88 UreaN-12 Creat-0.8 Na-141
K-4.0 Cl-110* HCO3-20* AnGap-15
___ 11:30AM BLOOD cTropnT-<0.01
___ 11:30AM BLOOD Calcium-8.5 Phos-2.7 Mg-1.9
___ 11:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 11:47AM BLOOD Lactate-1.3
MICROBIOLOGY
==============
___ CULTURE-FINALEMERGENCY WARD
IMAGING/STUDIES
==============
___ EKG
Sinus bradycardia. Compared to the previous tracing of ___
there are no significant changes.
___ CXR
IMPRESSION:
No evidence of acute cardiopulmonary process.
DISCHARGE LABS
==============
___ 07:40AM BLOOD WBC-4.5 RBC-3.70* Hgb-11.4 Hct-34.7
MCV-94 MCH-30.8 MCHC-32.9 RDW-12.4 RDWSD-43.0 Plt ___
___ 07:40AM BLOOD Plt ___
___ 07:40AM BLOOD Glucose-81 UreaN-12 Creat-0.8 Na-137
K-4.0 Cl-105 HCO3-21* AnGap-15
___ 07:40AM BLOOD ALT-11 AST-16 AlkPhos-38 TotBili-0.3
___ 07:40AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.9
___ 07:40AM BLOOD Cortsol-10.4
Brief Hospital Course:
___ is a ___ year-old woman with a month-long
history of copious diarrhea presenting to ___ with
right-sided numbness and paresthesia, and was transferred to
___ after an episode of syncope, bradycardia, and
hypotension for further evaluation. Notably, the patient
recently underwent extensive workup for possible stroke/TIA and
infectious causes of diarrhea at BID-P, with no etiology found.
At ___ the patient's ED course was notable for negative
tropsx2 and non-specific t-wave inversions on several EKGs (no
baseline comparison available), AM cortisol 10.4 (nl). She was
monitored on telemetry overnight with no arrhythmias identified,
and had no further parasthesias or syncopal episodes, though she
had one short episode of dizziness. Low concern for cardiac
etiology, presumed vasovagal exacerbated by stress of recent
diarrhea, patient discharged to follow up with planned
outpatient colonoscopy on ___ in ___.
ACTIVE PROBLEMS
===============
# Syncope: Syncope in the setting of bradycardia and
hypotension, EKG with T-wave inversions of varying depths.
Differential diagnosis initially bradyarrhythmia vs. vasovagal
vs. hypocortisolism as primary causes. Ischemia seemed unlikely
in setting of negative trops and minimal chest discomfort in a
woman with high exercise tolerance. Seemed very likely vasovagal
and less likely cardiac, AM cortisol within normal limits. Safe
for discharge with outpatient follow-up
# Chest heaviness: Patient with chest heaviness and dyspnea
after crossfit workout on ___, resolved with rest, though
patient had repeat, milder chest heaviness and slight dyspnea on
___ while walking. Patient also with T-wave changes, DDx
vasospasm vs. MSK vs. anxiety. Determined low risk and possible
___ anxiety in setting of diarrhea, can ___ with PCP outpatient
for cardiology referral if deemed necessary
# Diarrhea: Voluminous, loose, non-bloody diarrhea ___ times
daily since ___. DDx infectious vs. autoimmune vs. IBS. Has had
extensive infectious workup at BID-P, all negative. Patient w/
colonoscopy schedule ___, should complete for most diagnostic
utility.
# Transient weakness/numbness extremities: Patient with
extensive workup at BID-P, no cause seen for stroke/TIA (MRI,
CTA/MRA, TTE w/ bubble), also no sign of MS on MRI. PCP should
___ hypercoag labs and Lyme studies from BID-P.
CHRONIC PROBLEMS
================
# Borderline B12 deficiency: Continue B12 PO as outpatient.
TRANSITIONAL ISSUES
===================
Transitional issues
[] Follow up with Dr. ___, ___
[] Complete scheduled colonoscopy on ___ with prep the night
before
[] Talk to your PCP about their perspective on starting a statin
and on the need for further cardiac workup of the T-wave changes
on your EKGs
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
-Vasovagal syncope
Secondary diagnosis
-Diarrhea, unexplained etiology
-Unspecified disturbances of skin sensation
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 from ___ because you
had a syncopal episode in the ER, with low heart rate and blood
pressure. When you came here your vital signs were stable, and
the enzyme we check for people with heart attacks (troponin)
were negative. You had some changes in your EKG, but since we
didn't have a comparison, we didn't know if they were new.
While in the hospital we watched your heart rate on telemetry
and you didn't have any unusual rhythms or more syncopal
episodes. We felt the episode was likely due to a vasovagal
response, which can occur in times of emotional or physiologic
stress such as your recent diarrhea.
We feel it's important to diagnose what's causing your diarrhea,
and feel it's safe for you to be discharged home to complete the
colonoscopy on ___.
Please follow up with your primary care physician on your
appointment ___ they may recommend additional follow-up
with cardiology, but we didn't feel the need to run additional
cardiac tests during your admission. Please do not drive until
you feel well again.
Thank you for letting take part in your medical care.
Sincerely,
Your ___ Health Team
Followup Instructions:
___
|
10683018-DS-19
| 10,683,018 | 24,934,415 |
DS
| 19 |
2167-10-26 00:00:00
|
2167-10-26 21:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left open olecranon fracture
Major Surgical or Invasive Procedure:
Left olecranon irrigation and debridement ___, ___
Left olecranon open reduction and internal fixation ___,
___
History of Present Illness:
From ED Admission Note:
___, no PMHx, s/p MCA roughly 30mph w/ helmet, "lost control of
motorcycle" when he saw a car coming in the other ___ and
overcorrected. Did not hit the other car; fell onto his left
side. Briefly AAOx1 at the scene. +HS no LOC. On arrival, HDS,
GCS15, MAE, c/o pain at L elbow and L knee. No CP, SOB, abd
pain, naus, vom, diarrhea, f/c, headache, blurry vision or neck
pain. No back pain. No presyncopal component to the accident.
Past Medical History:
T&A ___
Social History:
___
Family History:
noncontributory
Physical Exam:
Admission Physical Exam:
General: well appearing young male in bed in C-collar pleasant
and conversant no distress with scattered road rashes
Vitals:
Right upper extremity:
- Large skin abrasion 5x13cm extending over the extensor surface
of the elbow
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender arm and forearm
- Full, painless AROM/PROM of shoulder, elbow, wrist, and digits
- EPL/FPL/DIO (index) fire
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse
Left upper extremity:
- Two lacerations, one at the extensor surface 2cm long which is
deep and may probe into the joint capsule, with active bleeding
noted. Distally, along the ulnar aspect of the forearm, there is
a 5cm more superficial laceration.
- Gross deformity noted at the elbow with surrounding edema and
ecchymosis.
- No other deformity, erythema, edema, induration or ecchymosis
- Moderate to severely tender forearm especially proximally at
the site of the elbow laceration and proximal humerus.
- Nontender hand and wrist.
- Soft compartments. No pain with passive motion of the wrist or
digits.
- Limited supination and pronation due to pain. Severe
limitation at flex/extension of the elbow. Moderate limitation
of flexion, extension and abduction of the shoulder.
- EPL/FPL/DIO (index) fire, all limited by pain.
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse, 2+ ulnar pulse
Right lower extremity:
- Skin intact, save for small abrasion over the knee
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender thigh and leg
- Full, painless AROM/PROM of hip, knee, and ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Left lower extremity:
- Skin intact save for scattered abrasions
- No deformity, erythema, edema, induration or ecchymosis
- Tender to palpation medially and laterally along the proximal
tibia
- Soft, non-tender thigh and leg otherwise
- Full, painless AROM/PROM of hip, knee, and ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Discharge Physical Exam:
Gen: AOx3, NAD
CV: RRR, no m/r/g
Pulm: CTAB
Abd: Soft, nontender, nondistended
Left upper extremity:
- Skin intact, incision c/d/i, staple line intact.
- Soft compartments. No pain with passive motion of the wrist or
digits.
- Elbow in orthoplast splint at 90 degrees. Able to actively
range wrist and digits without pain. Passive range of motion and
active assisted range of motion at elbow with some mild
stiffness and pain.
- EPL/FPL/DIO (index) fire.
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse, 2+ ulnar pulse
Pertinent Results:
___ 04:01PM PO2-119* PCO2-32* PH-7.41 TOTAL CO2-21 BASE
XS--2 COMMENTS-GREEN TOP
___ 04:01PM GLUCOSE-127* LACTATE-2.6* NA+-139 K+-3.3
CL--107
___ 04:01PM HGB-16.0 calcHCT-48 O2 SAT-97 CARBOXYHB-2 MET
HGB-0
___ 04:01PM freeCa-1.08*
___ 03:55PM UREA N-13 CREAT-0.9
___ 03:55PM LIPASE-11
___ 03:55PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 03:55PM WBC-10.7* RBC-4.98 HGB-15.3 HCT-44.4 MCV-89
MCH-30.7 MCHC-34.5 RDW-11.9 RDWSD-38.4
___ 03:55PM PLT COUNT-198
___ 03:55PM ___ PTT-27.1 ___
___ 03:55PM ___
Left CT Upper extremity ___:
FINDINGS:
There is a comminuted fracture of the proximal ulna. There is
dislocation at
the ulnar trochlear articulation with the coronoid process
displaced dorsally
in relation to the trochlea. There is also dorsal dislocation
of the radial
head in relation to the capitellum. Several fracture fragments
and soft
tissue gas is identified. The 3D reformatted images confirm the
above
findings.
There are no displaced fractures of the distal humerus or
proximal radius.
Evaluation of the soft tissue structures including the vascular
structures are
limited.
On the larger field-of-view images of the left chest, no
displaced rib
fractures are seen. The visualized lung field is grossly clear.
IMPRESSION:
1. Comminuted fracture of the proximal ulna.
2. Dorsal dislocation of the radial head in relation to the
capitellum.
Left CT Lower Extremity:
FINDINGS:
A joint effusion is present with layering hyperdense material
consistent with
blood. Several tiny locules of air are also noted. A femoral
corner fracture
is (400b:96). This may not explain the hemorrhagic joint
effusion. In
addition, there is subtle irregularity along the medial tibial
plateau, which
may represent a very subtle impacted fracture. Ligamentous
injury is not
excluded. Significant soft tissue edema is noted along the
medial aspect of
the knee.
This preliminary report was reviewed with Dr. ___,
___
radiologist.
IMPRESSION:
1. Femoral corner fracture.
2. Possible impacted fracture of the medial tibial plateau.
This is not well
assessed on the current examination. MRI of the knee is
recommended for
better evaluation.
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have an open left olecranon fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for an irrigation and debridement of
the left elbow, followed by a left open reduction and internal
fixation of the elbow on ___. The patient tolerated both
procedures well. For full details of the procedures please see
the separately dictated operative reports. In both instances,
the patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. After the patient's second operation
on ___, 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
with services was appropriate. Of note, the patient did complain
of pain one day prior to discharge, this was felt to be due to
not elevating the arm. Compartment checks of the swollen forearm
were performed regularly without any notable issues. With arm
elevation, the pain and swelling improved. He was fitted in a
padded, comfortable orthoplast splint and worked with physical
and occupational therapy. 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
nonweightbearing in the left upper extremity, and will be
discharged on aspirin 325mg 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.
The patient was also instructed regarding the results of his CT
of his left leg, and was told that he could weight bear as
tolerated and to follow up and ask regarding possible further
workup of his left knee pain at his follow up appointment if
still symptomatic.
Medications on Admission:
None
Discharge Medications:
1. Aspirin 325 mg PO DAILY Duration: 14 Days
Please take this for 14 days to prevent clots.
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
3. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every three hours as
needed for pain Disp #*80 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left olecranon fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Non-weight bearing. You may pronate and supinate the elbow,
and you may extend the elbow with assistance from your other
hand. You may flex the elbow. You may range your wrist, fingers,
and shoulder 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 aspirin 325mg daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
Physical Therapy:
Non-weight bearing in the LUE. You may pronate and supinate the
elbow, and you may extend the elbow with assistance from your
other hand. You may flex the elbow. You may range your wrist,
fingers, and shoulder as tolerated.
Treatments Frequency:
Wound care:
Site: Incision
Type: Surgical
Dressing: Gauze - dry
Comment: please overwrap any dressing bleedthrough with ABDs
and ACE
Please keep arm ELEVATED AT ALL TIMES until your follow up
appointment.
Followup Instructions:
___
|
10683322-DS-2
| 10,683,322 | 27,299,396 |
DS
| 2 |
2129-07-09 00:00:00
|
2129-07-09 17:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
metronidazole
Attending: ___.
Chief Complaint:
Mandible fx, seizure
Major Surgical or Invasive Procedure:
ORIF of mandibular fx
History of Present Illness:
___ with stress induced seizures, HTN, Bipolar s/p seizure and
fall hitting her chin on ground. Went to ___ and
transferred to BI ED. Pt complains of pain on opening, trismus,
inability to occlude teeth, pain throughout jaw, minor
dysphagia.
Pt denies chest pain, dyspnea, odynophagia, sob, vision
disturbances, hearing disturbances, diplopia.
Past Medical History:
PMH: bipolar, stress induced seizure disorder since childhood,
HTN, arthritis
PSH: hysterectomy, back surgery, other minor surgeries
Social History:
___
Family History:
Stroke in elderly family member
___- several family members
___- cousin
___- mother
___ Cancer- aunt
DM2- a few family members
Physical Exam:
Alert and oriented
Afebrile, VSS
Jaw wired shut with elastics
Incision to chin, C/D/I
Breathing unlabored
Heart RRR
Abdomen soft, nontender
MAE, WWP x4
Pertinent Results:
___ 05:29AM ___ PTT-24.8* ___
___ 03:00AM URINE bnzodzpn-NEG barbitrt-POS opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 02:45AM VALPROATE-15___ 02:45AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 02:45AM WBC-10.8 RBC-3.80* HGB-12.6 HCT-37.2 MCV-98
MCH-33.0* MCHC-33.7 RDW-12.8
___ 02:45AM NEUTS-76.5* ___ MONOS-3.3 EOS-0.8
BASOS-0.3
___ 02:45AM PLT COUNT-168
Brief Hospital Course:
Ms. ___ was admitted to the trauma surgery service after having
a seizure in which she fell and broke her mandible. She was
seen by our Oral MaxiloFacial surgeons, who desired to operate
but requested neurological clearance first.
Our neurological service saw her and changed her home dose of
Depakote XR from 1000mg to 1500mg, declared her safe for surgery
and thought she could follow up with her primary neurologist.
After evaluation with a CT max face with 3D reconstructions she
was taken to the OR for fixation by OMFS.
After surgery was performed it was discovered that for proper
fixation OMFS had given her arch bars with elastics, thus making
her unable to open her jaw. She was to be put on a full liquid
diet. She noted that she had space between her teeth and cheek
to place a straw, and that she had some missing molars through
which she could pass small pills, but would be unable to take
her large Depakote. Given the importance of this medication,
Pharmacy and Neurology were both asked for opinions and the plan
was made to switch her to 750mg Depakene Liquid BID. She stayed
an extra night to receive a ___ and AM dose without issue.
At the time of discharge she was alert and oriented, ambulating
without assistance, voiding per normal, and tolerating a full
liquid diet.
Medications on Admission:
depakote xr 1000mg daily
cymbalta 60mg daily
trazadone 50mg QHS
atenolol 50mg QAM
lipitor 20mg daily
Discharge Medications:
1. Atenolol 50 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Peridex (chlorhexidine gluconate) 0.12 % Mucous Membrane BID
Post Procedure
RX *chlorhexidine gluconate 0.12 % ___ mouth rinse twice a
day Disp #*1 Bottle Refills:*0
4. TraZODone 50 mg PO HS:PRN insomnia
5. Valproic Acid ___ mg PO Q12H
RX *valproic acid (as sodium salt) 250 mg/5 mL (5 mL) 750/15
mg/ml by mouth twice a day Disp #*2 Bottle Refills:*0
6. Clindamycin Solution 300 mg PO Q8H Duration: 6 Days
Please flavor if possible. Take for a total of 7 days
RX *clindamycin palmitate HCl 75 mg/5 mL 300/20 mg/ml by mouth
three times a day Disp #*1 Bottle Refills:*0
7. OxycoDONE Liquid ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg/5 mL ___ mg/ml by mouth Every 4 Hours
Disp #*1 Bottle Refills:*0
8. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain
RX *acetaminophen 500 mg/5 mL 500-100/5-10 mg/ml by mouth 4
times a day Disp #*1 Bottle Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Mandible Fx, Seizures
Discharge Condition:
Overall, good
Alert and Oriented
Pain controlled with PO medication
Ambulating without assistance
Voiding as usual
Tolerating FULL LIQUID diet
Discharge Instructions:
You were admitted to the trauma service after a fall in which
you sustained mandible fractures. You were evaluated by our
neurologists who recommended increasing your dose of Depakote
from 1000mg to 1500mg. You were taken to the OR with our Oral
MaxiloFacial surgeons who repaired your mandible fractures.
After a discussion with the neurologists as well as our
pharmacist, we altered your depakote to depakene liquid, 750mg
twice a day dosing.
Please follow all instructions that the oral surgeons have given
you. These include:
Liquid Diet only
Clindamycin for a total of 7 days
Peredex Mouthwash Twice a day until followup
Normal brushing of teeth
Scissors at bedside in case of emergency
HOB, ice to face for 48 hours, may switch to heat packs for
___ days after that.
Liquid tylenol for pain, 500-1000mg Q6hrs as needed
Liquid Oxycodone for breakthrough pain, ___ Q4hrs as needed
Your chin sutures will be removed by the surgeons in clinic next
week. They may have already given you an appointment. If not
their number is listed below.
Followup Instructions:
___
|
10683330-DS-6
| 10,683,330 | 20,081,852 |
DS
| 6 |
2153-11-17 00:00:00
|
2153-11-18 17:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fatigue
Major Surgical or Invasive Procedure:
Blood transfusion x1
Esophogastroduodenoscopy
Colonoscopy
History of Present Illness:
Ms. ___ is a ___. without a significant PMH who presents
as
a referral from her primary care physician ___ 3mo of fatigue,
myalgias and dyspnea on exertion found to have anemia with a HgB
of 6.0. She was recently evaluated at ___ for sore
throat/ear pain and received a course of Penicillin with
improvement.
Several months ago, Ms. ___ reports visiting her physician
who prescribed vitamin B12 (she subsequently ran out) as well as
vitamin D. She then represented to her primary care physician
for
ongoing myalgias, shortness of breath as well as fatigue for the
past 3 months and was subsequently sent to ___ for a HgB of
6.0. Patient states she gets tired doing chores around the house
which is unusual for her, and she also had to stop working
(previously worked at a ___) due to these symptoms. Her
SOB is worse with activity, but has become largely persistent
over the last month, as she now has intermittent SOB at rest.
She
intermittently has palpitations and some leg swelling at the end
of the work-day, but otherwise denies any CP or
cough/wheezing/mucus production. She has BM's 3x/week which is
normal for her and they have not had any hematochezia or
black/tarry stools. She notes acid reflux, but otherwise denies
any diarrhea, abdominal pain, N/V. She has chronic headaches
which occur daily with some blurry vision that subsequently
resolves. These are stable. She otherwise denies any fevers,
chills, epistaxis, rashes, bruising or numbness/tingling.
Ms. ___ last had her menstural period ___ years ago. She had
an ovarian cyst removed, but she has never had any GI surgeries
in the past. She reports eating a balanced meal with chicken,
vegetables and rice two times/day although she does eat chips
and
other snacks throughout the night. She has not yet had a
colonoscopy, but she has regular pap smears. Her sister
unfortunately passed away from stomach cancer.
Past Medical History:
Ovarian cyst removal
Social History:
___
Family History:
- Father: heart disease (unknown)
- Mother: lung disease (unknown)
- Cancer: sister passed away from stomach cancer
Physical Exam:
ADMISSION PHYSICAL EXAM.
GENERAL: sitting on side of bed, pale but comfortable
HEENT: PERRLA, EOMI, pale conjunctiva, MMM but discoloration of
the hard palate
NECK: supple without lymphadenopathy, no thyroid nodules
CARDIAC: Normal S1/S2 with RRR, no MRG
LUNG: no respiratory distress, clear to auscultation
bilaterally,
no crackles, wheezes, or rhonchi
ABD: +BS, soft, mild tenderness to palpation below epigastrum,
nondistended, no hepatosplenomegaly
EXT: Warm, well perfused, no lower extremity edema, 2+/symmetric
distal pulses
NEURO: Awake, alert, oriented, CN II-XII intact, ___ strength
bilaterally, intact sensation to light touch bilaterally
SKIN: No significant rashes evident
DISCHARGE PHYSICAL EXAM.
VS: T 98|BP 113/62|HR 76|RR 18|SpO2 97% RA
GENERAL: standing in room NAD
HEENT: PERRLA, EOMI, pale conjunctiva, MMM but discoloration of
the hard palate
NECK: supple without lymphadenopathy, no thyroid nodules
CARDIAC: Normal S1/S2 with RRR, no MRG
LUNG: no respiratory distress, clear to auscultation
bilaterally,
no crackles, wheezes, or rhonchi
ABD: +BS, soft, non tender non distended, no hepatosplenomegally
EXT: Warm, well perfused, no lower extremity edema, 2+/symmetric
distal pulses
NEURO: Awake, alert, oriented, CN II-XII intact, ___ strength
bilaterally, intact sensation to light touch bilaterally
SKIN: No significant rashes evident
Pertinent Results:
ADMISSION LABS
==============
___ 08:00PM BLOOD WBC-9.8 RBC-3.18* Hgb-6.0* Hct-22.0*
MCV-69* MCH-18.9* MCHC-27.3* RDW-20.8* RDWSD-50.8* Plt ___
___ 08:00PM BLOOD Neuts-65.9 ___ Monos-6.4 Eos-1.5
Baso-0.8 Im ___ AbsNeut-6.44* AbsLymp-2.45 AbsMono-0.63
AbsEos-0.15 AbsBaso-0.08
___ 11:33PM BLOOD ___ PTT-35.1 ___
___ 08:00PM BLOOD Ret Aut-1.1 Abs Ret-0.04
___ 08:00PM BLOOD Glucose-95 UreaN-15 Creat-0.5 Na-141
K-3.9 Cl-102 HCO3-23 AnGap-16
___ 08:00PM BLOOD ALT-27 AST-50* LD(LDH)-186 CK(CPK)-54
AlkPhos-95 TotBili-0.3
___ 08:00PM BLOOD calTIBC-729* VitB12-1339* Hapto-130
Ferritn-5.9* TRF-561*
NOTABLE INTERVAL LABS
=====================
___ 07:03AM BLOOD TSH-0.86
___ 07:03AM BLOOD Free T4-1.5
___ 07:05AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
___ 07:03AM BLOOD IgA-475*
___ 07:03AM BLOOD tTG-IgA-16
___ 07:05AM BLOOD HCV Ab-NEG
DISCHARGE LABS
==============
___ 07:05AM BLOOD WBC-7.9 RBC-4.04 Hgb-8.4* Hct-29.9*
MCV-74* MCH-20.8* MCHC-28.1* RDW-24.4* RDWSD-61.3* Plt ___
___ 07:05AM BLOOD Glucose-106* UreaN-12 Creat-0.6 Na-144
K-4.1 Cl-105 HCO3-21* AnGap-18
___ 07:05AM BLOOD ALT-32 AST-49* AlkPhos-80 TotBili-0.4
___ 07:05AM BLOOD Calcium-10.3 Phos-4.2 Mg-1.9
IMAGING
=======
___ RUQUS
1. Echogenic liver consistent with steatosis. Other forms of
liver disease and more advanced liver disease including
steatohepatitis or significant hepatic fibrosis/cirrhosis cannot
be excluded on this study.
2. Normal gallbladder.
RECOMMENDATION(S): Radiological evidence of fatty liver does
not exclude
cirrhosis or significant liver fibrosis which could be further
evaluated by ___. This can be requested via the Liver
Center (FibroScan), or the Radiology Department with MR
___, in conjunction with a GI/Hepatology consultation
___ EGD
Normal esophagus and duodenum, 5mm stomach polyp that was
biopsied
___ Colonscopy
Normal mucosa, single non bleeding polyp (biopsied) in rectum,
fair prep. Will need repeat colonscopy in ___ year.
Brief Hospital Course:
PATIENT SUMMARY
===============
___ year old female with no significant PMH presented to outside
provider with fatigue, dyspnea, and weight loss, found to have
hgb of 6.0 and referred to ___ for blood transfusion with
appropriate rise in Hgb, now s/p unrevealing EGD and colonoscopy
discharged with plan for pill endsoscopy with GI in outpatient
setting and PCP follow up for iron deficiency anemia of unknown
etiology.
TRANSITIONAL ISSUES
===================
[ ] f/u stomach and rectal polyp biopsy results
[ ] will need pill endoscopy in outpatient setting with GI
[ ] consider fibroscan to assess for cirrhosis
[ ] f/u H pylori stool antigen, HBV and HCV serologies
[ ] will need HLA DQ2 and DQ8
[ ] colonoscopy here was inadequate for screening, she will need
a repeat colonoscopy in ___ year (___)
ACUTE ISSUES
============
#Iron deficiency anemia
Found to have hgb of 6 in outpatient setting after a few months
of fatigue. She denies any further menstrual bleeds or abnormal
uterine bleeding. She had appropriate increase in Hct to 8.6 in
the setting of pRBC transfusion and IV iron x3d. Patient
underwent EGD and colonoscopy that were not revealing for any
source of bleed or malignancy, however prep was moderate and
will require pill endoscopy in outpatient setting. IgA 475 and
tTG-IgA 16. H pylori stool antigen pending at time of discharge.
Current etiology remains unknown at this time. Discharged with
PO ferrous sulfate to take every other day.
#Transaminitis
#Elevated INR
#Hepatic Steatosis
AST 50 and ALT 27 on admission, INR of 1.2. RUQUS during
admission with steatosis but cannot exclude cirrhosis. Hemolysis
labs and CK unremarkable. No known risk factors for cirrhosis at
this time. Will need fibroscan in outpatient setting to rule out
cirrhosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Ferrous Sulfate 325 mg PO 4X/WEEK (___)
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
every other day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Iron deficiency anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
- You were feeling fatigued
- You reported that you were loosing weight
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- You received a blood transfusion because your blood levels
were low. This increased your blood levels
- A gastroenterologist looked in your esophagus, stomach, and
colon for any signs of bleeding
- They found a polyp in your stomach and rectum, but no evidence
of bleeding
- You began to feel better and were ready to go home
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please continue to take all your medications and follow up
with your doctors at your ___ appointments.
- We prescribed you a new medication to help keep your iron
levels up. Please take this pill every other day.
We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10683389-DS-10
| 10,683,389 | 26,197,674 |
DS
| 10 |
2200-02-17 00:00:00
|
2200-02-17 15:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RLQ Abdominal pain
Major Surgical or Invasive Procedure:
___: Laparoscopic appendectomy
History of Present Illness:
Ms. ___ is a ___ woman who was in her usual
state of health until 2pm yesterday ___, when she developed
diffuse, sharp, abdominal pain which eventually localized to the
RLQ today. She has had poor appetite since the pain began, but
no
nausea or vomiting. She was able to tolerate some soup this
morning. She reports feeling chills, no fever. Her last bowel
movement was this morning, with non-bloody and regular stools.
She denies any dysuria or pelvic pain. ROS per HPI. Also denies
any headache, dizziness, chest pain, shortness of breath, or
weakness.
Past Medical History:
Past Medical History: Hypertension
Past Surgical History: No prior surgeries
Social History:
___
Family History:
Uncle with colon cancer
Physical Exam:
Admission Physical Exam:
Vitals: T 97.7, HR 105 BP 149/83 RR 16 Sat 100% RA
GEN: Pleasant, alert, in no acute distress
HEENT: EOMI, no scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, tender to palpation at ___. Positive
Rovsing's sign. Nondistended. No palpable masses. Normoactive
bowel sounds.
Ext: Warm and well perfused, no ___ edema
Neuro: AAOx3, moving all extremities equally.
Discharge Physical Exam:
VS: 98.6, 129/73, 74, 18, 94 Ra
Gen: A&O x3, lying in bed in NAD
CV: HRR
Pulm: LS ctab
Abd: soft, mildly TTP incisionally. Lap sites CDI closed with
duoderm
Ext: WWP no edema
Pertinent Results:
___ 09:44AM BLOOD WBC-11.5* RBC-4.70 Hgb-12.0 Hct-37.9
MCV-81* MCH-25.5* MCHC-31.7* RDW-15.2 RDWSD-43.8 Plt ___
___ 09:44AM BLOOD ___ PTT-25.8 ___
___ 09:44AM BLOOD Glucose-94 UreaN-10 Creat-0.8 Na-140
K-6.9* Cl-103 HCO3-18* AnGap-19*
___ 09:44AM BLOOD ALT-15 AST-45* AlkPhos-61 TotBili-0.5
Imaging:
CT abdomen / pelvis:
1. The appendix appears enlarged, measuring up to 2.0 cm with
marked adjacent fat stranding, and minimal fluid compatible with
appendicitis. Tiny, 8 mm circumscribed rim enhancing pocket of
fluid adjacent to the tip of the appendix may reflect a tiny
abscess, raising possibility of microperforation.
2. Background mild circumferential thickening of the wall of the
transverse, descending and sigmoid colon with areas of
submucosal fat deposition suggesting chronic colitis.
3. Enlargement of the main pancreatic duct, measuring up to 5
mm, incompletely evaluated on this study.
4. 2-3 mm pulmonary nodule seen in the right lung base.
Brief Hospital Course:
The patient was admitted to the General Surgical Service on ___
for evaluation and treatment of abdominal pain. Admission
abdominal/pelvic CT revealed acute appendicitis. WBC was
elevated at 11. The patient underwent laparoscopic appendectomy,
which went well without complication (reader referred to the
Operative Note for details). After a brief, uneventful stay in
the PACU, the patient arrived on the floor tolerating clears, on
IV fluids, and oral analgesia for pain control. The patient was
hemodynamically stable.
.
When tolerating a diet, the patient was converted to oral pain
medication with continued good effect. Diet was progressively
advanced as tolerated to a regular diet with good tolerability.
The patient voided without problem. During this hospitalization,
the patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
amLODIPine 5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*10 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth once a
day Disp #*14 Packet Refills:*0
5. amLODIPine 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Your incisions may be slightly red. This is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10683554-DS-2
| 10,683,554 | 29,014,003 |
DS
| 2 |
2131-02-20 00:00:00
|
2131-02-20 15:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dysarthria and facial droop
Major Surgical or Invasive Procedure:
tPA at OSH prior to being transferred to ___.
History of Present Illness:
___ year old woman with history of multiple prior strokes
___ with residual left visual field cut, mild left sided
weakness, walker dependent at baseline), HTN, T2 DM who presents
with acute onset of dysarthria and left facial droop. History
provided primarily by family friend/caregiver who was tending to
the patient at the time of symptom onset.
The patient was in her usual state of health until 1:30 ___ on
___. She was at home at the time, and a family friend was
staying with her. The friend recently returned from the store
and had a brief conversation with the patient between 1:20 ___
and
1:30 ___. She was in her usual state of health and at her
neurologic baseline at that time. The friend went into the
kitchen to put away some items, and immediately came back to
notice that the patient developed a left facial droop and
dysarthria. She reports that initially, the patient was able to
answer simple questions, however moments later continue to
repeat
"My throat, my throat." EMS was called. She was transferred to
___ for further evaluation.
At the outside hospital emergency department, vitals were
notable
for blood pressure 182/95, otherwise unremarkable. Telestroke
was
called. NIHSS was 8 (2 for disorientation; 1 for L visual field
cut; 2 for L facial droop; 1 for limb ataxia; 1 for
mild-moderate
aphasia; 1 for dysathria). Notably, she was following commands
and with no expressive aphasia at this time. She underwent CT
head which revealed evidence of multiple prior strokes affecting
bilateral cerebellar, bilateral thalamocapsular, right PCA and
left subinsular cortex, as well as extensive chronic small
vessel
ischemic changes. INR was 1.1. Decision was made to give tPA;
received at 1536 on ___. Patient presents to ___ for post-TPA
care.
Currently, patient reports she feels at her baseline apart from
dysarthria.
Past Medical History:
-HTN
-Diabetes type 2
-Prior strokes- first in ___ after presenting with left sided
weakness, residual mild left sided weakness and left field cut.
Second in ___ after presenting with "memory loss" with no
residual symptoms.
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: Awake, alert, in no acute distress
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: warm, well perfused; regular on telemetry
Pulmonary: breathing non labored on room air
Abdomen: Soft, NT, ND, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented to self, month, and
hospital (not to ___, not oriented to year. Able to relate
history only some recent history, not in further detail.
Attentive to conversation. Speech is fluent with full sentences,
intact repetition to simple phrases but not more complex ones
(can say "Today is a sunny day" but not "I only know that ___
is
the one to help today"), and intact verbal comprehension. Naming
intact to high frequency objects only. No paraphasias. Mild to
moderate dysarthria. Normal prosody. No apraxia. No evidence of
hemineglect. No left-right confusion. Able to follow both
midline
and appendicular commands.
- 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. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor: Normal bulk; increased tone in bilateral legs. No
drift. No tremor or asterixis.
[___]
L 5 5 5 5 ___ 5 5 5 5 5
R 5 5 5 5 ___ 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
Plantar response extensor on L, flexor on R
- Sensory: No deficits to light touch, pin, or proprioception
bilaterally. No extinction to DSS.
- Coordination: Mild dysmetria bilaterally with finger to nose
testing bilaterally.
- Gait: Deferred (post tPA)
DISCHARGE PHYSICAL EXAM:
Physical Exam:
Tmax: 98.3
BP: 139-160/75-94
HR: ___
Spo2 94-97%
RR 18
General: Awake, alert, in no acute distress
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: warm, well perfused; regular on telemetry
Pulmonary: breathing non labored on room air
Abdomen: Soft, NT, ND, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- mental status: Patient awake lying in bed, knows her name,
unsure of the year, knows current president but not previous
president. Able to state she is in hospital. Pupils 4-->3.5
bilaterally. Mild pronation on the right but no drift.
- Cranial Nerves: PERRL 3->2 brisk. VFF bilaterally to finger
count. EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor: Normal bulk; increased tone in bilateral legs. No
drift. No tremor or asterixis.
[Delt][Bic][Tri][ECR][FEx][IO][IP][Quad][Ham][TA]
L 5 4+* 4+* 5 5- 5- 5 5 5 0
R 5 4+* 4+* 5 ___ 5 5 5
*limited by giveway wewakness
- Reflexes:
not tested today
- Sensory: No deficits to light touch. No extinction to DSS.
- Coordination: Mild dysmetria bilaterally with finger to nose
testing.
Pertinent Results:
=========
LABS
=========
___ 05:50PM BLOOD WBC-10.8* RBC-4.81 Hgb-14.4 Hct-42.6
MCV-89 MCH-29.9 MCHC-33.8 RDW-13.1 RDWSD-42.8 Plt ___
___ 05:50PM BLOOD ___ PTT-26.4 ___
___ 05:50PM BLOOD Glucose-127* UreaN-20 Creat-0.9 Na-140
K-4.7 Cl-100 HCO3-26 AnGap-14
___ 02:27AM BLOOD ALT-20 AST-18 LD(LDH)-160 CK(CPK)-79
AlkPhos-66 TotBili-0.8
___ 02:27AM BLOOD CK-MB-3 cTropnT-<0.01
___ 05:50PM BLOOD Cholest-136
___ 09:05PM BLOOD %HbA1c-7.3* eAG-163*
___ 05:50PM BLOOD Triglyc-138 HDL-42 CHOL/HD-3.2 LDLcalc-66
___ 02:27AM BLOOD TSH-0.22*
___ 05:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
=========
IMAGING
=========
CT Head w/o Contrast (OSH) evidence of multiple prior strokes
affecting bilateral cerebellar, bilateral thalamocapsular, right
PCA and left subinsular cortex, as well as extensive chronic
small vessel ischemic changes
CTA Head/Neck: Reviewed. Per my read notable for diffuse
atherosclerosis affecting the majority of the intracranial
vasculature. No large vessel occlusion or aneurysm. Very
diminuitive bilateral PCAs. Per prelim report, "There is
intermittent narrowing of the bilateral V4 segments of the
vertebral arteries, severe on the right right (series 3: Image
190) and moderate on the left (series 3: Image 188), likely due
to atherosclerotic disease. The carotid arteries and their major
branches appear patent with no evidence of stenosis or
occlusion.
Atherosclerotic calcifications are seen in the carotid
bifurcations. There is no evidence of internal carotid stenosis
by NASCET criteria."
___ 02:27AM BLOOD TSH-0.22*
___ 05:20AM BLOOD D-Dimer-562*
___ 12:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-MOD*
___ 12:00PM URINE RBC-1 WBC-13* Bacteri-FEW* Yeast-NONE
Epi-<1 TransE-<1
Brief Hospital Course:
#R precentral gyrus stroke:
Pt initially presented to OSH on ___ at 1330 for new dysarthria
and L facial droop. Code Stroke was called with NIHSS of 8 (of
note, pt has residual neurologic deficits consistent with NIHSS
of 5). ___ showed prior multifocal infarcts but no clear sign
of bleed and malignant infarct. She received tPA at 1536 and was
subsequently transferred to ___ for post-tPA care. MRI showed
R precentral gyrus ischemic stroke.
Upon arrival to ___, pt was evaluated in ED and underwent CTA
H&N which showed diffuse atherosclerosis but no clear vessel
occlusion. On examination, her NIHSS was seen to have improved
to close to her baseline and pt was admitted to NeuroICU for
post-tPA monitoring. She was monitored on telemetry and
continued on her home Coreg halved in dosage, per protocol.
Other BP medications and antithrombotic agents were held per
protocol. She underwent 24 hr post tPA MRI which showed acute
infarct in R precentral gyrus. LDL was 68. A1C 7.3%. TSH was
0.22. D-dimer was checked to evaluate for possible occult
malignancy given multiple strokes, the d-dimer level was
elevated at the level expected post stroke (562), but not
greatly elevated to the point of suggesting occult malignancy.
Her home statin, insulin regimen were continued. TTE was
essentially normal, but LA was slightly enlarged. Overall given
the patient's multiple strokes in different territories and the
occurrence of stroke while on aspirin, it was felt that the most
likely etiology was cardioembolic. Slightly enlarged LA and low
TSH, might support pAfib. Given the multiple strokes, we decided
it would be beneficial to start her on systemic anticoagulation
with warfarin 5 mg daily with a goal INR of ___, and remaining
on an aspirin bridge in the interim. (Aspirin 81 mg daily).
Aspirin can be stopped once INR is therapeutic. Her exam
improved and was essentially at her baseline at time of
discharge. She was discharged to rehab.
#UTI - patient reported dysuria, became less oriented, UA showed
13 WBC, moderate ___. Treated as UTI with ceftriaxone 1 gm daily.
She received 2 doses, she should receive the last dose of
ceftriaxone at rehab on ___ for a total 3 day course for
uncomplicated UTI.
#HTN - she can resume her home blood pressure regimen upon
discharge, it was initially held for permissive hypertension.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed â () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 68) - () 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 if LDL >70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ x] LDL-c less than 70 mg/dL] (already on statin)
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
IMAGING:
TTE ___
"The left atrium is elongated. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with mild hypokinesis of the
basal inferior/inferolateral walls. The remaining segments
contract normally (LVEF = 50-55%). No masses or thrombi are seen
in the left ventricle. 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. The mitral valve leaflets are structurally
normal. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is an
anterior space which most likely represents a prominent fat pad.
IMPRESSION: No ASD, PFO or left ventricular thrombus. Very mild
regional left ventricular systolic dysfunction, c/w CAD. Mild
mitral regurgitation. "
MRI brain ___
"1. Acute infarction within the right precentral gyrus.
2. Chronic areas of encephalomalacia within the right occipital
lobe and
bilateral cerebellar hemispheres.
3. Global cerebral atrophic changes and evidence for chronic
small vessel
ischemic disease."
CTA Head neck ___
" 1. Confluent areas of low signal intensity within the white
matter are
nonspecific but likely reflect the sequela of severe chronic
small vessel
disease.
2. Old lacunar infarctions within the basal ganglia, left
inferior parietal
lobule, left medial occipital lobe, and bilateral cerebellar
hemispheres. No
large acute infarct or intracranial hemorrhage.
3. Extensive intracranial atherosclerosis as detailed above,
most advanced
within the posterior circulation with severe narrowing of the
bilateral V4
segments, right worse than left.
4. 2 mm infundibulum of a lenticulostriate artery from the
right M1 segment
versus a small aneurysm.
5. Mild extracranial atherosclerotic disease, without
significant stenosis. "
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Carvedilol 12.5 mg PO BID
3. levemir 20 Units Q12H
4. Magnesium Oxide 400 mg PO BID
5. Omeprazole 20 mg PO DAILY
6. Pravastatin 40 mg PO QPM
7. Enalapril Maleate 20 mg PO DAILY
8. Citalopram 20 mg PO DAILY
9. MetFORMIN (Glucophage) 500 mg PO BID
10. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. CefTRIAXone 1 gm IV Q24H Duration: 3 Doses
RX *ceftriaxone in dextrose,iso-os 1 gram/50 mL 1 gram IV daily
Disp #*1 Intravenous Bag Refills:*0
2. Warfarin 5 mg PO DAILY16
RX *warfarin 5 mg 1 tablet(s) by mouth at night Disp #*15 Tablet
Refills:*0
3. levemir 20 Units Q12H
4. Aspirin 81 mg PO DAILY
5. Carvedilol 12.5 mg PO BID
6. Citalopram 20 mg PO DAILY
7. Enalapril Maleate 20 mg PO DAILY
8. Magnesium Oxide 400 mg PO BID
9. MetFORMIN (Glucophage) 500 mg PO BID
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Pravastatin 40 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
acute ischemic stroke
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neuro exam: Does not know year, name of hospital. ___ in L arm
flexors, slight L NLFF
Discharge Instructions:
Dear ___,
___ were hospitalized due to symptoms of garbled speech, facial
droop 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. ___ received tPA at the hospital ___
were at prior to coming here. tPA is a medication that destroys
clots to try to restore blood flow. A MRI of your brain
confirmed that there was a new stroke in the part of your brain
that controls your left arm. There was evidence of your old
strokes as well.
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:
High blood pressure ___ are already on medications for this)
Diabetes ___ are already on medications for this)
High cholesterol ___ are already on medications for this, your
cholesterol was at its goal)
We are changing your medications as follows:
Start taking warfarin 5 mg daily (warfarin is a blood thinner).
We felt that your pattern of strokes was concerning for a clot
coming from somewhere, and given that ___ had a stroke while
taking aspirin, we felt that ___ needed a blood thinner. Which
should reduce your chance of stroke. ___ will need your INR
monitored to make sure your warfarin dose is correct. Your INR
should be between ___, it may take a week before it reaches this
level, your primary care doctor can arrange following the level
of your INR and adjusting your dose of warfarin, as different
people need different doses. Once your INR is between ___ ___
can stop taking aspirin.
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician.
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
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10683770-DS-8
| 10,683,770 | 27,052,738 |
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| 8 |
2153-10-11 00:00:00
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2153-10-19 16:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
S/p fall from bicycle
Major Surgical or Invasive Procedure:
___: Right chest tube placement
History of Present Illness:
___ with history of afib not on AC presenting after sustaining
right ___, 5th rib fracture and scapular fracture diagnosed
at ___ now with intractable pain. The patient was
bicycling at 17 mph and making a turn when he fell with the bike
and landed on his right side. He mentioned that he hit his head
and helmet cracked and soon after noticed significant pain in
his right clavicular area.
He presented to ___ where he was diagnosed with
above fracture, treated with Morphine followed by Percocet and
discharged with right arm sling, Oxycodone and instructed to
make f/u appointment with orthopedics on ___. Since then,
patient has been using Ice, Ibuprofen and Oxycodone with minimal
relief. Continues to note pain primarily in right clavicular
area. Denies
any numbness/tingling, decreased sensation, difficult to for
patient to say if right arm weak ___ pain. No fevers/chills. Had
road rash on right upper arm treating with Bacitracin without
any pus noted.
Patient otherwise denies any headaches,
lightheadedness/dizziness, changes in vision, nausea/vomiting,
chest pain, hemoptysis. Breathing somewhat limited due to rib
pain though patient has been trying to take deep breaths.
Past Medical History:
Atrial fibrillation (not on anticoagulation)
Social History:
___
Family History:
Non-contributory
Physical Exam:
Physical Exam on Admission:
T 98.1 HR 66 BP 122/81 RR 16 96% RA
NAD
Alert and orientedx3
RRR
CTA bil. tender to palpation in right upper thorax, no
respiratory distress
Abdomen soft, non-tender
Extremities: RUE in sling. Motor and sensory intact
Physical Exam on Discharge:
Vitals: Temp: 98.2 (Tm 98.7), BP: 104/69 (104-146/69-91), HR:
57
(56-84), RR: 18 (___), O2 sat: 96% (93-97), O2 delivery: Ra
Gen: NAD, AxOx3
Card: RRR
Pulm: no respiratory distress.
Abd: Soft, non-tender, non-distended, normal bs.
Wounds: c/d/i
Ext: No edema, warm well-perfused
Pertinent Results:
___ 05:45AM BLOOD WBC-5.8 RBC-4.36* Hgb-12.6* Hct-39.3*
MCV-90 MCH-28.9 MCHC-32.1 RDW-13.8 RDWSD-45.5 Plt ___
___ 05:30PM BLOOD Neuts-67.9 ___ Monos-8.8 Eos-1.0
Baso-0.6 Im ___ AbsNeut-6.09 AbsLymp-1.93 AbsMono-0.79
AbsEos-0.09 AbsBaso-0.05
___ 05:30PM BLOOD ___ PTT-27.8 ___
___ 05:45AM BLOOD Glucose-93 UreaN-12 Creat-0.9 Na-141
K-4.4 Cl-106 HCO3-23 AnGap-12
___ 05:45AM BLOOD Calcium-8.7 Phos-2.9 Mg-1.7
CT HEAD W/O CONTRAST ___:
IMPRESSION:
No evidence of acute intracranial abnormality.
CLAVICLE RIGHT ___:
IMPRESSION:
In comparison with the study of ___, there appears to
be and
overriding fracture of the mid-portion of the right clavicle,
though given the angulation of the views presented this is not
optimally seen. Comparison with the outside hospital study
would be most helpful.
The AC joint is well maintained with minimal degenerative
disease.
CT CHEST W/O CONTRAST ___:
IMPRESSION:
1. Moderate right-sided pneumothorax without definite signs of
tension.
2. Mildly displaced, obliquely oriented fracture through mid
right clavicle.
3. Comminuted fracture involving the body in spine of the right
scapula. No involvement of the glenohumeral joint identified.
4. Moderately displaced fracture at the lateral right third rib
and mildly
displaced fracture at the lateral right fourth rib.
5. Partial collapse of the right lower lobe. Mild left base
atelectasis.
CHEST (PA & LAT) ___:
IMPRESSION:
Small right apical pneumothorax, likely decreased in size since
prior CT
status post placement of right chest tube.
Brief Hospital Course:
Mr. ___ is a ___ year old male, who presented here at ___
after a fall off his bicycle. He had originally gone to OSH
where he had imaging done and was discharged home. However, due
to his increasing pain, he came to the emergency department at
___. Imaging done upon admission here showed that he sustained
a right pneumothorax, a right mid-clavicular fracture, right
comminuted right scapular fracture, right ___ rib fracture. He
had a chest tube placed for his pneumothorax and was sent to the
floor for further monitoring and treatment.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed with IV dilaudid and oral
oxycodone.
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. Patient had
serial CXRs performed. Incentive spirometry was encouraged
throughout hospitalization.
GI/GU/FEN: Patient was placed on a regular diet, which was well
tolerated. Patient's intake and output were closely monitored.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay and was encouraged to
get up and ambulate as early as possible.
Orthopedics was consulted for patient's right clavicular and
scapular fractures. Their recommendations are for non-weight
bearing in right upper extremity with a sling for comfort.
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.
treatment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
Take as needed once pain decreases.
2. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate
Please take with food.
3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
Please take lowest effective dose and wean as tolerated.
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*25 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY
Hold for loose stool.
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
Hold for loose stool.
6. Aspirin 81 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Right pneumothorax
Right clavicle fracture
Right scapular fracture
Right ___ rib fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Right upper extremity: non-weight bearing w/ sling for comfort.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ because you had a fall off your bike
and sustained injuries including right ___ rib, right
clavicle, and right scapula fracture. You also had a small air
leak between your right lung and your chest wall called a
pneumothorax which was treated with a chest tube. While here,
your respiratory status was monitored. Your chest tube was
removed after getting serial chest xrays, which showed that your
pneumothorax was resolving. You were also seen by orthopedics
regarding your right clavicle/scapula fracture. They recommend
that you be non-weight bearing in your right upper extremity and
wear a sling for comfort. You have been doing well. Your pain
has been well-controlled on oral pain medications and you are
ambulating and voiding without issue. You are ready to be
discharged home to continue your recovery. Please follow the
instructions below.
Rib Fractures:
* Your injury caused right ___ rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Followup Instructions:
___
|
10684247-DS-10
| 10,684,247 | 27,682,283 |
DS
| 10 |
2172-10-28 00:00:00
|
2172-10-28 14:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
CHF exacerbation
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is an ___ yo Caucasian male with CAD (CABG x1, BMS to RCA
and POBA to PLV, DES to D1 and LCx), AS s/p recent ___,
sCHF (EF 25%), HTN, HLD, ___, presents from ___ with
mild CHF exacerbation.
Patient states that last night, he went to sleep and woke up at
2AM on ___ felt very SOB. He denied CP, diaphoresis, N/V at that
time. The SOB progressed, and he eventually called ___ and was
sent to ___. Of note, Mr. ___ underwent
___ placement here at ___ on ___. The procedure was
complicated by complete heart block and left external iliac
dissection. Afterthe ___ he did very well. He has been
doing statinary bicycle and treadmill at home. He could walk to
12 mins without difficulty. There were no DOE while climbing
stairs at home, and he sleeps with one pillow at night, without
orthopnea / PND. He denies any recent F/C, cough or URI
symptoms. There were no sick contacts. He has not made much
changes in his diet either. His torsemide was decreased from 40
mg to 20 mg one week ago. He stated that his urine output
decreased since then. His dry weight was 180 lbs, and he weighed
183 lbs tonight.
While at ___, pt was put on bipap. His VS
initially were 98.0, ___, 97% on NRB. EKG appeared to
be sinus tachycardia, although read as A-fib with RVR. BiPAP was
started. Lab showed ___ with Cr to 1.6. His CP was consistent
with pulmonary edema. Pt was given 40 mg iv lasix and ASA 325.
He improved significantly afterwards, and subsequently
transferred to ___ for further management at 8 AM. It is
unclear how much urine he put out from the iv lasix.
In the ED, initial vitals were 98 81 118/76 16 98% on NC?. Pt
had negative Tn X2. His labs were otherwise unremarkable.
Cardiology was consulted, and decision was made to admit pt to
heart failure service for UOP monitoring.
REVIEW OF SYSTEMS
On review of systems, s/he denies any prior history of stroke,
___, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
Cardiac History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +HTN
2. CARDIAC HISTORY:
-CABG: ___ PTCA and single vessel CABG utilizing LIMA to LAD
-PERCUTANEOUS CORONARY INTERVENTIONS:
-CAD s/p cath in ___ revealed a 60% lesion of mid LAD and 50%
of D2 as well as a 20% stenosis of the pRCA.
-___ inferior MI ->stenting of proximal R coronary and balloon
angio of posterior left ventricular branch
-___ stenting of first diag and L circ with cypher DESs
-PACING/ICD:
ICD placed ___ ___ Fortify VR 1231-40
3. OTHER PAST MEDICAL HISTORY:
___ Class II heart failure
Chronic kidney disease
S/p ___ w/o residual disabilities
Atrial fibrillation
Psoriasis
Gout
Social History:
___
Family History:
Significant for heart disease: mother with CAD and MI.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS- T=98.4 BP=103/72 HR=59 RR=20 O2 sat=95% on RA
GENERAL- WDWN M in NAD. Oriented x3. Mood, affect appropriate,
lying flat comfortably on bed
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK- Supple with JVP of 10 cm.
CARDIAC- PMI located in ___ intercostal space, midclavicular
line. irregular rhythm, normal S1, S2, +S4 at apex, ___ systolic
ejection murmur. No thrills, lifts
LUNGS- No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. bibasilar crackles, no
improvement after cough, ___ilaterally
ABDOMEN- Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES- No pitting edema. No femoral bruits.
SKIN- No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: 2+ ___ bilaterally
DISCHARGE PHYSICAL EXAM:
VS: 98.6, 96-133/45-78, 62-83, 0.90ra
GENERAL- WDWN M in NAD. Oriented x3. Mood, affect appropriate,
lying flat comfortably on bed
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK- Supple with JVP of 1cm but with cannon a waves.
CARDIAC- PMI located in ___ intercostal space, midclavicular
line. irregular rhythm, normal S1, S2, +S4 at apex, ___ systolic
ejection murmur. No thrills, lifts. Cannon a waves as above.
LUNGS- No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. bibasilar crackles, no
improvement after cough, ___ilaterally
ABDOMEN- Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES- No pitting edema. No femoral bruits.
SKIN- No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: 2+ ___ bilaterally
Pertinent Results:
ADMISSION LABS:
___ 09:20AM BLOOD WBC-7.9 RBC-4.18* Hgb-12.3* Hct-38.8*
MCV-93 MCH-29.5 MCHC-31.8 RDW-13.1 Plt ___
___ 09:20AM BLOOD Neuts-81.5* Lymphs-13.0* Monos-5.0
Eos-0.3 Baso-0.2
___ 09:20AM BLOOD ___ PTT-44.9* ___
___ 09:20AM BLOOD Glucose-110* UreaN-29* Creat-1.5* Na-143
K-4.6 Cl-104 HCO3-29 AnGap-15
___ 09:20AM BLOOD ALT-14 AST-24 AlkPhos-62 TotBili-0.4
___ 09:20AM BLOOD proBNP-2641*
___ 09:20AM BLOOD Albumin-4.1 Calcium-9.3 Phos-3.1 Mg-2.1
TROPONINS:
___ 09:20AM BLOOD cTropnT-0.03*
___ 03:00PM BLOOD cTropnT-0.03*
___ 08:20AM BLOOD CK-MB-3 cTropnT-0.02*
DISCHARGE LABS:
___ 07:30AM BLOOD WBC-7.3 RBC-4.07* Hgb-11.8* Hct-37.4*
MCV-92 MCH-28.9 MCHC-31.5 RDW-13.1 Plt ___
___ 07:30AM BLOOD Glucose-125* UreaN-33* Creat-1.3* Na-143
K-4.5 Cl-103 HCO3-29 AnGap-16
___ 07:30AM BLOOD Calcium-9.4 Phos-3.6 Mg-2.2
CXR ___
FINDINGS: PA and lateral views of the chest were reviewed.
Compared to the most recent prior, mild pulmonary edema has
slightly improved and the
endotracheal tube and Swan-Ganz catheter has been removed. Upper
lung vascular redistribution, tiny bilateral pleural effusions
and moderate cardiomegaly are unchanged. A left pectoral
defibrillator lead ends in the mid to distal right atrium.
Aortic core valve and median sternotomy wires are intact and
unchanged in alignment. Aortic core valve is unchanged in
position. Mediastinal surfaces are relatively unchanged.
IMPRESSION: Slight improvement in mild pulmonary edema.
Brief Hospital Course:
Mr. ___ was admitted to ___ on ___ after being
transferred from the ED at ___ with mild CHF
exacerbation/flash pulmonary edema for consideration of pacer
upgrade. His hospital course, by problem, is as follows:
# PUMP: Mild CHF exacerbation on arrival in setting of chronic
systolic heart failiure (EF ___, received 40mg furosemide IV
in ___ ED and received 40mg IV furosemide in a.m.
of ___. Gave 20mg torsemide in evening of ___ and planned
return to 40mg torsemide daily on ___. Will follow-up with ___
clinic in approximately one week after discharge for
consideration of dual-v pacer upgrade.
# CORONARIES: Pt has known significant CAD. The presentation was
unlikely ACS. Mild troponin elevation as above was likely in the
setting of ___ and CHF. Continued aspirin 81mg, simvastatin
80mg, metoprolol 25mg BID.
# Rhythm: Pt has history of A-fib with CHADS 5. He is well rate
controlled and on therapeutic anticoagulation. He developed
complete heart block post ___. His rhythm in the past 24
hours likely involved sinus tachycardia to 120s, wenckebach,
intermittent complete heart block. This could be the underlying
cause of his flash pulmonary edema. Will follow-up with ___
clinic in approximately one week after discharge for
consideration of dual-v pacer upgrade.
# ___ - Creatinine at baseline 1.0. Arrived at 1.5, trended down
to 1.2 but back up to 1.4 with 40mg IV furosemide + 20mg
torsemide on HD#1. On day of discharge, creatinine trending down
to 1.3. Encouraged PO intake and will follow-up with PCP
approximately one week after discharge.
# Hypertension: continue home metoprolol and losartan
# Hyperlipidemia: continue home simvastatin
# Microhematuria: likely in the setting of anticoagulation and
foley.
- remove foley
- Will continue to follow clinically
- outpatient workup
TRANSITIONAL ISSUES:
- ___: Baseline creatinine 1.0. Arrived with creatinine of 1.5,
trending down to 1.3 on day of discharge. Should be followed by
PCP at next visit.
- Resume normal INR monitoring. Warfarin dosing managed by PCP,
___, ___. Suggest INR check at
next PCP visit, ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Losartan Potassium 50 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Simvastatin 80 mg PO HS
5. Torsemide 20 mg PO DAILY
6. Warfarin 2.5 mg PO 2X/WEEK (MO,WE)
7. Warfarin 5 mg PO 5X/WEEK (___)
8. Fish Oil (Omega 3) 1000 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Losartan Potassium 50 mg PO DAILY
3. Simvastatin 80 mg PO HS
4. Torsemide 40 mg PO DAILY
RX *torsemide [Demadex] 20 mg 2 tablet(s) by mouth daily Disp
#*60 Tablet Refills:*0
5. Warfarin 2.5 mg PO 2X/WEEK (MO,WE)
6. Warfarin 5 mg PO 5X/WEEK (___)
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Fish Oil (Omega 3) 1000 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
- acute exacerbation of congestive heart failure with flash
pulmonary edema
- atrial fibrillation with rapid ventricular response
- complete heart block
SECONDARY:
- aortic stenosis, status post transcatheter aortic valve
replacement
- acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Thank you for choosing ___ for your medical care. You were
admitted to ___ from the ER at ___ for
consideration of pacemaker upgrade following an acute
exacerbation of CHF (causing your breathing difficulty).
Upon discharge, please weigh yourself every morning, and call
your doctor ___, (___) if your weight goes up
more than 3 lbs. It is important you take all medications as
prescribed. Please keep all your appointments with your doctors,
and bring a copy of your medication list to these visits.
Your dose of torsemide should now be increased from 20mg to 40mg
daily.
Followup Instructions:
___
|
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