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10684247-DS-8
| 10,684,247 | 28,430,275 |
DS
| 8 |
2172-07-31 00:00:00
|
2172-08-01 20:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
This is a ___ with history of history of CAD s/p CABG, CHF
with ICD, HTN, HLD, afib on coumadin, who presents with after
syncopal fall.
Patient reports that he was in USOH today however after leaving
church this afternoon, while walking to his car, he felt weak
and thought his legs were "going to give out." He then notes
that the next thing he remembers was waking up on the ground. He
denies any dizziness/LH, chest pain or palpitations prior to the
event. Endorses LOC but denies head strike. Episode was
witnessed and there was no report of jerking movements. Denies
bowel or bladder incontinence.
He reports having SOB earlier that day however states that it is
a struggle he has been dealing with over the last few months.
States that he suffered from a PNA 3 months ago and since then
his breathing "has not been the same." Reports that he was
undergoing a work-up for this and was told he needed valve
replacement.
After the syncopal event, he was brought the ED for evaluation.
Initial VS: 97.2 52 116/80 16 97%. Evaluatin revealed normal
labs. EKG: 76bpm, Afib, LAD, normal intervals, no ST changes and
CXR was otherwise unremarkable. Patient was then admitted for
___. VS prior to transfer were: 98.4 70 134/81 20 98%
On arrival to the floor, patient reports feeling very well and
would like to go home.
Past Medical History:
Cardiac History:
S/P IMI in ___
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.
___ PTCA and single vessel CABG utilizing LIMA to LAD at
___
___ inferior MI ->stenting of proximal R coronary and balloon
angio of posterior left ventricular branch
___ stenting of first diag and L circ with cypher drug eluting
stents
ICD placed ___ ___ Fortify VR ___
Hyperlipidemia
Hypertension
S/P TIA no residual disabilities
HTN
HLD
afib on coumadin
psoriasis
gout
Social History:
___
Family History:
significant for heart disease
Physical Exam:
On Admission:
VS - 98.5, 72-77, 122/67, 18, 99RA
orthostatics - 138/64 88 supine, 144/82 96 lying, 132/84 102
standing
satting 94-97% RA while ambulating. Tachy to 140's while working
with ___.
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, quiet breath sounds, no r/rh/wh, good air
movement, resp unlabored, no accessory muscle use
HEART - irregular rate, nl s1, diminished A2. III/VI late
peaking crescendo decrescendo systolic murmur loudest at RUSB,
II/VI holosystolic murmur at the apex radiating to axilla. No
S3 or S4. no tenderness over ICD
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - scaly erythematous plaque on chest
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact
On Discharge:
VS - 98, 59-80's, 114/68 (lowest was 93/64), 18, 96RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, quiet breath sounds, no r/rh/wh, good air
movement, resp unlabored, no accessory muscle use
HEART - irregular rate, nl s1, diminished A2. III/VI late
peaking crescendo decrescendo systolic murmur loudest at RUSB,
II/VI holosystolic murmur at the apex radiating to axilla. No
S3 or S4. no tenderness over ICD
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), Radial and femoral bandages c/d/i, no bruits
SKIN - scaly erythematous plaque on chest
Pertinent Results:
On admission:
___ 06:00PM BLOOD WBC-8.9 RBC-4.49* Hgb-14.0 Hct-41.4
MCV-92 MCH-31.1 MCHC-33.8 RDW-13.7 Plt ___
___ 06:00PM BLOOD Neuts-77.9* Lymphs-16.3* Monos-4.7
Eos-0.8 Baso-0.3
___ 06:50AM BLOOD ___ PTT-44.0* ___
___ 06:00PM BLOOD Glucose-151* UreaN-27* Creat-1.2 Na-141
K-4.3 Cl-101 HCO3-26 AnGap-18
___ 06:50AM BLOOD ALT-10 AST-20 CK(CPK)-56 AlkPhos-58
TotBili-0.8
___ 06:00PM BLOOD cTropnT-<0.01
___ 06:50AM BLOOD CK-MB-3 cTropnT-0.01 proBNP-2920*
___ 06:50AM BLOOD Albumin-4.1 Calcium-9.1 Phos-2.9 Mg-2.2
___ 06:40PM BLOOD Type-ART pO2-100 pCO2-35 pH-7.47*
calTCO2-26 Base XS-1 Intubat-NOT INTUBA
Labs on discharge:
___ 06:29AM BLOOD WBC-8.1 RBC-4.38* Hgb-13.2* Hct-40.1
MCV-92 MCH-30.2 MCHC-33.0 RDW-13.4 Plt ___
___ 06:29AM BLOOD ___ PTT-39.0* ___
___ 06:29AM BLOOD Glucose-96 UreaN-27* Creat-1.3* Na-141
K-3.9 Cl-101 HCO3-30 AnGap-14
EKG ___
Atrial fibrillation, rate 76. Left axis deviation. Q waves in
leads III, aVF.
Poor T wave progression consistent with an anteroseptal
myocardial infarction
of indeterminate age. There are lateral T wave inversions and
flattening
raising a question of ischemia or electrolyte disturbance. Left
atrial
abnormality.
TRACING #1
Read ___.
IntervalsAxes
___
___
CXR ___
FINDINGS: Frontal and lateral views of the chest were obtained.
The patient
is status post median sternotomy and CABG. There is a
single-lead left-sided
AICD with lead in the expected position of the right ventricle.
Mild
bibasilar atelectasis is seen without definite focal
consolidation. There is
no pleural effusion or pneumothorax. There is mild pulmonary
vascular
congestion. The cardiac silhouette remains mildly enlarged.
The aorta
remains calcified and tortuous.
IMPRESSION:
1. Mild bibasilar atelectasis.
2. Mild cardiomegaly and pulmonary vascular congestion.
ECHO ___
The left atrium is moderately dilated. The left atrium is
elongated. Left ventricular wall thicknesses are normal. The
left ventricular cavity is moderately dilated. Overall left
ventricular systolic function is moderately-severely depressed
(quantitative biplane LVEF= 30 %) secondary to moderate global
hypokinesis and akinesis of the mid-distal anterior septum,
apex, and distal anterior wall. A left ventricular mass/thrombus
cannot be excluded. Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are moderately thickened. There is
critical aortic valve stenosis (valve area <0.8cm2). The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate (___) mitral regurgitation is seen.
The left ventricular inflow pattern suggests a restrictive
filling abnormality, with elevated left atrial pressure. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Moderate left ventricular dilatation with
moderate-severe regional and global left ventricular dysfunction
c/w CAD. Mild-moderate functional mitral regurgitation. Critical
calcific aortic stenosis by continuity equation (moderate by
transaortic velocity/gradients but this could be related to low
LVEF). Moderate pulmonary artery hypertension.
Dental Panorex ___ still unread
Cardiac Cath Report ___:
Coronary angiography: right dominant
LMCA: No angiographically apparent CAD
LAD: Totally occluded after diagonal at edge of previous stent
with robust collaterals from RCA
LCX: Heavily calcified with mild luminal irregularities and 50%
proximal stenosis.
RCA: Heavily calcified with proximal 50% stenosis.
LIMA-LAD: Known occluded
Converted access to femoral because unable to engage the LCA via
the radial approach. IN addition there was significant vascular
disease in the right radial artery making catheter torque and
advancement difficult.
Assessment & Recommendations
1.Secondary prevention CAD.
2.Severe AS with ___ (0.67 cm2 at baseline), (0.62 cm2 at 5
mcg/kg/min IV), (0.5 cm2 with Dobutamine 10 mcg/kg/min and 0.5
mg IV atropine. With 20 mcg/kg/min, there was no change in
valve
area.
Brief Hospital Course:
Summary:
___ M with significant cardiac history including afib, chf and
cad with ICD presenting after syncopal fall concerning for
severe AS, worked up for surgical valve replacement vs. core
valve.
# Syncope: EKG and enzymes did not suggest acute MI. Tele
notable for wenckebach, then concern for CHB however ventricular
rate was at 50 during CHB and patient was asymptomatic, in
addition the QRS morphology suggested the escape was high up and
so nothing was done for this except changing the backup rate on
his pacer from 30 to 50. Pacemaker interrogation did not show
an event that would have caused syncope. This left severe AS as
the most likely cause of his syncope.
#Severe Aortic Stenosis
He underwent an ECHO which showed critical calcific aortic
stenosis by continuity equation (moderate by transaortic
velocity/gradients but this could be related to low LVEF). He
also underwent cardiac catheterization as part of the work up
for surgical aortic valve replacement vs. core valve. This
showed severe AS with ___ (0.67 cm2 at baseline), (0.62 cm2 at 5
mcg/kg/min IV), (0.5 cm2 with Dobutamine 10 mcg/kg/min and 0.5
mg IV atropine. He was previously seen at ___ where a chest CT
and carotid duplex were performed, so the rest of the workup
here included a dental panorex (results pending). He was seen
by Dr. ___ and by cardiology while here and he will follow
up with the core valve clinic.
Non-active Issues:
# CHF: euvolemic appearing
- Continued home medications
# Afib: rate well controlled
- Continued metoprolol and warfarin
#CAD
-continued home meds
# HLD: continued home medications. ok to continue simva 80mg qd,
lft's and ck normal
# HTN: continued home medications
Transitional Issues:
#Severe aortic stenosis - His grand-daughter in law, ___, is an
NP with the core valve clinic and she has already spoken to him
and will call him on ___ for an appointment. They will
coordinate the rest of his workup and decide if he will be a
core valve candidate, surgical candidate or will be randomized.
He will also follow up with his PCP this week, and with his
regular cardiologist at the ___ in a few weeks.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Aspirin 81 mg PO DAILY
2. Losartan Potassium 75 mg PO DAILY
hold for sbp < 100
3. Simvastatin 80 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
hold for sbp < 100 and hr < 60
5. Warfarin 5 mg PO DAILY16
6. Furosemide 60 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Furosemide 60 mg PO DAILY
3. Losartan Potassium 75 mg PO DAILY
hold for sbp < 100
4. Metoprolol Succinate XL 50 mg PO DAILY
hold for sbp < 100 and hr < 60
5. Simvastatin 80 mg PO DAILY
6. Warfarin 5 mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
syncope, severe aortic stenosis
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 passed out. The
most likely cause for your passing out is your aortic stenosis.
You will follow up with Dr. ___ (they will call you
for an appointment next week) to consider a core valve vs.
surgery for aortic valve replacement. While you were here the
cardiologists changed one of the settings in your ICD so that it
will start to work at a higher heart rate. This is because we
noticed a heart rhythm called heart block. We did not change
your medications.
Followup Instructions:
___
|
10684279-DS-14
| 10,684,279 | 21,968,750 |
DS
| 14 |
2190-02-07 00:00:00
|
2190-02-12 17:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / IV contrast dye / Sulfa (Sulfonamide
Antibiotics)
Attending: ___.
Chief Complaint:
back pain, abdominal pain, N/V
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with PMH significant for SLE, fractured
pelvis, and chronic pancreatitis that presented to ___ ED from
home with acute onset N/V, abdominal pain and inability to
tolerate PO after injuring her back. She was lifting an air
conditioner up the stairs on ___, and felt a ripping
sensation with immediate pain in her lower sacral region. She
went to bed that evening after taking 15mg MS ___, and she
woke up in the morning with left sided abdominal pain radiating
to the side and back with persistent non-bloody, non-bloody,
grey emesis. She was unable to tolerate any PO so called her PCP
who referred her to the ED.
In the ED, initial vitals were: 97.9 79 144/69 18 98% RA.
Initial labs significant for normal WBC, chem-10, lipase, LFTs,
and lactate. Trop (-) x1. UA without evidence of UTI. She
underwent NCCT A/P to evaluate for recurrent pancreatitis which
showed a normal pancreas with likely acute L4 burst fracture.
She was evaluated by neurosurgery who believed the fracture to
be chronic rather than acute, and recommended no interventions.
She was given total of 2mg IV dilaudid, 8mg zofran, and 2L IVF.
___ was not able to tolerate PO and still requiring IV pain
meds so admitted to medicine.
Upon arrival to the floor, ___ reports ___ L. sided
abdominal pain similar to previous episodes of pancreatitis
which can occur 2x/month. She is supposed to be taking creon for
this, but cannot afford the medication. Also with nausea,
anorexia, lethargy, fatigue, and HA. Symptoms previously
responded well to IV dilaudid. Of note, an engorged tick was
found on her back and she reports hiking in the woods on
___.
Past Medical History:
#SLE
#Sjogrens
#Raynaud's
#Juvenile polyposis syndrome (multiple polyps throughout the
colon with recommendation for colectomy by GI)
#Chronic pancreatitis (should be on creon, but cannot afford),
thought to be ___ lupus
#H/o migraines
#Osteoporosis
#H/o pelvis fracture
#Endometriosis
Social History:
___
Family History:
No h/o autoimmune disease
Physical Exam:
EXAM ON ADMISSION:
================
Vitals: 98.3 122/55 80 16 98%RA
General: Lethargic, but oriented x3. Moderate distress ___
abdominal pain
HEENT: Sclera anicteric, Dry MM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP ~5cm, no LAD
CV: RRR. NS1&S2. ___ systolic murmur heard best at RUSB
Lungs: CTAB. No adventitious sounds. Good air flow
Abdomen: BS+. Diffuse tenderness to palpation worse in LUQ.
Voluntary guarding without rebound or rigidity.
GU: No foley
Ext: WWP, 2+ pulses. No c/c/e
Back: TTP over left paraspinal muscles near thoracolumbar
junction
EXAM ON DISCHARGE:
================
Vitals: T 98 BP 125/65 (90-140s/50-60s) HR 72 RR 18 O2 100% RA
General: alert, NAD
HEENT: Sclera anicteric
CV: RRR. NS1&S2. NO m/r/g.
Lungs: CTAB above brace. No adventitious sounds. Good air flow
Abdomen: brace in place as ___ is sitting up so deferred
exam
Ext: WWP, No c/c/e
Neuro:
- Light touch: slightly diminished (with numbness) in LLE,
slight numbness over medial aspect of right foot, numbness in
groin around both labia
- Motor strength: ___ strength in BLE
plantarflexion/dorsiflexion and knee extension, slight weakness
(___) in LLE knee flexion and extension compared to RLE, ___
strength in BLE hip flexion
Pertinent Results:
LABS ON ADMISSION:
===============
___ 05:45PM BLOOD WBC-8.5 RBC-4.30 Hgb-13.6 Hct-39.1 MCV-91
MCH-31.6 MCHC-34.8 RDW-13.0 Plt ___
___ 05:45PM BLOOD Neuts-85.5* Lymphs-7.1* Monos-6.3 Eos-0.6
Baso-0.4
___ 05:45PM BLOOD Glucose-102* UreaN-10 Creat-0.5 Na-138
K-3.6 Cl-102 HCO3-26 AnGap-14
___ 05:45PM BLOOD ALT-22 AST-32 AlkPhos-42 TotBili-0.4
___ 05:45PM BLOOD Lipase-25
___ 05:45PM BLOOD cTropnT-<0.01
___ 05:45PM BLOOD Albumin-4.1 Calcium-9.3 Phos-3.5 Mg-2.1
___ 05:58PM BLOOD Lactate-0.6
___ 09:00PM URINE Color-Straw Appear-Clear Sp ___
___ 09:00PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 09:00PM URINE RBC-10* WBC-<1 Bacteri-NONE Yeast-NONE
Epi-<1
PERTINENT LABS:
===============
___ 05:45PM BLOOD cTropnT-<0.01
___ 03:40AM BLOOD CK-MB-5 cTropnT-<0.01
___ 03:36PM BLOOD CK-MB-7 cTropnT-<0.01
___ 05:20AM BLOOD 25VitD-40
LABS ON DISCHARGE:
===============
___ 04:45AM BLOOD WBC-3.3* RBC-3.91* Hgb-12.6 Hct-35.7*
MCV-91 MCH-32.1* MCHC-35.2* RDW-12.0 Plt ___
___ 04:00AM BLOOD ___ PTT-29.3 ___
___ 04:20AM BLOOD Glucose-85 UreaN-7 Creat-0.6 Na-140 K-3.9
Cl-106 HCO3-27 AnGap-11
___ 04:20AM BLOOD Calcium-8.3* Phos-2.8 Mg-2.1
MICROBIOLOGY: NONE
STUDIES:
===============
ECGStudy Date of ___ 10:01:38 ___
Sinus rhythm. Prominent voltage in leads I and aVL for left
ventricular hypertrophy. Left anterior fascicular block.
Biphasic to inverted T waves in leads V2-V6 and biphasic T waves
in leads II, III and aVF. These findings are more prominent as
compared with previous tracing of ___, especially in leads
II, III and aVF. Otherwise, no diagnostic interim change.
Clinical correlation is suggested.
Intervals Axes
RatePRQRSQTQTc (___) ___ 39-5080
CT ABDOMEN W/O CONTRASTStudy Date of ___ 7:11 ___
IMPRESSION:
1. Limited study without contrast. Within limitations, pancreas
appear normal.
2. L4 burst fracture, likely recent and compatible with
___ history of trauma 1 day prior.
CHEST (SINGLE VIEW)Study Date of ___ 7:52 ___
IMPRESSION:
No acute cardiopulmonary process.
MR ___ SPINE W/O CONTRASTStudy Date of ___ 12:22 ___
IMPRESSION:
1. Acute burst fracture deformity of the L4 vertebral body, with
expected posterior soft tissue swelling. No gross ligamentous
injury identified.
2. At L4-L5, a posterior disc bulge causes moderate right and
mild left neuroforaminal narrowing and contact with the
traversing nerve roots.
ECGStudy Date of ___ 8:59:06 AM
Sinus rhythm. Left anterior fascicular block. Non-diagnostic Q
waves in the high lateral leads. Left ventricular hypertrophy
with extensive ST-T wave changes consistent with hypertrophy
versus ischemia. Clinical correlation is suggested. Compared to
the previous tracing of ___ the overall findings are
similar.
Intervals Axes
RatePRQRSQTQTc (___) ___ ___
ECGStudy Date of ___ 9:12:10 AM
Sinus rhythm. Left anterior fascicular block. Biphasic to
inverted T waves
in leads V1-V6 with continued ST segment elevation. Compared to
the previous
tracing of ___ no diagnostic interim change. Clinical
correlation is
suggested.
Intervals Axes
RatePRQRSQTQTc (___) ___
___ ___
ECGStudy Date of ___ 5:36:18 ___
Sinus rhythm. Left atrial abnormality. Left ventricular
hypertrophy. Possible left anterior fascicular block.
Repolarization abnormalities may be due to left ventricular
hypertrophy or ischemia. Clinical correlation is suggested.
Compared to the previous tracing of ___ findings are
similar.
Intervals Axes
RatePRQRSQTQTc (___) ___
___
CT L-SPINE W/O CONTRASTStudy Date of ___ 6:22 ___
IMPRESSION:
Further retropulsion of the posterior superior aspect of the L4
vertebral body with approximately 25% effacement of the ventral
CSF space. Given the symptoms of saddle anesthesia and fecal
incontinence, surgical evaluation is recommended. If concern
for cauda equina signal abnormality, MRI can be obtained.
CT L-Spine without contrast Date: ___
An acute L4 burst fracture is redemonstrated. Retropulsion of
the superior fracture fragment causes substantial but unchanged
spinal canal narrowing. Fracture angulation is unchanged. As
far as can be seen on CT, the epidural space appears clear with
no evidence of epidural hematoma. Marked degenerative disc
disease at L2-3 with disc space narrowing, vacuum phenomenon,
and endplate sclerosis is unchanged. Degenerative spinal
stenosis at L4-5 from posterior disc bulging and ligamentum
flavum hypertrophy is also unchanged. Screws transfixing the
right sacroiliac joint are unchanged.
IMPRESSION:
No interval change in the displacement or angulation of the L4
fracture
fragment, which causes substantial canal narrowing. Although
evaluation of the epidural space is limited on CT, there is no
evidence of epidural
hematoma. If more definitive evaluation is desired, MRI should
be performed.
___ ___
1. Mild loss of normal pancreatic T1 signal could reflect early
sequelae from chronic pancreatitis. No calcifications
demonstrated on recent CT.
2. Prominence of extrahepatic and central intrahepatic bile
ducts without
choledocholithiasis or visualized periampullary mass. Mild
prominence of the main pancreatic duct within the head, without
definite focal stricture. The ducts encircle a medially
projecting second segment duodenal diverticulum. Findings could
represent ampullary stenosis or possibly due to mass effect from
the duodenal diverticulum.
3. No significant peripancreatic stranding or overt parenchymal
edema to
specifically indicate acute pancreatitis. No complications from
pancreatitis are appreciated.
4. Other findings as detailed above.
Brief Hospital Course:
This is a ___ year old female with past medical history of
juvenile polyposis syndrome, pancreatitis, lupus on
prednisone/plaquenil, chronic pain on chronic opiates, admitted
___ w L4 burst fracture, course complicated by abdominal
pain and nausea presumed to be related to her chronic
pancreatitis, improving with conservative management.
# L4 fracture with L4-L5 disc herniation: seen on MRI from
___. ___ with radicular pain shooting down bilateral
legs. Developed numbness in LLE, episodes of fecal incontinence
while urinating (adequate rectal tone, though with poor muscle
twitch on vaval maneuver), difficulty beginning urine stream
(though normal PVRs). The ___ had generalized weakness while
in the hospital ___ throughout with slightly weaker ___
flexion/extension at left knee. Repeat CT L-Spine on ___
showed further retropulsion of the posterior superior aspect of
the L4 vertebral body with approximately 25% effacement of the
ventral CSF space. For management of this unstable lumbar
fracture, Neurosurgery recommended modified bedrest; ___ may
ambulate or sit higher than 10 degrees with brace on; otherwise,
may lie down in bed < 10 degrees and logroll without brace. She
must apply the brace while lying flat before sitting up or
standing. Conservative management was undertaken due the
___ active pancreatitis as well as complicated anatomy
(would need anterior/posterior approach, and operation would be
difficult given prior surgery. Exam remained stable and ___
had a repeat CT Lspine on ___ which was stable. Therefore,
neurosurgery recommended that the ___ continue use of the
brace and follow up in clinic with repeat CT Lspine in 2 weeks.
For pain control, pain mgmt service was consulted. Managed
medically with increase of home Morphine SR (MS ___ to 15 mg
PO Q8H, Gabapentin 300 mg PO/NG TID (refused increasing dose, as
it had not worked previously), and HYDROmorphone (Dilaudid) ___
mg PO/NG Q3H:PRN pain.
#Abdominal pain / Nausea / Vomitting - ___ course
complicated by onset of abdominal pain and nausea worsened with
eating. Given persistance of symptoms in complex ___, she
was seen by GI consult. Symptoms were felt to relate to
exacerbation of her chronic condition (chronic pancreatitis of
uncertain etiology) although gastritis, peptic ulcer disease and
referred pain from back injury were also discussed. ___ of
pancreas showed changes that could be consistent with early
sequelae from chronic pancreatitis. She was able to slowly
increase her diet to tolerate solid food. She was recommended
for close GI follow-up after discharge. Of note ___ also showed
suggestion of ampullary stenosis or possibly due to mass effect
from the duodenal diverticulum, which GI did not feel was
relevant to current presentation and could be followed up as an
outpatient. Throughout the course of her stay, abdominal pain
slowly improved. ___ refused NG or NJ tube for tube feeds.
However, ___ began tolerating small amounts of solid food so
this was deferred. Pain was managed per pain service as above.
# Papular rash over L back: course complicated by new rash at
site of lidocaine patch, thought to represent a contact
dermatitis; improved with conservative management,
triamcinolone, sarna lotion PRN, and benadryl PRN.
# Tick bite: Engorged tick on back on presentation, so ___
received Doxycycline 200mg x1 for lyme ppx upon admission.
# Microscopic hematuria: 10 RBCs on UA (___) -> 8 RBCs on
___. Needs repeat UA at next PCP ___.
# SLE: continued on prednisone and chloroquine
# Juvenile polyposis: Has not seen GI in ___ year and should be
getting regular screening colonoscopy if not undergoing
colectomy. Recommended for appropriate outpt GI follow-up.
# Migraine: on triptan PRN at home; this was held while
in-house, ___ asymptomatic.
# Osteoprosis: continued on calcium and vitamin D while
in-house. Will resume denosumab as outpatient upon discharge.
TRANSITIONAL ISSUES:
- Modified bedrest: ___ may only be out of brace when lying
flat. If >10 degrees, ___ must be wearing brace. She needs
to apply brace while lying flat. With the brace on ___ has
no activity restrictions.
- Follow up with neurosurgery with repeat CT Lumbar spine in 2
weeks
- ___ has Juvenile polyposis and has not seen GI in ___ year
and should be getting regular screening colonoscopy if not
undergoing colectomy. Needs close follow up with outpatient GI
Dr. ___
- ___ had microscopic hematuria with 8 RBCs during
admission. Please repeat UA at next PCP ___.
- ___ chronic pain regimen was augmented significantly
during this visit, and needs to be continued and then
downtitrated appropriately as an outpatient as her symptoms
improve.
-___ needs to continually/slowly augment her diet to ensure
she is getting enough calories.
-___ was provided w/ a supply of Creon after obtaining
insurance approval, and absolutely needs to stay on this
medication for her chronic pancreatitis. Please ensure that she
maintains coverage of this medication.
-___ was inquiring about dose/frequency changes in
Hydroxychloroquin (can be addressed as outpatient)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 5 mg PO DAILY
2. Dextroamphetamine 5 mg PO PRN low energy
3. Gabapentin 300 mg PO DAILY
4. Hydroxychloroquine Sulfate 200 mg PO QOD
5. ammonium lactate 12 % topical ___
6. Denosumab (Prolia) 60 mg SC Q6MONTH
7. Polyethylene Glycol 17 g PO BID
8. Ibuprofen 600 mg PO PRN pain
9. Calcium Carbonate 600 mg PO DAILY
10. eletriptan HBr 40 mg oral daily:pRN headache
11. Vitamin D ___ UNIT PO DAILY
12. Morphine SR (MS ___ 15 mg PO Q12H
Discharge Medications:
1. Creon 12 1 CAP PO TID W/MEALS
RX *lipase-protease-amylase [Creon] 12,000 unit-38,000
unit-60,000 unit 1 capsule(s) by mouth TID w/ meals Disp #*90
Capsule Refills:*3
2. Calcium Carbonate 600 mg PO DAILY
3. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*42 Capsule Refills:*0
4. Hydroxychloroquine Sulfate 200 mg PO QOD
5. Morphine SR (MS ___ 15 mg PO Q8H
RX *morphine 15 mg 1 tablet(s) by mouth Q8 hours as needed for
pain Disp #*15 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO BID
7. PredniSONE 5 mg PO DAILY
8. Vitamin D ___ UNIT PO DAILY
9. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth Q3 hours prn: pain
Disp #*120 Tablet Refills:*0
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 40 mg PO DAILY
RX *omeprazole 20 mg 2 tablet(s) by mouth daily Disp #*28 Tablet
Refills:*0
12. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID
Do not use for longer than 2 weeks. Do not apply to skin folds
or face
RX *triamcinolone acetonide 0.1 % apply small amount to rash TID
as needed for itching Refills:*0
13. Denosumab (Prolia) 60 mg SC Q6MONTH
14. eletriptan HBr 40 mg oral daily:pRN headache
15. Ibuprofen 600 mg PO PRN pain
16. ammonium lactate 12 % topical ___
17. Ondansetron 4 mg PO TID W/MEALS
RX *ondansetron 4 mg 1 tablet(s) by mouth TID prior to meals
prn: nausea Disp #*42 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
- Chronic Pancreatitis
- L4 burst fracture
- L4-L5 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:
Dear Ms. ___,
It was a pleasure to take care of you at ___
___. You were admitted with nausea, vomiting,
abdominal pain and back pain. You were found to have a burst
fracture of L4 in your spine. You were seen by neurosurgery who
recommended conservative management with an LSO brace at all
times when you are not lying flat. This brace must be applied
while you are lying flat as you have been doing in the hospital.
You will follow up with neurosurgery (spine) in 2 weeks with a
repeat CT scan of your lumbar spine at that time. While
inpatient you has nausea and vomiting which was thought to be a
flare of your chronic pancreatitis. You were started on zofran
prior to meals and an acid blocking medication called
omeprazole. You had an ___ to look more closely at your
pancreas which showed changes that could be consistent with your
chronic pancreatitis. You should continue to follow up with your
outpatient gastroenterologist about this. You were able to
slowly increase your intake to tolerate solid food and you
should continue doing this once you leave the hospital.
We expect that you will be able to slowly improve your intake of
food over time. Please call your physician if you are unable to
tolerate any intake of food or fluids. Please call or return to
the emergency room if you develop any significant weakness in
your lower extremities, significant change in numbness, or any
bowel or bladder incontinence.
We wish you the best!
Sincerely,
Your ___ medical team
Followup Instructions:
___
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2176-02-19 11:43:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Macrobid
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
___ y/o F with PMH of CAD s/p CABG (last EF 45% in ___, HTN,
and hyperlipidemia presents with one day hx of chest pain. ___
mid-sternal chest tightness/discomfort that radiates down left
arm. Took nitro and aspirin with reported relief. Intermittent
pain continued morning of admission, took aspirin and called EMS
asking to be brought in. Patient denies
sob/palpitations/diaphoresis. No f/c.
In the ED, initial vitals were: 97.7 72 149/78 18 100% RA. Labs
were significant for grossly normal cbc, bmp, Trop-T <0.01, u/a
unremarkable. Imaging revealed EKG with new LBBB compared to
prior from ___ years ago. The patient was given IV heparin and IV
nitro drips, atorva 80. Vitals prior to transfer were: 97.4 68
148/61 20 97% RA. Upon arrival to the floor, patient reports
some continued mid sternal discomfort, improved from prior.
Past Medical History:
Past Medical History:
Cardiac Risk Factors: - Diabetes, + Dyslipidemia, + Hypertension
.
Cardiac History:
___: CABG (grafts to LAD, RCA)
- Coronary artery bypass grafting times 2, left internal mammary
artery graft, left anterior descending reverse saphenous vein
graft to right coronary artery.
___: PTCA of LAD, diagonal and Cx OM.
___: stent to proximal Cx
___: NQWMI
___: stent to mid LAD (EF 61%, pLAD 50%, Cx without
significant disease, RCA with moderate disease)
.
Other past medical history
Hypertension
Hemiarthroplasty on right
Peripheral neuropathy
Chronic UTIs
History of macrobid-induced lung injury
- CT w/ bilateral pulmonary infiltrates
- mild restrictive deficit
Hiatal hernia
GERD
Back surgery ___
History of intermitted hyponatremia
Social History:
___
Family History:
Family History: One brother with stents in his ___, another
brother with CABG in his ___, two sisters with CABG's: one in
her ___ and
the other in her ___
Physical Exam:
PHYSICAL EXAM on ADMISSION:
Vitals: 97.5 151/70 61 18 98 RA 52.5 kg
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP 2 cm above clavicle at 30 degrees
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur
Lungs: trace crackles at bases with good air movement
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding
GU: foley
Ext: Warm, well perfused, 2+ pulses, trace ankle edema
Neuro: cn ___ grossly intact, moving all extremities
PHYSICAL EXAM on DISCHARGE:
Vitals: Tm 98.8 BP 110s-150s/50s-80s P ___ R ___ SatO2
98-100/RA
GENERAL: lying in bed in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP 3 cm above clavicle.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. ___ systolic murmur. No thrills, lifts.
No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: trace edema bilaterally, no cyanosis.
Pertinent Results:
LABS on ADMISSION:
___ 12:00PM BLOOD WBC-5.1 RBC-3.76* Hgb-11.1* Hct-34.5
MCV-92# MCH-29.5 MCHC-32.2 RDW-13.8 RDWSD-46.7* Plt ___
___ 08:00PM BLOOD ___ PTT-150* ___
___ 12:00PM BLOOD Glucose-90 UreaN-14 Creat-0.8 Na-133
K-4.6 Cl-95* HCO3-25 AnGap-18
___ 02:40AM BLOOD Calcium-9.2 Phos-4.1 Mg-1.5*
___ 12:00PM BLOOD cTropnT-<0.01
___ 02:40AM BLOOD cTropnT-<0.01
LABS on DISCHARGE:
___ 07:05AM BLOOD WBC-5.3 RBC-3.67* Hgb-11.0* Hct-32.9*
MCV-90 MCH-30.0 MCHC-33.4 RDW-13.6 RDWSD-44.7 Plt ___
___ 07:05AM BLOOD ___ PTT-30.9 ___
___ 07:05AM BLOOD Glucose-84 UreaN-11 Creat-0.7 Na-130*
K-4.3 Cl-95* HCO3-24 AnGap-15
___ 07:05AM BLOOD Calcium-9.4 Phos-3.7 Mg-1.6
PERTINENT STUDIES:
- cardiac cath (___):
left dominant LCX patent with 40% ramus stenosis
LAD occluded
RCA with 90% proximal and non-dominant
SVG-RCA patent
LIMA-LAD patent with 50% stenosis in LAD distal to touchdown
with bridge
recommendation: medical therapy; stress test in ___ weeks
Brief Hospital Course:
Ms. ___ has a history of CAD s/p CABG (last EF 45% in ___,
HTN, and hyperlipidemia p/w cp c/f unstable angina.
ACUTE ISSUE:
# S/p cardiac cath: Patient had cath ___, with no stents
placed. - cardiac cath (___): left dominant LCX patent with
40% ramus stenosis, LAD occluded, RCA with 90% proximal and
non-dominant, SVG-RCA patent, LIMA-LAD patent with 50% stenosis
in LAD distal to touchdown with bridge, recommendation: medical
therapy; stress test in ___ weeks.
CHRONIC ISSUES:
# CAD: on aspirin, statin
# CHF: last EF 45% in ___ on home beta-blocker, lisinopril
# HTN: home Acei and bb per above
# Chronic UTI: u/a without signs of infection. Trended.
# Neuropathy: home gabapentin
# GERD: home omeprazole
TRANSITIONAL ISSUES:
- Please follow up with cardiologist regarding if need to start
nitrate (imdur). She was given 10 mg of short acting nitrate,
however, had a 30 point drop in SBP to 100s systolic. Could
consider decreasing other BP meds in favors for a nitrate.
- Stress test in ___ weeks (discuss with cardiologist)
- Please follow up with PCP.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral DAILY
2. cranberry (cranberry conc-ascorbic acid;<br>cranberry
extract) 250 mg oral unknown
3. Docusate Sodium 100 mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. Gabapentin 300 mg PO TID
6. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
7. Lisinopril 10 mg PO DAILY
8. Nadolol 40 mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Simvastatin 80 mg PO QPM
11. Zolpidem Tartrate 10 mg PO QHS
12. Aspirin 81 mg PO DAILY
13. Bisacodyl 10 mg PO DAILY:PRN constipation
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Lisinopril 10 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 300 mg PO TID
5. Multivitamins 1 TAB PO DAILY
6. Nadolol 40 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Simvastatin 80 mg PO QPM
9. Bisacodyl 10 mg PO DAILY:PRN constipation
10. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral DAILY
11. cranberry (cranberry conc-ascorbic acid;<br>cranberry
extract) 250 mg oral unknown
12. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
13. Zolpidem Tartrate 5 mg PO QHS
RX *zolpidem [Ambien] 5 mg 1 tablet(s) by mouth at bedtime Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Coronary artery disease
Secondary Diagnoses:
Diabetes Mellitus II
Hypertension
Dyslipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
because you had chest pain. You had a cardiac cath, which showed
multi-vessel disease, but no stenting was placed. Instead, you
will be receiving medications.
We wish you the best,
Your ___ team
Followup Instructions:
___
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10684347-DS-18
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2177-01-12 22:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Macrobid
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
___ with history of CAD s/p CABG, HTN, MDR UTI (E. coli in ___
with chronic dysuria, and bilateral THA presenting s/p fall at
home 2 weeks prior with head trauma (goose egg) and R hip and L
knee pain resulting. She did not receive medical care
immediately after the fall. She presents today at her children's
insistence because of increased difficulty ambulating at home,
with shuffling gait, dragging of her left foot, and complaints
of right hip pain. He denies LOC, dizziness, headache, visual
changes, nausea/vomiting, or confusion following the fall. She
also denies CP, SOB, palpitations or pre-syncopal symptoms prior
to the fall. In the ED, she endorses pain in both hips L>R, left
knee pain, and burning with urination and generally in the
vaginal area. She denies headache, CP, dizziness SOB,
palpiations, nausea, vomiting, abdominal pain or diarrhea.
Of note, pt on opioid pain medication and zolpidem for sleep, so
polypharmacy may be contributing factor to instability. She has
fallen at least 2x before (resulting in hip fracture and
replacements)
Past Medical History:
Past Medical History:
Cardiac Risk Factors: - Diabetes, + Dyslipidemia, + Hypertension
.
Cardiac History:
___: CABG (grafts to LAD, RCA)
- Coronary artery bypass grafting times 2, left internal mammary
artery graft, left anterior descending reverse saphenous vein
graft to right coronary artery.
___: PTCA of LAD, diagonal and Cx OM.
___: stent to proximal Cx
___: NQWMI
___: stent to mid LAD (EF 61%, pLAD 50%, Cx without
significant disease, RCA with moderate disease)
.
Other past medical history
Hypertension
Hemiarthroplasty on right
Peripheral neuropathy
Chronic UTIs
History of macrobid-induced lung injury
- CT w/ bilateral pulmonary infiltrates
- mild restrictive deficit
Hiatal hernia
GERD
Back surgery ___
History of intermitted hyponatremia
Social History:
___
Family History:
Family History: One brother with stents in his ___, another
brother with CABG in his ___, two sisters with CABG's: one in
her ___ and
the other in her ___
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: 97.8 PO 148 / 81 81 20 96 RA
Gen: Frail appearing woman, conversational, in no acute
distress
HEENT: Sclera anicteric, moist mucus membranes
CV: ___ systolic murmur, normal S1S2, RRR
Pulm: Clear bilaterally to auscultation
Abd: Soft, non-tender, non-distended
GU: No foley
Ext: Large ecchymoses below the L knee. Right hip: tenderness to
palpation over right greater trochanter, pain with internal and
external rotation of right hip. No pain with ext/int rotation of
left hip. No visible hematomas.
___ dorsi/plantar flexion on right, ___ dorsi/plantar
flexion on left
Vaginal: Skin without erythema or lesions, no rash apparent
DISCHARGE EXAM
=======================
VS: 98.1 ___
Gen: Frail appearing woman, conversational, in no acute
distress
HEENT: Sclera anicteric, moist mucus membranes
CV: ___ systolic murmur, normal S1S2, RRR
Pulm: Clear bilaterally to auscultation
Abd: Soft, non-tender, non-distended
GU: No foley
Ext: Large ecchymoses below the L knee. Right hip: tenderness to
palpation over right greater trochanter, pain with internal and
external rotation of right hip. No pain with ext/int rotation of
left hip. No visible hematomas.
___ dorsi/plantar flexion on right, ___ dorsi/plantar
flexion on left
Pertinent Results:
ADMISSION LABS
============================
___ 02:05PM BLOOD WBC-6.5 RBC-3.53* Hgb-10.9* Hct-33.8*
MCV-96 MCH-30.9 MCHC-32.2 RDW-13.0 RDWSD-45.1 Plt ___
___ 02:05PM BLOOD Neuts-60.2 ___ Monos-10.0 Eos-2.0
Baso-0.6 Im ___ AbsNeut-3.91 AbsLymp-1.73 AbsMono-0.65
AbsEos-0.13 AbsBaso-0.04
___ 02:05PM BLOOD Glucose-100 UreaN-15 Creat-0.7 Na-130*
K-5.2* Cl-96 HCO3-21* AnGap-18
DISCHARGE LABS
=============================
___ 07:45AM BLOOD WBC-4.6 RBC-3.25* Hgb-10.0* Hct-30.5*
MCV-94 MCH-30.8 MCHC-32.8 RDW-12.7 RDWSD-43.8 Plt ___
___ 07:45AM BLOOD Glucose-91 UreaN-13 Creat-0.6 Na-130*
K-3.9 Cl-92* HCO3-25 AnGap-17
IMAGING
=============================
X-ray bilateral hip ___ IMPRESSION: Unchanged appearance of
bilateral hip prostheses without evidence of acute
superimposed fracture, dislocation or loosening.
The acetabular cup of the right prosthesis is positioned more
axial relative
to the left, more pronounced from ___ with associated
remodeling of
the native acetabulum. Clinical correlation is requested.
Minimal lucency along the medial proximal left femoral
component is unchanged
compared with ___ and could represent background osteopenia
rather than
periprosthetic loosening.
No pubic ramus fracture is detected. No displaced fracture is
detected about
the pelvic girdle. SI joint degenerative changes again noted.
CT head w/o contrast ___ IMPRESSION:
1. Study is mildly degraded by motion.
2. No acute intracranial abnormality.
3. No evidence acute intracranial hemorrhage or fracture.
CT c-spine w/o contrast ___ IMPRESSION:
No acute fracture or change in alignment. Degenerative changes
similar to
prior exam.
X-ray ankle ___ IMPRESSION: No fracture or dislocation.
X-ray knee ___ IMPRESSION: No fracture or dislocation.
X-ray tib/fib ___ IMPRESSION: No fracture or dislocation.
Brief Hospital Course:
___ with history of CAD s/p CABG, HTN, MDR UTI (E. coli in ___
with chronic dysuria, and bilateral THA presenting s/p fall at
home 2 weeks prior with head trauma (goose egg) and R hip and L
knee pain resulting. She had CT head imaging that showed no
acute bleed, as well as x-rays that showed no fracture or
dislocation. She was found to have hyponatremia to 130. She was
evaluated by our physical therapists who recommended home
physical therapy.
ACTIVE ISSUES:
==========================
S/P fall: Imaging was reassuring against fracture of the
extremities or acute intracranial process. Patient has fallen
before, and falls were the precipitating factor in both of her
previous hip replacements. For this episode, history is
consistent with mechanical fall, given patient's lack of
dizziness, lightheadedness, palpitations. Orthostatics were
negative. Patient takes vicodin, zolpidem at home. ___ saw the
patient and determined her toe be stable for return to home with
home ___.
Hyponatremia: 130, previously at 139 in ___. Has history of
"intermittent hyponatremia" during previous hospitalizations.
Possibly in the setting of poor PO intake. Patient without
symptoms of nausea or confusion.
Hyperkalemia: Potassium at 5.2, at 4.0 in ___. Renal function
currently at baseline. K trended down to 3.9.
Dysuria: Negative UA in ED reassuring against UTI. Patient last
had documented UTI in ___ with E.coli (resistant to ampicillin,
gentamicin, Bactrim) but has had chronic dysuria and vaginal
itching and burning since then. Patient does not have apparent
fungal infection or cellulitis in the groin. Pyridium was given
for dysuria.
CHRONIC ISSUES:
==========================
# CAD: Continuednadolol
# Neuropathy: continued gabapentin, vicodin, Tylenol PRN
# HTN: Held home Lisinopril in the setting of hyperkalemia
***Transitional issues***:
- Patient on 10 mg of ambien at home, which is above the
recommended limit per our pharmacy. Since she slept well on 5 mg
in-house, she was discharged on 5 mg.
- based on renal clearance, patient's gabapentin regimen was
decreased to 300 mg BID.
- Would continue to address pain regimen of narcotics and
gabapentin that could be contributing to unsteadiness.
- hyponatremia: 130, urine lytes suggested SIADH which could
have been in the setting of pain or poor PO intake. Should have
lytes rechecked at next PCP ___.
FULL CODE
Contact: ___ (daughter)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Bisacodyl 5 mg PO DAILY:PRN constipation
3. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral ONCE
4. cranberry extract ___ mg oral DAILY
5. Docusate Sodium 100 mg PO BID
6. Multivitamins 1 TAB PO DAILY
7. Estrogens Conjugated 1 gm VG DAILY
8. Gabapentin 300 mg PO TID
9. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain -
Moderate
10. Lisinopril 10 mg PO DAILY
11. Nadolol 40 mg PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
Discharge Medications:
1. Gabapentin 300 mg PO BID
2. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 5 mg PO DAILY:PRN constipation
5. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral ONCE
6. cranberry extract ___ mg oral DAILY
7. Docusate Sodium 100 mg PO BID
8. Estrogens Conjugated 1 gm VG DAILY
9. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain
- Moderate
10. Lisinopril 10 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Nadolol 40 mg PO DAILY
13. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Unsteadiness
Hyponatremia
Secondary diagnoses:
Osteoarthritis
HTN
CAD s/p CABG
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 ___,
___ were admitted to the hospital after a fall because there was
concern for your steadiness on your feet. ___ were evaluated
with imaging studies that showed no fractures or acute head
injuries. ___ had bloodwork that showed that ___ currently have
a low sodium level, which should be followed up in the
outpatient setting. Please continue with physical therapy at
home.
It was a pleasure taking care of ___ and we wish ___ the best!
Sincerely,
Your ___ team
Followup Instructions:
___
|
10684430-DS-11
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2162-09-02 00:00:00
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2162-09-03 15:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Diabetic foot ulcer or right toe
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a PMH of DM complicated by neuropathy, HTN, HL,
Alzheimers who presents to the ED as a referral from his PCP at
___ for increased swelling, redness and
ulceration/blistering to his right big toe. Patient was seen at
___ yesterday and started on bactrim and
augmentin PO BID. He was additionally given ceftriaxone 1gm IM
daily (yesterday and today). WBC at clinic yesterday was 13.3,
today on admission is 9.3. Denies fevers/chills. He does not
remember how long the swelling, redness and blister have been
there. He denies pedal pain, denies n/v. Relates he has scabs
all over both lower legs ___ chronic itching. No other
complaints.
.
In the ED, VS 96.2 82 109/57 16 100%. WBC 9.3, N 63.6%. Hct 34.6
(baseline 38). Blood cultures drawn. Given vancomycin 1g and
ciprofloxacin 500mg. Right foot xray showed no osteo or soft
tissue swelling, no SC air. Admitted for antibiotic treatment
and monitoring, as there is concern that patient is able to
stick to outpatient antibiotic regimen.
.
On the floor, patient is comfortable without complaints. Cannot
feel his feet well, denies any pain, fevers, chills. Memory
deficits, A&Ox2 (doesn't know month, year).
Past Medical History:
DM c/b neuropathy
obesity
hypertension
dementia/alzheimers
hyperlipidemia
PSx: R ___ digit amputation
Social History:
___
Family History:
Per ___ Notes- Mother and Father with Alzheimers,
Paternal Uncle with diabetes
Physical Exam:
Admission Exam:
Vitals: T:97.9 BP: 125/65 P: 78 R: 18 O2: 98%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,
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: 0.7 x 0.5 x 0.1 cm to plantar aspect of right hallux. No
purulence, no drainage.
Neuro: A&Ox1, pleasantly demented, significant sensory deficits
of the feet bilaterally, moving all extremities
Discharge Exam:
Vitals: Tc/m:98.0 BP: 109/68 (109-125/55-68) P: 76 (70s) R: 18
O2: 97%RA
___ 120
General: Alert/oriented, no acute distress, resting comfortable
in bed
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
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: 0.7 x 0.5 x 0.1 cm to plantar aspect of right hallux,
erythema dorsally surrounding nail, lateral aspect of nail
missing. No purulence, no drainage. Multiple scabbed
exoriations over shins, elbows, hands
Neuro: A&Ox1, pleasantly demented, significant sensory deficits
of the feet bilaterally, moving all extremities
Pertinent Results:
Admission Labs:
___ 04:32PM BLOOD WBC-9.3 RBC-4.17* Hgb-12.3* Hct-34.6*
MCV-83 MCH-29.4 MCHC-35.4* RDW-13.5 Plt ___
___ 04:32PM BLOOD Neuts-63.6 ___ Monos-5.1 Eos-6.9*
Baso-0.6
___ 04:32PM BLOOD ___ PTT-36.5 ___
___ 04:32PM BLOOD Glucose-126* UreaN-23* Creat-1.2 Na-135
K-5.0 Cl-101 HCO3-24 AnGap-15
___ 04:46PM BLOOD Lactate-1.8
Discharge Labs:
___ 07:35AM BLOOD WBC-7.5 RBC-4.13* Hgb-12.3* Hct-34.1*
MCV-83 MCH-29.7 MCHC-36.0* RDW-13.4 Plt ___
___ 07:35AM BLOOD Glucose-105* UreaN-16 Creat-1.0 Na-136
K-4.4 Cl-101 HCO3-26 AnGap-13
___ 07:35AM BLOOD Calcium-9.2 Phos-4.1 Mg-2.1
Micro: ___ blood cultures x2: no growth on discharge
Imaging:
___ xray right foot: (prelim read) AP, lateral, and oblique
views of the right foot. No prior. Postoperative changes of
fifth phalanx amputation and osteotomy of the distal fifth
metatarsal are noted. There is no visualized fracture. Posterior
and inferior calcaneal spurs noted. Os trigonum also noted.
Mineralization of the bones is unremarkable without suspicious
lucency. No definite soft tissue swelling, subcutaneous gas or
radiopaque foreign body identified. IMPRESSION: No definite
radiographic evidence of osteomyelitis.
Brief Hospital Course:
___ with a PMH significant for DM complicated by neuropathy who
was admitted for persistent superficial toe ulcer, improving on
oral antibiotics.
.
# Diabetic Foot Ulcer, plantar surface right hallux: Likely
caused by repeated trauma secondary to diabetic neuropathy, as
patient has minimal feeling of his feet bilaterally. Wagners
diabetic wound classification of grade 1 (superficial). Podiatry
was consulted in the ED and requested admission to medicine for
monitoring and treatment of cellulitis. Xray of foot report
showed no osteomyelitis or soft tissue swelling. Afebrile, WBC
within normal limits (9.3 on admission to 7.5 the following day
on discharge), lactate remained within normal limits. WBC at
clinic the day prior to admission on ___ was 13.3, when patient
started treatment with bactrim and augmentin, and ceftriaxone
1gm IM. Per clinic notes, cellulitis was improving on this
antibiotic regimen. This time around, patient received IV vanc
and cipro 500mg in ED. Borders of the cellulitis were marked.
Given rapid improving cellulitis, patient was continued on his
outpatient oral antibiotic regimen of bactrim and augmentin for
a total of a 10day course (___). Podiatry recommended
saline or diluted betadine wet to dry dressings daily for which
patient was assigned a ___.
.
# Diabetes: ___ HgbA1c was 7.5% (improved from 9.5% on
___. Held metformin/glimepiride and patient was maintained
on lantus and HISS. Aspirin and lisinopril were continued.
Family expressed concern about the patient's self-management of
his diabetes, given his progressing dementia. The patient was
willing to allow his wife to assume the responsibility of his
diabetic regimen. His wife was trained with the nurse on insulin
administration and felt comfortable with this.
.
# Anemia: On admission patient had a hct of 34.1 (baseline
around 38-40). MCV 83. Patient had no evidence of bleeding. It
is possible that his decreased hct was due to myelosuppression
from infection or antibiotics. Hct was trended and remained
stable over admission.
.
# Excoriations on shins, elbows, hands: Family is concerned that
patient continues to scratch and pick at his skin. There was no
indication for a dermatology consult, despite families request
for it. Patient has bee set up with an outpatient dermatology
consult in the upcoming months. Mr. ___ appears to be
subconsciously picking at his skin for unclear reasons. Despite
being told by his family to stop, he has Alzheimers and a very
short term memory. Mupirocin was applied to lesions to prevent
infection and it was recommended that Mr. ___ where long
sleeve shirts and pants to prevent self-injury.
.
# Hypertension: Continued lisinopril, BP remained well
controlled during admission.
.
# Hypercholesterolemia: Continued atorvastatin.
.
# BPH: Continued finasteride, tamsulosin.
.
# Dementia: Continued donepezil Qhs.
Transitional Issues:
___ blood cultures pending on discharge
Patient has PCP ___ clinic) and podiatry follow up.
CONTACT: ___ - wife Phone: cell ___, Alternate
Name: ___ daughter Phone: ___. ___ (daughter in law) ___, home
___ ___ and ___
___ on Admission:
Ceftriaxone (ROCEPHIN) 1 gram IM (given ___
Sulfamethoxazole-Trimethoprim 800-160 mg Tablet BID for 10 days
(started ___
Amoxicillin-Pot Clavulanate 875-125 mg Oral Tablet Take 1 tablet
every 12 hours for 10 days (started ___
Insulin Glargine (LANTUS) 100 unit/mL Subcutaneous Solution 40
units once in evening
Donepezil (ARICEPT) 10 mg Oral Tablet 1 po qd
Atorvastatin 80 mg Oral Tablet take one tablet daily
Tamsulosin (FLOMAX) 0.4 mg Oral Capsule, Ext Release 24 hr 1
tablet daily 30 minutes after breakfast
Finasteride (PROSCAR) 5 mg Oral Tablet 1 tablet daily
Aspirin 81 mg Oral Tablet None Entered
Lisinopril 5 mg Oral Tablet Take 1 tablet daily for blood
pressure and protecting the kidneys in diabetes
Glimepiride 2 mg Oral Tablet Take 1 tablet daily with breakfast
for diabetes
Metformin 1,000 mg Oral Tablet 1 TAB BID
MULTIVITAMIN CAPSULE PO (MULTIVITAMINS) 1 po qd
Discharge Medications:
1. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: Two (2)
Tablet PO BID (2 times a day) for 8 days: Take until ___.
Disp:*32 Tablet(s)* Refills:*0*
2. Augmentin XR 1,000-62.5 mg Tablet Extended Release 12 hr Sig:
Two (2) Tablet Extended Release 12 hr PO every twelve (12) hours
for 8 days: Take until ___.
Disp:*32 Tablet Extended Release 12 hr(s)* Refills:*0*
3. donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
6. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. mupirocin calcium 2 % Cream Sig: One (1) Appl Topical BID (2
times a day): Apply to open skin wounds.
Disp:*1 tube* Refills:*0*
11. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
12. glimepiride 2 mg Tablet Sig: One (1) Tablet PO once a day.
13. Lantus 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous at bedtime.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
cellulitis
diabetic foot ulcer
Secondary:
DM type II
Alzheimer's dementia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you in the hospital. You were
admitted with cellulitis and a foot ulcer. You were treated
wtih oral antibiotics and did well. You will be going home to
complete a ten day course of antibiotics. A visiting nurse ___
help care for your wounds. Please follow up with your PCP and
podiatry (see appointments below).
The following medications were added:
1) Bactrim Double Strength Tab; take 2 tabs twice daily until
___
2) Augmentin Extended Release 1000mg; take 2 tabs twice daily
until ___
3) Mupirocin cream; apply twice daily to open skin areas
Followup Instructions:
___
|
10684908-DS-6
| 10,684,908 | 22,957,648 |
DS
| 6 |
2134-03-16 00:00:00
|
2134-03-19 20:00:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
rectal pain
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ ___ speaking patient with hx chronic perirectal
wound, morbid obesity, hydradenitis suppurativa, eczema who
presents with worsening of his chronic perirectal wound.
Patient has hx of infections to his perianal area due to severe
excoriations secondary to eczema. ___ years ago, he underwent
debridement and STSG graft of perianal area at ___. At that time
he was hospitalized for ___ months for management and recovery
from perianal skin breakdown and infection. He states that they
had performed biopsies but does not recall the results. He has
since had poor follow-up regarding this wound. However he has
continued to use Betamethasone topical cream. He notes that his
insurance no longer gives him coverage at ___. He has had
continued drainage from his perirectal area for the past ___ years
requiring him to wear a small towel at all times. Over the past
5 months he has had worsening purulent drainage. Denies recent
fevers or chills. Given his job has a ___ and his
continued concern for poor wound healing, he
presented to his PCP for further evaluation and was subsequently
referred to the ED.
In the ED, initial vital signs were: 97.0 103 166/66 18 97% RA
- Labs were notable for: WBC 8.1, Hgb 12.1 (MCV 71), normal
chem.
- Imaging: CT Pelvis showing "Skin thickening, irregular with
apparent mass in the left upper thigh abutting the anus. No
fluid collection or extension into the pelvis. Differential
considerations include neoplasm and clinical correlation/biopsy
recommended. No pelvic sidewall adenopathy. No inguinal
adenopathy."
- The patient was given:
___ 16:39 IV Piperacillin-Tazobactam 4.5 g
___ 16:39 IVF 1000 mL NS @ 250/hour
___ 17:40 IV Vancomycin 1000 mg
- Consults: Surgery: Recommended exam under anesthesia, but
patient refusing. They discovered "A large ulcerated fungating
mass... at the right anterior perianal region." Surgery writes
in their note: "There is currently no evidence of erythema,
purulent drainage, or infection. He is not acutely ill.
Therefore, there is no
indication for inpatient admission." They recommend outpatient
workup including punch biopsies via Colorectal Surgery.
On my discussion with ED resident, ED attending disagreed with
the surgical assessment above and felt that, due to pain and
signs of local infection, the patient would benefit from
admission for further dx and tx, and initiation of abx for
cellulitis.
Vitals prior to transfer were: 98 87 164/79 16 97% RA.
Upon arrival to the floor, patient reports significant rectal
pain, particularly with hard bowel movements and with cleaning
after a BM. He has lost 5# 270->265 cannot say over how long. He
notes that he was doing very well after his surgery, but began
to develop itchiness and skin breakdown after he returned to his
work as a ___.
Denies f/c, HA, chest pain, dyspnea, abdominal pain, n/v.
Past Medical History:
-- chronic perirectal wound
-- hydradenitis suppurativa
-- HTN
-- hemoglobinopathy
-- AFib
-- morbid obesity
-- eczema
-- hypothyroidism s/p thyroidectomy
Social History:
___
Family History:
Deferred
Physical Exam:
ADMISSION EXAM:
===============
VITALS: 98 87 164/79 16 97% RA.
Genl: well appearing NAD
HEENT: no icterus, MMM, no OP lesions
Neck: no LAD
Cor: RRR NMRG
Pulm: CTAB
Abd: soft ntnd
MSK: extr wwp with dry skin and 1+ symmetric pitting edema
Neuro: AOX3
Skin: the gluteal cleft is notable for indurated, chronically
scarred appearing skin. This is erythematous and, in the area of
the rectum, appears to be ulcerated. There is no malodor or
drainage. The location of the anus is not apparent.
DISCHARGE EXAM
===============
VS: 98.6 143/73 (143-168/60-73) ___ 17 98%RA
Genl: well appearing, NAD
CV: rrr, s1 s2, no mgr
Pulm: ctabl
Abd: +BS, soft, ntnd
MSK: wwp, no b/l ___ edema
Neuro: AAox3
Skin: gluteal cleft w/indurated, chronically scarred,
erythematous, lower rectal ulceration. no active purulence
though some bleeding.
Pertinent Results:
ADMIT LABS
========
___ 03:32PM BLOOD WBC-8.1 RBC-5.19 Hgb-12.1*# Hct-36.9*#
MCV-71*# MCH-23.3*# MCHC-32.8 RDW-14.9 RDWSD-37.4 Plt ___
___ 03:32PM BLOOD Neuts-67.1 Lymphs-15.6* Monos-13.7*
Eos-1.9 Baso-1.1* Im ___ AbsNeut-5.44 AbsLymp-1.26
AbsMono-1.11* AbsEos-0.15 AbsBaso-0.09*
___ 03:32PM BLOOD ___ PTT-29.0 ___
___ 03:32PM BLOOD Glucose-89 UreaN-8 Creat-0.8 Na-135 K-3.5
Cl-101 HCO3-27 AnGap-11
___ 04:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
MICRO/IMAGING
==========
___ Imaging CT PELVIS W/CONTRAST
Superficial irregular soft tissue mass arising from the left
upper thigh posteromedially with adjacent skin thickening in the
perianal region structure arising from the upper thigh in the
perianal region is concerning for malignancy. Clinical
correlation and biopsy recommended
Blood Cultures x2 (___): NGTD
DISCHARGE LABS
===========
___ 07:00AM BLOOD WBC-7.0 RBC-5.02 Hgb-11.8* Hct-36.0*
MCV-72* MCH-23.5* MCHC-32.8 RDW-15.3 RDWSD-38.7 Plt ___
___ 07:00AM BLOOD Glucose-82 UreaN-10 Creat-0.9 Na-139
K-4.1 Cl-100 HCO3-28 AnGap-15
___ 07:00AM BLOOD Calcium-9.4 Phos-4.6* Mg-2.0 Iron-36*
___ 07:00AM BLOOD calTIBC-215* Ferritn-376 TRF-165*
Brief Hospital Course:
___ w/hx of chronic perirectal wound, morbid obesity,
hydradenitis suppurativa, eczema who p/w worsening of his
chronic perirectal wound, was started on Vanc/Zosyn with c/f
cellulitis, found to have large Lt perianal mass, evaluated by
surgery in the ED though refused exam under anesthesia, admitted
for further w/u of the mass. Abx held on admission as wound not
thought to be infected, colorectal surgery evaluated pt, was
concerned for SCC, want to biopsy as outpatient.
ACTIVE
======================
# Perirectal wound/Perianal mass:
Pt with fungating mass on evaluation and imaging c/f malignancy.
Infxn thought to be less likely as wound appears chronic, pt w/o
current fevers or leukocytosis. Pt w/mild weight loss, decrease
in appetite, poor medical f/u. Surgical evaluation in the ED was
less c/f cellulitis and recommended against admission, though
enough concern in the ED that he was started on Cef/Vanc and
admitted for cellulitis. Initially refused evaluation under
anesthesia in the ED, though now that pt admitted, agreed to
colorectal surgical evaluation, which was very concerning for
___. Initially hesitant to accept that mass was cancerous,
however after further discussion w/pt, revealed that was worried
and agreed to f/u with Colorectal surgery as outpatient. No
further Abx were given. Wound care was consulted, gave pt recs
and equipment to better deal with chronic issue. SW also
consulted, assisted in dealing with pt's occupational issues.
CHRONIC
===============
# HTN: continued home atenolol, lisinopril, nifedipine CR
# Hypothyroidism: continued home levothyroxine
# Vitamins: continue home Vit D
TRANSITIONAL ISSUES
====================
-Pt has perianal mass c/f malignancy, evaluated by colorectal
surg, exceeding concern for ___. When evaluated by colorectal
surg after admission, would not believe that he has actual
malignancy, though after further discussion with patient, was
agreeable to continue further w/u for biopsy/possible
interventions
-consider derm outpatient for chronic hydradenitis suppurativa
# CONTACT: ___ (wife) ___
# CODE STATUS: FULL (confirmed)
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
2. Atenolol 50 mg PO DAILY
3. Levothyroxine Sodium 150 mcg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. NIFEdipine CR 30 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Atenolol 50 mg PO DAILY
2. Levothyroxine Sodium 150 mcg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. NIFEdipine CR 30 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Psyllium Powder 1 PKT PO DAILY constipation
RX *psyllium husk (aspartame) [Natural Fiber Supplement] 3.4
gram 1 powder(s) by mouth daily Disp #*54 Packet Refills:*0
7. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
8. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
do not drive while on this medication
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
========
hydradenitis suppurativa
rectal mass concern for malignancy
SECONDARY:
==========
HTN
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to ___ after you were found to have skin
breakdown and rectal issues. There was a concern that your
rectal area could be infected, but after admission it did not
appear to be infected. A CT scan was done which showed that
there could be a mass. Our surgeons evaluated you and thought
that the mass was very concerning for cancer. They would like to
see you in their clinic so that they can schedule a biopsy and
appropriately treat the mass.
It was a pleasure taking care of you!
Your ___ Team
Followup Instructions:
___
|
10685006-DS-18
| 10,685,006 | 29,974,491 |
DS
| 18 |
2121-05-25 00:00:00
|
2121-05-25 17:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / Bactrim / Bactrim
Attending: ___.
Chief Complaint:
right occipiatl hemorrhage
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ yo F hx recent Right Pcomm aneurysm Pipeline embolization
with several days of headache and left eye visual symptoms. Pt
developed HA with left eye symptoms of "zig zags" on ___.
Since
that time her HA has persisted and her vision complaint has
changed to what she describes as double vision. She was seen by
an outside neuro ophthalmologist who recommended outpatient MRI
for concern for stroke in the setting of Left inferior
homonymous
quadrantopia however when the patient spoke with our
neurosurgery
office today we referred her for urgent evaluation in the ED.
She continues to take ASA 325mg and Plavix 75mg daily. Headache
is constant and right sided.
Past Medical History:
___ Pipeline embolization Right Pcomm aneurysm
___ Pipeline embolization Left paraclinoid aneurysm
Crani for aneurysm clip ___ after SAH
Depression
Former smoker
Bladder susp ___
Neg stress/echo post pluritic CP
Social History:
___
Family History:
NC
Physical Exam:
On Discharge: Aox3, PERRL ___, ___ drift, MAE ___, diplopia
+ blurred vision to left eye
Pertinent Results:
Please see OMR for relevant imaging reports
Brief Hospital Course:
# right occipital hemorrhage:
The patient presented with 1 week of headaches, and left eye
diplopia and blurred vision. NCHCT was performed and
demonstrated right occipital hemorrhage. MRI performed and was
concerning for hemorrhagic melanoma metastesis as she had a
history of melanoma. CT torso was performed and negative for
malignancy. The patient underwent an ultrasound of her left
breast/ axilla (mammogram not available to be performed while
inpatient) which demonstrated hypoechoic focus measuring up to
0.8 cm in the inferior left lateral breast, nonspecific though
benign-appearing. A Three-month follow-up was recommended with
dedicated breast ultrasound. Dermatology saw and evaluated the
patient and did not identify and concerning skin lesions.
neurooncology saw and evaluated the patient given concern for
underlying lesion. She was instructed to follow up with Dr.
___ Dr. ___ in 3 weeks with a MRI with and without
contrast of her brain. She continued her aspirin and Plavix
given recent pipeline embolization stent placement.
Medications on Admission:
aspirin 325 mg daily, clopidogrel 75 mg daily, Calcium Antacid
___ mg daily, Vitamin C 500 mg daily, Vitamin D3 1,000 unit
capsule 2 capsule(s) daily, Zoloft 150mg daily, alendronate 70
mg weekly, bupropion HCl XL 300 mg 24 hr tablet, extended
release daily butalbital-acetaminophen-caffeine 50 mg-325 mg-40
mg Q6hrs PRn headache, Multivitamin capsule, trazodone 50-100 mg
at bedtime.
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 5 mg by mouth every four (4) hours Disp #*25
Tablet Refills:*0
4. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Headache
5. Aspirin 325 mg PO DAILY
6. BuPROPion XL (Once Daily) 300 mg PO DAILY
7. Calcium Carbonate 500 mg PO QID:PRN heartburn
8. Clopidogrel 75 mg PO DAILY
9. Sertraline 150 mg PO DAILY
10. TraZODone 50-100 mg PO QHS:PRN sleep
Discharge Disposition:
Home
Discharge Diagnosis:
right occipital hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions
Brain Hemorrhage without Surgery
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Ibuprofen,
Coumadin) until cleared by the neurosurgeon. You have been
cleared to continue your Aspirin and Plavix to keep your
pipeline stent patent.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
10685197-DS-18
| 10,685,197 | 24,323,791 |
DS
| 18 |
2150-03-14 00:00:00
|
2150-03-30 14:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / codeine / ampicillin
Attending: ___.
Chief Complaint:
Fever and abdominal pain
Major Surgical or Invasive Procedure:
ERCP with Sphincterotomy
History of Present Illness:
___ MEDICINE ATTENDING ADMISSION NOTE .
Date: ___
Time: 330 AM
_
________________________________________________________________
PCP:
Name: ___
___: ___
Address: ___
Phone: ___
Fax: ___
_
________________________________________________________________
HPI:
___ female with history of CAD who presents for
evaluation of fever and abdominal pain. She was in a GSOGH until
3 days ago she was ate a heavy meal with ice cream (she is
lactose intolerant) and she developed brown diarrhea. Sixteen
hour later she developed a band of sharp ___ periumbilical pain
x 3 mins. Afterwards she had malaise and didn't feel well. She
then presented to urgent care who did blood tests which
demonstrated elevated liver function tests. She then had an US
which demonstrated sludge and a minally enlarged CBD. After her
US she developed b/l pressure under her bra and then she had
bilious emesis one day prior to presentation. She endorses
decreased po intake and anorexia. + chills alternating with
subjective fevers. T = 100.5 -> 101.6 on the day of admission.
She also noticed that her urine had turned orange. She fainted
on the day of admission. She went to see her PCP yesterday and
had ultrasound performed which showed evidence of sludge and a
distended gallbladder. Her LFTs were elevated. Today she
developed a fever to 100.4 in the morning and up to a max of
101.6. She called her PCP who referred her into the
emergency department for further evaluation. She was going to
get dressed when she passed out and came to seconds later while
laying on the floor. Tbili 5.8 on presentation to ___ (1.6 -
___ ALT 761 AST 416 / AP 381 on presentation to ___/ RUQ
u/s with no CBD dilation given unasyn 3g 40meq K for K 2.6
in addition to zofran 4mg IV. She remained hypertensive in the
___ ED with SBP = 160s- 170s. No cultures drawn at ___.
.
5.84 H 361 H 761 H 416 H
In ER: (Triage Vitals:0 99 71 170/44 16 99% )
Meds Given: unasyn given in ___
Fluids given: None
Radiology Studies:had RUQ US at ___
consults called: ERCP notified by ___
.
___
________________________________________________________________
REVIEW OF SYSTEMS: 10 or 2 with "all otherwise negative"
CONSTITUTIONAL: [] All Normal
[+ ] Fever [ +] Chills [ ] Sweats [ ] Fatigue [ ] Malaise
[ ]Anorexia [ ]Night sweats
[ +] __a few___ lbs. weight loss/gain over _____ months
Eyes
[X] All Normal
[ ] Blurred vision [ ] Loss of vision [] Diplopia [ ]
Photophobia
ENT
[ +] Dry mouth [ ] Oral ulcers [ ] Bleeding gums [ ] Sore
throat [] Sinus pain [ ] Epistaxis [ ] Tinnitus
[ ] Decreased hearing [ ] Other:
RESPIRATORY: [X] All Normal
[ ] Shortness of breath [ ] Dyspnea on exertion [ ] Can't
walk 2 flights [ ] Cough [ ] Wheeze [ ] Purulent sputum
[ ] Hemoptysis [ ]Pleuritic pain
[ ] Other:
CARDIAC: [X] All Normal
[ ] Palpitations [ ] Edema [ ] PND [ ] Orthopnea [ ]
Chest Pain [ ] Dyspnea on exertion [ ] Other:
GI: [] All Normal
[ +] Nausea [+] Vomiting [+] Abd pain [] Abdominal swelling
[ +] Diarrhea - last 4 days ago and last BM- [ ] Constipation
[ ] Hematemesis
[ ] Blood in stool [ ] Melena [ ] Dysphagia: [ ] Solids
[ ] Liquids [ ] Odynophagia [ ] Anorexia [ ] Reflux
[ ] Other:
GU: [X] All Normal
[ ] Dysuria [ ] Incontinence or retention [ ] Frequency
[ ] Hematuria []Discharge []Menorrhagia
SKIN: [X] All Normal
[ ] Rash [ ] Pruritus
MS: [X] All Normal
[ ] Joint pain [ ] Jt swelling [ ] Back pain [ ] Bony pain
NEURO: [X] All Normal
[ ] Headache [ ] Visual changes [ ] Sensory change [
]Confusion [ ]Numbness of extremities
[ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo
[ ] Headache
ENDOCRINE: [X] All Normal
[ ] Skin changes [ ] Hair changes [ ] Heat or cold
intolerance [ ] loss of energy
HEME/LYMPH: [X] All Normal
[ ] Easy bruising [ ] Easy bleeding [ ] Adenopathy
PSYCH: [X] All Normal
[ ] Mood change []Suicidal Ideation [ ] Other:
ALLERGY:
[+ ]Medication allergies
Codeine -> nausea
Sulfa -> rash
ampicillin- diarrhea
[ ] Seasonal allergies
[]all other systems negative except as noted above
Past Medical History:
CAD s/p CABG x 1 in ___
Chronic cough without clear etiology
GERD
HLD
Osteopenia
Sinusitis
R Carotid bruit
Rhinitis
Positional vertigo- She cannot lay flat.
Social History:
___
Family History:
Her father died of an MI at age ___. Her mother died of an MI at
age ___. Two of her uncles died of MI. Maternal GPs with DM.
Physical Exam:
DISCHARGE PHYSICAL EXAM:
Vitals: T 98 bp 161/79 HR 80 RR 18 SaO2 95 RA
GEN: NAD, awake, alert
HEENT: supple neck, dry mucous membranes, no oropharyngeal
lesions
PULM: normal effort, CTAB
CV: RRR, no r/m/g/heaves
ABD: soft, NT, ND, bowel sounds present
EXT: normal perfusion
SKIN: warm, dry
NEURO: AOx3, no focal sensory or motor deficits
PSYCH: calm, cooperative
ADMISSION PHYSICAL EXAM: I3 - PE >8
VITAL SIGNS:
GLUCOSE:
PAIN SCORE
1. VS T = 97.9 P = 82 BP 188/ 79 RR 16 O2Sat on __98% on RA
GENERAL: Elderly female laying in bed.
Mentation: alert, she is vervy funny, cracking jokes
2. Eyes: [] WNL
EOMI without nystagmus, Conjunctiva: clear
3. ENT [] WNL
[] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____ cm
[X] Dry [] Poor dentition [] Thrush [] Swelling [] Exudate
4. Cardiovascular [X] WNL
[X] Regular [] Tachy [X] S1 [X] S2 [-] Systolic Murmur /6,
Location:
[] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6,
Location:
[X] Edema RLE None
[X] Edema LLE None
2+ DPP b/l.
[] Vascular access [X] Peripheral [] Central site:
5. Respiratory [ X]WNL
[X] CTA bilaterally [ ] Rales [ ] Diminshed
6. Gastrointestinal [ ] WNL
[X] Soft [] Rebound [] No hepatomegaly [X] Non-tender [] Tender
[] No splenomegaly
7. Musculoskeletal-Extremities [X] WNL
[ ] Tone WNL [ X]Upper extremity strength ___ and symmetrical
[ ]Other:
[ ] Bulk WNL [X] Lower extremity strength ___ and symmetrica
[ ] Other:
[] Normal gait []No cyanosis [ ] No clubbing [] No joint
swelling
8. Neurological [] WNL
[X] Alert and Oriented x 3 - she is a very good historian[ ]
Romberg: Positive/Negative [ ] CN II-XII intact [ ] Normal
attention [ ] FNF/HTS WNL [] Sensation WNL [ ]
Delirious/confused [ ] Asterixis Present/Absent [ ] Position
sense WNL
[ ] Demented [ ] No pronator drift [] Fluent speech
9. Integument [X] WNL
Multiple SKs.
10. Psychiatric [X] WNL
[X] Appropriate [] Flat affect [] Anxious [] Manic []
Intoxicated [] Pleasant
Pertinent Results:
___ 12:35AM BLOOD WBC-10.8 RBC-4.38 Hgb-13.6 Hct-38.9
MCV-89 MCH-31.0 MCHC-34.9 RDW-12.9 Plt ___
___ 12:35AM BLOOD Neuts-85.5* Lymphs-8.7* Monos-4.8 Eos-0.9
Baso-0.2
___ 12:35AM BLOOD Plt ___
___ 12:35AM BLOOD ___ PTT-30.4 ___
___ 12:35AM BLOOD Glucose-113* UreaN-11 Creat-0.8 Na-140
K-3.7 Cl-102 HCO3-26 AnGap-16
___ 12:35AM BLOOD estGFR-Using this
___ 12:35AM BLOOD ALT-680* AST-353* AlkPhos-367*
TotBili-5.2*
___ 12:35AM BLOOD Albumin-4.1
___ 12:35AM BLOOD LtGrnHD-HOLD
___ 12:48AM BLOOD Lactate-2.2*
ADMISSION CXR: IMAGES REVIEWED BY AUTHOR
The patient is status post CABG surgery and median sternotomy.
The aorta is calcified. Cardiac silhouette is normal in size
with prominent fat pads. There is no evidence of pulmonary
edema, infection, pneumothorax or pleural effusion.
IMPRESSION:
No evidence of acute cardiopulmonary process.
___ 05:35AM BLOOD WBC-5.9 RBC-3.89* Hgb-12.2 Hct-34.8*
MCV-89 MCH-31.3 MCHC-35.1* RDW-13.2 Plt ___
___ 06:15AM BLOOD WBC-6.6 RBC-4.14* Hgb-12.4 Hct-36.6
MCV-88 MCH-30.0 MCHC-34.0 RDW-13.1 Plt ___
___ 05:35AM BLOOD Glucose-67* UreaN-9 Creat-0.6 Na-141
K-3.0* Cl-103 HCO3-25 AnGap-16
___ 06:15AM BLOOD Glucose-75 UreaN-8 Creat-0.8 Na-140
K-2.8* Cl-100 HCO3-24 AnGap-19
___ 06:15AM BLOOD ALT-361* AST-96* AlkPhos-275*
TotBili-3.0*
___ 05:35AM BLOOD ALT-239* AST-55* AlkPhos-242*
TotBili-1.6*
___ 05:35AM BLOOD Calcium-8.5 Phos-2.6* Mg-1.8
ERCP ___
Procedures: A sphincterotomy was performed in the 12 o'clock
position using a sphincterotome over an existing guidewire.
Stone fragments, sluge and small amount of pus was extracted
successfully using a balloon.
Impression: There was a filling defect that appeared like sludge
/ stone fragments in the level of the lower third of the CBD.
Rest of the biliary tree was normal.
The cyst duct was patent and filling of the gallbladder was
noted.
A sphincterotomy was performed.
Stone fragments, sluge and small amount of pus was extracted
successfully using a balloon.
(sphincterotomy, stone extraction)
Otherwise normal ercp to third part of the duodenum
Brief Hospital Course:
___ with h/o CAD s/p CABG x 1 vessel, HTN, HLD who presents with
fevers, abdominal pain and elevated LFTS consistent with
cholangitis.
.
# Bile Duct Obstructition with Ascending Cholangitis: Pt
presented with RUQ pain, fever and found to have elevated
bilirubin to 5. The patient underwent ERCP on ___ during which
a sphincterotomy was performed and biliary sludge and pus
drained. The patient was initially placed on Unasyn and did not
have any fevers. The morning after, she had no abdominal pain,
and her diet was advanced to regular, again without any
complications. I spoke with the ERCP attending who agreed she
can be seen by surgery as an outpatient. Her PCP should draw
her LFTs within ___ weeks of discharge, and if normal, can
restart her statin, and if they have not normalized, can refer
her back to the ERCP program at ___.
..
# HTN: Pt was initially just continued on her beta-blocker in
the setting of SIRS. Her antihypertensives were slowly added
back after she had a max inpatient SBP of 165.
.
# GERD: continue PPI bid
.
#Diarrhea - patient has functional diarrhea in the setting of
IBD which has been chronic for years. She reports having
episodes of loose stools which coincide with her receiving
Ampicillin, an ABX that she has an explicit reaction of diarrhea
to in the past. On the afternoon of ___, she was switched to
oral Cipro which she reportedly had no problems with in the
past. She states that this diarrhea is not significantly
different from functional diarrhea episodes in the past; it is
non-bloody. She was told that if her diarrhea worsens or
accompanied with pain, she will need to seek immediate medical
condition.
.
# HLD: Held statin in setting of elevated transaminases
.
# ALPRAZolam 0.25 mg PO DAILY:PRN anxiety
.
# CAD: Held ASA in setting of ERCP but restarted on discharge.
TRANSITION ISSUES:
Code Status: FULL ___- d/w pt on admission.
Check LFTs ___ weeks after discharge to ensure they have
normalized; if not, can refer back to ___ clinic at ___
I spent > 30 minutes in discharge planning. -___, MD
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nitroglycerin SL 0.3 mg SL PRN chest pain
2. NexIUM *NF* (esomeprazole magnesium) 40 mg Oral bid
3. Atorvastatin 40 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
Hold for SBP <120 and HR <60.
5. Hydrochlorothiazide 12.5 mg PO DAILY
Hold for SBP <120.
6. Diltiazem Extended-Release 180 mg PO DAILY
Hold for SBP <120 and HR <60.
7. Losartan Potassium 50 mg PO DAILY
Holding for SBP < 120.
8. ALPRAZolam 0.25 mg PO DAILY:PRN anxiety
Hold for RR <10.
9. Aspirin 162 mg PO DAILY
Discharge Medications:
1. ALPRAZolam 0.25 mg PO DAILY:PRN anxiety
2. Diltiazem Extended-Release 180 mg PO DAILY
3. Losartan Potassium 50 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Aspirin 162 mg PO DAILY
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. NexIUM *NF* (esomeprazole magnesium) 40 mg Oral bid
8. Nitroglycerin SL 0.3 mg SL PRN chest pain
9. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
#14, no refills
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
10. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
#10, no refills
RX *oxycodone 5 mg 0.5 to 1 tablet(s) by mouth q6 PRN Disp #*10
Tablet Refills:*0
11. Docusate Sodium 100 mg PO BID:PRN constipation
#60
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
- Bile Duct Obstruction secondary to sludge
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 abdominal pain. You were
found to have "sludge" in your bile duct for which you underwent
a procedure called an ERCP.
Followup Instructions:
___
|
10685285-DS-12
| 10,685,285 | 24,072,945 |
DS
| 12 |
2113-06-12 00:00:00
|
2113-06-12 13:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril / hydrochlorothiazide
Attending: ___.
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/COPD on chronic steroids presented on ___ from ___
with hypotension requiring pressors.
Pt noted to have fever and lethargy at nursing facility. In the
___, labs were remarkable for WBC 21.3, Hgb 7.7, Cr
1.5, and a grossly positive urinalysis. Patient was noted to be
hypotensive despite aggressive resuscitation with 4 L IVF. A RIJ
was placed and patient was started on norepinephrine and
phenylephrine. He also received vancomycin, Zosyn, and Decadron
10mg given chronic steroid use. Foley catheter exchange was
performed and purulent drainage noted. Blood and urine cultures
were obtained. Patient was transferred to ___ for a higher
level of care.
Past Medical History:
Hypertension
Coronary artery disease
- s/p MI
COPD on chronic steroids
prior CDI
Gastritis
Nephrolithiasis
- c/b renal/perinephric abscess s/p ureteral stent placed ___
and ?chronic foley
Cataract
Depression
Social History:
___
Family History:
unknown
Physical Exam:
ADMISSION
100.6, 93, 94/56, 24, 100% NC
GENERAL: Chronically ill-appearing male in no distress
HEENT: Sclera anicteric, mucous membranes dry, oropharynx clear
NECK: Supple, JVP flat, no LAD, RIJ in place
LUNGS: Crackles at the bases bilaterally, L > R
CV: RRR, nl S1/S2, no MRG
ABD: Soft, NTND, normoactive bowel sounds
EXT: Warm, well-perfused, no cyanosis/clubbing/edema
SKIN: Warm and dry
NEURO: AAOx3, attention intact, CN II-XII intact
DISCHARGE
Vitals: AVSS, Tmaxes have been 99-100.2
Gen: NAD, lying in bed
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear
Cardiovasc: distant heart sounds, no harsh murmurs, full pulses,
no edema
Resp: normal effort, no accessory muscle use, markedly
diminished
lung sounds bilaterally, few scattered rhonchi.
GI: soft, NT, ND, BS+
MSK: No significant kyphosis. No palpable synovitis.
Skin: No visible rash. No jaundice.
Neuro: AAOx3. No facial droop.
Psych: Full range of affect
GU: Foley catheter in place draining clear urine
Pertinent Results:
___ CT ABD/PEL IMPRESSION:
1. Markedly thickened urinary bladder concerning for cystitis
with thickening of the distal ureters concerning for ascending
infection. No evidence of pyelonephritis or perinephric
abscess.
2. Cystic lesion within the distal body of the pancreas, 1.9 x
1.5 x 1.6 -recommend MRCP to further assess.
3. Bilateral renal cysts. Indeterminate 10 mm right interpolar
cystic
structure which may can also be further assessed at the time of
MRCP.
4. Cholelithiasis without evidence of cholecystitis.
5. Small bilateral pleural effusions. Nodular consolidation in
the left lower lung likely rounded atelectasis. 3 month
followup is needed.
6. Emphysema.
___ CXR IMPRESSION: Appropriately positioned right IJ central
venous catheter. Retrocardiac opacity better assessed on
subsequent CT abdomen pelvis
URINE CULTURE ___
YEAST. >100,000 ORGANISMS/ML.
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 2 S
MEROPENEM------------- =>16 R
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
BLOOD CULTURE ___
PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES.
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- 8 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 4 S
MEROPENEM------------- =>16 R
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
BLOOD CULTURE ___ Source: Line-RIJ.
YEAST, PRESUMPTIVELY NOT C. ALBICANS
Fluconazole = SENSITIVE sensitivity testing performed by ___
___.
___ ALBICANS
Fluconazole = SENSITIVE sensitivity testing performed by ___
___.
Brief Hospital Course:
This is a complicated ___ with CAD s/p MI, COPD, adrenal
insufficiency on prednisone, unspecified anemia (previously on
iron), gastritis, depression, hypertension, deconditioning,
prior alcohol use as well as multiple relatively recent ___
admissions with sepsis, C difficile, polymicrobial bacteremia,
UTI, nephrolithiasis s/p ureteral stent, and placement of
chronically indwelling foley catheter along with rash of
uncertain etiology. He presented to an OSH with septic shock and
was transferred and stabilized in the FICU with Vanc/Zosyn then
Zosyn monotherapy.
His shock appeared to be caused by Pseudomonal UTI and
bacteremia. After initial stabilization with pressors, IVF,
Vanc/Zosyn, he was transitioned to cefepime monotherapy but the
Pseudomonal isolate in blood culture returned as intermediate,
so he was transitioned back to Zosyn.
He also had a single blood culture positive for yeast, which
could theoretically have been contaminant (drawn off a central
line on a followup blood culture several days into his clinical
improvement, no persistence or other cultures positive), but he
had yeast growing in urine as well, and the ID service has
recommended a course of micafungin.
Given his bacteremia, he was given a 48h line free interval.
Given his UTI, his foley catheter was exchanged. He does still
have ureteral stents, though those appeared to be in good
position, he was making good urine, and he has a followup
scheduled with Urology.
He will require followup with infectious disease, urology, and
___ dermatoloy. The ID service here will enroll him in OPAT to
determine ultimate course of antibiotic therapy given his
complexity, but they are recommending at least 3 weeks from ___.
# Septic shock
# Nephrolithiasis, ureteral stent
# Gram negative bacteremia
# Urinary tract infection:
- Continue Zosyn per ID
- Has outpatient appointment with ___ Urology
- ___ ID will enroll him in OPAT
- He should have weekly CBC/diff, BUN/Cr, and LFTs while on
these antibiotics
# Yeast in blood culture:
- Micafungin for now
- Follow up with ID team
# C difficile infection: He was admitted on PO Vancomycin. He
was tested for C difficile and his test was negative. Given his
history, his vancomycin was adjusted to BID dosing for
prophylaxis.
- Continue BID vancomycin until other antibiotics are stopped
# Electrolyte abnormalities including hyperkalemmia,
hypokalemia, hypophosphatemia: He had various abnormalities
throughout his hospital stay. Thought to be fluid and
electrolyte shifts in context of diarrhea and electrolyte
repletion.
- Monitor labs at least weekly until documented stability, more
frequent if clinical condition changes
# NSTEMI this admission (had downtrending Tns from OSH to here)
# History of HTN
# History of CAD: He was on a suboptimal regimen for CAD per
records and so his regimen was optimized with initiation of ASA,
statin, and continuation of Metoprolol.
# Adrenal insufficiency: He was initially treated with stress
dose steroids but was quickly tapered to home dose of 5mg daily.
# COPD: Stable. He was continued on home medications and Spiriva
was added.
# Question of aspiration: SLP has eval'd and felt he was OK for
regular solids/thin liquids.
- Aspiration precautions
- Pt should be OOB or at least sitting up for meals, though he
prefers to lay more flat
# Rash: He had a confluent erythematous exanthem in the
dependent areas especially his back. He has been followed by ___
dermatology for nutritional deficiency related rash as well as a
drug rash. His sarna lotion was continued.
- He has an appointment with ___ dermatology for later in ___
# Deconditioning: He is reportedly bedbound, though the reasons
for this were not entirely clear and seem to some degree
volitional. He did occasionally make it out of bed to chair when
aided by nursing, max assist/___. He should continue OOB
trials as his skin improves. He should be moved frequently while
in bed to minimize skin damage and encourage his movement.
# Possible gastritis: There was no evidence of gastritis this
admission.
- Decreased PPI to daily given C diff, electrolyte disturbances,
and diarrhea
# Anemia: Stable. He has AoCD by laboratories, so iron
supplementation was discontinued.
- Monitor CBC weekly
# IV access: An attempt was made to place PICC, but he was found
to have central venous stenosis on the right side (asymptomatic,
likely related to PICC lines and other central line procedures).
He therefore had a non-heparin dependent midline placed ___.
# Code status: Full code
Billing: >30 minutes were spent coordinating his discharge from
the hospital
Medications on Admission:
The Preadmission Medication list is accurate and complete.
2. Senna 8.6 mg PO BID:PRN constipation
3. PredniSONE 5 mg PO DAILY malignant neoplasm NOS
4. Acetaminophen 650 mg PO Q6H:PRN pain
5. FoLIC Acid 1 mg PO DAILY
6. Sarna Lotion 1 Appl TP DAILY rash
7. Fluocinolone Acetonide 0.025% Cream 1 Appl TP BID rash
8. Ocuvite with Lutein (vit A,C & E-lutein-minerals) 1,000
unit-200 mg-60 unit-2 mg oral DAILY
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Nystatin Oral Suspension 5 mL PO QID:PRN ?
11. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
12. Thiamine 100 mg PO DAILY
13. Zinc Sulfate 220 mg PO DAILY
14. Omeprazole 40 mg PO BID
15. Lactinex (lactobacillus acidoph-L.bulgar) 100 million cell
oral BID ?
16. Enoxaparin Sodium 30 mg SC Q12H Acute Myocardial Infarction
Start: ___, First Dose: Next Routine Administration Time
17. Guaifenesin ER 600 mg PO Q12H cough
18. Ferrous Sulfate 325 mg PO DAILY
19. Ranitidine 150 mg PO DAILY reflux
20. Metoprolol Succinate XL 50 mg PO DAILY
21. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
22. Docusate Sodium 100 mg PO BID:PRN constipation
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
4. FoLIC Acid 1 mg PO DAILY
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Omeprazole 20 mg PO DAILY
7. PredniSONE 5 mg PO DAILY malignant neoplasm NOS
8. Sarna Lotion 1 Appl TP DAILY rash
9. Zinc Sulfate 220 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Atorvastatin 40 mg PO QPM
12. Calcium Carbonate 500 mg PO QID:PRN pyrosis
13. Magnesium Oxide 400 mg PO DAILY
14. Tiotropium Bromide 1 CAP IH DAILY
15. Vancomycin Oral Liquid ___ mg PO BID
Should continue treatment for 10 days after discontinuation of
other antibiotics.
RX *vancomycin 125 mg 1 capsule(s) by mouth twice daily Disp
#*50 Capsule Refills:*0
16. Fluocinolone Acetonide 0.025% Cream 1 Appl TP BID rash
17. Lactinex (lactobacillus acidoph-L.bulgar) 100 million cell
oral BID ?
18. Metoprolol Succinate XL 50 mg PO DAILY
19. Thiamine 100 mg PO DAILY
20. Senna 8.6 mg PO BID:PRN constipation
21. Ocuvite with Lutein (vit A,C & E-lutein-minerals) 1,000
unit-200 mg-60 unit-2 mg oral DAILY
22. Micafungin 100 mg IV Q24H
Treatment to be continued for at least 3 weeks from ___, final
course determined by OPAT.
RX *micafungin [Mycamine] 100 mg 1 vial IV daily Disp #*15 Vial
Refills:*0
23. Piperacillin-Tazobactam 4.5 g IV Q8H
Treatment to be continued for at least 3 weeks from ___, final
course determined by OPAT.
RX *piperacillin-tazobactam 4.5 gram 1 vial IV every 6 hours
Disp #*60 Vial Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Septic shock
Urinary tract infection
Pseudomonas bacteremia
Candidemia, non albicans type
Chronically indwelling foley catheter
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to the hospital with septic shock. You had a
urinary tract infection as well as bacteria and fungus growing
in your blood. You were treated with antibiotics and you got
significantly better. You are now ready to be discharged back to
your facility so you can resume followup with the ___ providers
who know you best.
Followup Instructions:
___
|
10685894-DS-34
| 10,685,894 | 23,518,555 |
DS
| 34 |
2147-05-31 00:00:00
|
2147-06-01 07:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right hip pain
Major Surgical or Invasive Procedure:
Central venous line
ECRP
History of Present Illness:
___ yo F hx Alcoholic cirrhosis s/p Liver transplant (___) on
prograf, Osteoporosis, hx DVT s/p IVC filter ___, HTN,
Asthma/COPD, Hyperlipidemia, GERD, vertebral compression
fractures, 2 prior hip replacements who presented to the
emergency department with a chief complaint of R hip pain in
setting of a fall. The patient reports taht at approximately
10AM on ___, she was getting out of bed and looked out the
window for a brief moment and lost her balance and fell of the
side of bed landing on her right side. She does endorse head
strike, denies LOC and states she was unbable to get up off the
floor on her own volition. Her roomate did find her on the
ground after she called for help and called ___ and she was
taken to this facility for further management. The patient
reports her only complaint is severe R hip pain since the fall.
She denies any headache, double vision, neck pain, back pain,
pain in UE, pain in LLE, abdominal pain, chest pain, n/v, since
fall. In addition, she denies any promdromal symptoms prior to
fall such as light headedness, dizziness, chest pain,
palpitations or sob. In the ED, the patient had a CT R
hip/pelvis and found to have a displaced comminuted R iliac wing
fracture with associated iliacus and gluteal hematoma.
Orthopedics was consulted at this time but felt that operative
management was not indicated and recommended weight bearing as
tolerated and outpatient orthopedics follow up. However, during
her time in the ED the patient did have a 7 point Hct drop,
became increasingly hypotensive in the ___ and put on levophed.
Subsequent Ct torso, head, C spine did not show any other
injuries and evaluation of pelvic fracture did not show evidence
of enlarging hematoma or extravasation at fracture site as
compared to earlier scan. Of note, the patient was given empiric
dose of vancomycin and zosyn for hypotension. As such, the
patient was admitted to the MICU for further management of her
care.
In the ED, initial vitals:T98 P87 BP77/45 RR18 95% NC
Exam/labs were notable for:
Imaging showed:
-CT hip: Comminuted fracture through the right iliac wing with
associated intramuscular right iliacus hematoma.
-CT torso: no injuries outside of those noted in Ct R hip and no
enlargement of previously noted hematoma or evidence of active
extravasation at this site.
-CT head/C spine: No acute intracranial abnormality or c spine
fracture.
Patient was given:
3L NS
Morphine 14mg
Dilaudid 1 mg
Levophed ggt
Vanc/Zosyn
Past Medical History:
- Alcoholic cirrhosis s/p Liver transplant (___) on prograf
- Osteoporosis ___ steroid use, s/p humerus fx ___
- h/o RUE and RLE Thrombophlebitis
- RLE DVT ___ on coumadin until s/p IVC filter ___, now off
warfarin
- h/o left foot cellulitis
- Chronic low back pain
- HTN
- Asthma/COPD
- Hyperlipidemia
- GERD
- Depression
- vertebral compression fractures
Past Surgical History:
- s/p Cholecystectomy ___
- s/p Orif rt hip fx
- s/p Bl prosthetic hips
- s/p ventral hernia repair
Social History:
___
Family History:
Mother with hx of CVA and seizure, sister with breast cancer,
Father died of lung cancer.
No family history of kidney disease.
Physical Exam:
====================================
ADMISSION PHYSICAL EXAM
====================================
GENERAL: Alert, oriented, answering questions appropriately. no
acute distress but is complaining of R hip pain.
HEENT: Pupils 2mm symmetric and reactive. Sclera anicteric, MMM,
oropharynx clear. no midline c spine tenderness. EOMI.
NECK: supple, JVP not elevated, no LAD
LUNGS: Very faint expiratory wheezes in posterior lung fields
bilaterally but is otherwise clear to auscultation. No 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. transverse
surgical incision in epigastrum.
EXT: Warm, well perfused, DPs +1 symmetric. No ___ edema. Severe
tenderness to palpation and PROM of R hip. N/V intact distal to
r hip. No bony tenderness or joint effusionof R knee or ankle.
No bony tenderness of UE bilaterally. AROM in UE intact without
pain.
SKIN: No rash.
NEURO: CN ___ intact. Moving all extremities. strength in ___
is intact and symmetric. Sensation to light touch intact in
___.
====================================
DISCHARGE PHYSICAL EXAM
====================================
Vitals: T 98.2 HR 69 BP 117/55 RR 18 O2 98% I/O not recorded
General: AAOx3, comfortable in bed, NAD
HEENT: 3 cm resolving ecchymosis on R mid-forehead, several AKs
CV: RRR, no murmurs, rubs, or gallops
Lungs: CTAB, no wheezes
Abd: Less distended than previously, increased tympany to
percussion, normoactive bowel sounds. Mild tenderness to
palpation of epigastric/mid abdomen primarily.
Pertinent Results:
============================
ADMISSION LABS
============================
___ 12:50PM BLOOD WBC-7.9 RBC-4.36 Hgb-13.6 Hct-42.1 MCV-96
MCH-31.2 MCHC-32.4 RDW-13.7 Plt ___
___ 12:50PM BLOOD Neuts-69.5 ___ Monos-7.0 Eos-2.9
Baso-0.9
___ 12:50PM BLOOD ___ PTT-30.1 ___
___ 12:50PM BLOOD Glucose-82 UreaN-18 Creat-1.4* Na-142
K-4.8 Cl-108 HCO3-24 AnGap-15
___ 12:50PM BLOOD ALT-14 AST-25 AlkPhos-70 TotBili-0.5
___ 12:50PM BLOOD Lipase-61*
___ 03:34AM BLOOD Calcium-7.6* Phos-3.3 Mg-2.0
___ 02:15AM BLOOD Type-CENTRAL VE pO2-45* pCO2-48* pH-7.24*
calTCO2-22 Base XS--6
___ 12:52PM BLOOD Lactate-2.1*
___ 11:53PM BLOOD Lactate-0.7
============================
INPATIENT LABS
============================
___ 08:00AM BLOOD WBC-5.9 RBC-3.32* Hgb-10.4* Hct-30.8*
MCV-93 MCH-31.3 MCHC-33.7 RDW-13.2 Plt ___
___ 03:34AM BLOOD Neuts-67.6 ___ Monos-8.4 Eos-3.3
Baso-0.5
___ 08:00AM BLOOD Plt ___
___ 08:00AM BLOOD ___ PTT-30.2 ___
___ 08:00AM BLOOD Glucose-98 UreaN-10 Creat-1.0 Na-138
K-4.6 Cl-101 HCO3-27 AnGap-15
___ 08:00AM BLOOD ALT-19 AST-25 AlkPhos-136* TotBili-0.3
___ 07:20AM BLOOD Lipase-527*
___ 07:48AM BLOOD Calcium-8.9 Phos-4.5 Mg-1.8
___ 07:35AM BLOOD tacroFK-6.5
============================
ORTHOPEDIC/NEURO IMAGING REPORTS
============================
CT Head:
IMPRESSION: No evidence of hemorrhage or acute territorial
infarction.
CT spine:
IMPRESSION: Degenerative changes with no evidence of acute
fracture or traumatic malalignment.
R. Femur and pelvic films
IMPRESSION:
Irregularity along the region of the right anterior superior
iliac spine could be an acute fracture or avulsive injury.
Further assessment with dedicated right hip radiographs is
recommended.
CXR:
IMPRESSION: No acute cardiac or pulmonary findings.
CT pelvis
IMPRESSION: 1. Comminuted fracture through the right iliac wing
with associated right iliacus intramuscular hematoma. The
fracture line does not disrupt the pelvic ring.
2. Colonic diverticulosis, without evidence of diverticulitis.
CTA abdomen and pelvis
CT Abdomen/Pelvis w/ contrast
IMPRESSION:
1. Stable right comminuted mildly displaced right iliac wing
fracture without ring disruption or sacroiliac joint extension.
Stable ipsilateral iliacus and to lesser degree gluteal
hematomas. No evidence of new hematoma nor active
extravasation.
2. Minimal periportal edema superimposed on stable intra- and
extra-hepatic biliary ductal dilatation in this patient with
liver transplant. Anastomoses are patent. No concerning liver
lesions identified. No perfusional abnormality is present.
3. Stable significant splenorenal varices.
4. Stable L1-L2 compression deformity treated with kyphoplasty.
5. Sigmoid diverticulosis without diverticulitis.
CT Abdomen/Pelvis ___
IMPRESSION:
1. Unchanged appearance of minimally displaced comminuted right
iliac wing fracture with adjacent right iliacus and gluteal
intramuscular hematoma. No appreciable change in size of the
hematoma. No new intra- or retroperitoneal hematoma.
2. Diverticulosis without signs of acute diverticulitis.
3. Treated L1 and L2 compression fractures by kyphoplasty,
unchanged.
============================
HEPATOBILIARY IMAGING
============================
Liver/Gallbladder Ultrasound ___
BILE DUCTS: There is a moderate degree of intrahepatic biliary
dilatation. TheCBD measures between 8 and 11 mm, increased as
compared to the prior examination.
LIVER DOPPLER: The main, right, and left portal veins are
patent with normal color Doppler and appropriate hepatopetal
flow. The right, middle, and left hepatic veins are patent with
appropriate hepatofugal flow. The main, right, and left hepatic
arteries are patent with normal spectral Doppler waveforms.
SPLEEN: The spleen is homogeneous in echotexture and measures 11
point cm maximum diameter.
IMPRESSION:
1. Patent hepatic vessels and normal hepatic echotexture.
2. Moderate common duct dilation, increased as compared to the
prior examination. Recommend further evaluation with MRCP to
exclude possible biliary stricture.
MRCP ___
(Preliminary Report)
1. Interval progression of intrahepatic and extrahepatic biliary
duct dilatation on either side of the biliary anastomosis where
there is persistent narrowing. Prominent bulge at the level of
the ampulla, may represent a prominent ampulla with stricture,
however a mass cannot be excluded. Consider ERCP for further
evaluation.
2. Status post liver transplant. Persistent splenorenal shunt.
3. Small right pleural effusion and bibasilar atelectasis.
4. Stable left adrenal adenoma.
5. 3mm pancreatic cystic lesion, likely representing an
intraductal papillary mucinous neoplasm (IPMN), recommend ___ year
follow-up MRI as clinically indicated.
6. Stable compression fractures with vertebroplasty at L1 and
L2.
Brief Hospital Course:
Ms. ___ is a ___ yo F with alcoholic cirrhosis s/p liver
transplant (___) on tacrolimus, a h/o osteoporosis with
multiple fractures, and a h/o DVT s/p IVC filter in ___,
admitted for a non-operative comminuted iliac wing fracture with
associated hematoma s/p traumatic fall off bed. Before being
transferred to the inpatient medicine floor she had a brief MICU
stay for hypotension secondary to over-medication with narcotic
pain medications and a 7 point Hct drop (likely due to IV fluid
administration). On the medical floor she developed abdominal
pain, and given pain and a bump in her LFTs a ___ ultrasound was
done; this was concerning for biliary stricture so and MRCP was
performed which demonstrated dilation of the common bile duct
with concern for stricture vs. mass. An ERCP was performed
___ showed a small pancreatic cyst, likely benign but
requiring follow up in ___ year. As a consequence of the ERCP she
developed acute pancreatitis. IV fluids given to treat the
pancreatitis resulted in pulmonary edema, with gradually
resolved over the course of the next several days. She was
discharged to rehab.
=======================
ACUTE CARE
=======================
# Pelvic fracture. Ms. ___ sustained a comminuted fracture of
the right iliac wing, which was deemed non-operative by
orthopedic surgery. A CT with contrast showed no evidence of
expanding hematoma or extravasation at fracture site and no
evidence of further intrathoracic/abdominal/pelvic injuries.
Pain initially required IV pain medications. She was
transitioned to PO pain medications only. Because the break was
in a non-weight bearing portion of the pelvis, she was allowed
to weight bear as tolerated. Physical therapy recommended
discharge to rehabilitation facility. She was continued on
enoxaprain as DVt ppx and will continue it till f.u appt with
orthopedics.
# Hypotension. Ms. ___ became Hypotensive to the ___ in the
ED after heavy narcotic use. CT contrast showed no intracranial
hemorrhage or evidence of ischemia. She had no signs of sepsis.
A central line was placed in the ED and she was started on
pressors and transferred to the MICU. She was quickly weaned off
of levophed when her blood pressure stabilized and transferred
to the medicine floor.
# LFT elevation. Ms. ___ is has a h/o alcoholic cirrhosis s/p
orthotopic liver transplant in ___. Her last liver biopsy in
___ showed no evidence of rejection or fibrosis (stage 0).
Ms. ___ experienced a slight increase in LFTs on admission;
these down-trended over the course of her hospitalization.
Because she experienced severe ___ pain on HD 2, Ms. ___
underwent a ___ ultrasound with doppler, which showed moderate
dilation of the common bile duct. A follow up MRCP showed common
bile duct dilated to the ampulla, with question stricture vs.
ampullar mass. An ERCP was performed ___. During the ERCP a
sphincterotomy was performed and brushings taken for pathology;
results of pathology returned benign. She was on cipro for 10
days after ERCP as prophylaxis.
# Acute pancreatitis. After the ERCP Ms. ___ developed
abdominal pain, nausea, and a lipase level elevated to >500,
consistent with ERCP-induced acute pancreatitis. She was given
supportive treatment with bowel rest and IV fluids. Her nausea
and abdominal pain gradually resolved and on discharge she was
able to tolerate adequate POs. The patient developed pulmonary
edema from IV fluids given for the acute pancreatitis. Her
volume status was monitored and this clinically resolved over
the next ___ days and she was satting on RA.
# Hct. In the ED she did have a 7 point drop in hematocrit
attributable to receiving 3L of fluid. After transfer to the
floor, on hospital days ___ she experienced another small drop
in hematocrit, but CT abdomen/pelvis showed no evidence of
hematoma expansion. Her Hct subsequently stabilized.
# Headache. On transfer to the medicine floor Ms. ___
developed a very severe headache at the site of a hematoma
sustained during her fall. Complaints of bilateral paraesthesias
in the legs coupled with increasing pain raised concern for an
evolving intracranial bleed; a non-contrast head CT revealed no
evidence of any acute or chronic intracranial process. Her
headache was managed with acetaminophen and oxycodone.
# Tacrolimus dosing. Although she was continued on her home dose
of tacrolimus, her levels in the hospital were found to be <2.0
(goal ___. With assistance of the hepatology team, her dose of
tacrolimus was increased from 0.5 mg BID to 1 mg PO BID.
# DVT prophylaxis. Lovenox for DVT prophylaxis for duration of
hospitalization.
=======================
CHRONIC CARE
=======================
# GERD/esophagitis: Ms. ___ has GERD at baseline. We
continued home omeprazole.
# Asthma/COPD: Ms. ___ was continued on her home
albuterol/ipratropium nebulizers PRN and home
fluticasone/salmeterol.
# Essential tremor: Held metoprolol 50 mg PO QD.
# Osteoporosis: Continued alendronate and calcium carbonate.
=======================
TRANSITIONS IN CARE
=======================
-Follow up with outpatient hepatology re: increased LFTs and
tacrolimus dosage and f.u after ERCP pancreatitis
-FOLLOW UP NEEDED: MRCP detected an incidental 3 mm pancreatic
cystic lesion (likely intraductal pancreatic mucinous neoplasm,
IPMN), recommend ___ year follow up imaging
-f.u with ortho re recent fracture
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Alendronate Sodium 70 mg PO QTUES
3. Calcium Carbonate 500 mg PO BID
4. Citalopram 40 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. Lactulose 30 mL PO QID
9. Metoprolol Tartrate 50 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 40 mg PO DAILY
12. Rifaximin 550 mg PO BID
13. Simvastatin 5 mg PO QPM
14. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
15. Tacrolimus 1 mg PO QPM
16. Tacrolimus 0.5 mg PO QAM
17. Vitamin D 800 UNIT PO DAILY
18. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
19. Magnesium Oxide 400 mg PO DAILY
20. Polyethylene Glycol 17 g PO BID
21. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
qid prn SOB
22. Qvar (beclomethasone dipropionate) 80 mcg/actuation
inhalation BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Alendronate Sodium 70 mg PO QTUES
3. Calcium Carbonate 500 mg PO BID
4. Citalopram 40 mg PO DAILY
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Lactulose 15 mL PO DAILY
8. Magnesium Oxide 400 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Omeprazole 40 mg PO DAILY
11. Rifaximin 550 mg PO BID
12. Simvastatin 5 mg PO QPM
13. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
14. Tacrolimus 1 mg PO QPM
15. Vitamin D 800 UNIT PO DAILY
16. Docusate Sodium 100 mg PO BID
17. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
18. Metoprolol Tartrate 50 mg PO DAILY
19. Qvar (beclomethasone dipropionate) 80 mcg/actuation
inhalation BID
20. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
qid prn SOB
21. Polyethylene Glycol 17 g PO BID
22. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
23. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 15 mg 1 tablet(s) by mouth q3 Disp #*10 Tablet
Refills:*0
24. Miconazole Powder 2% 1 Appl TP BID:PRN Rash
25. Ciprofloxacin HCl 500 mg PO Q12H Duration: 4 Days
26. Enoxaparin Sodium 40 mg SC Q24H
Start: Today - ___, First Dose: Next Routine Administration
Time
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
1. Pelvic fracture: comminuted fracture of the right iliac crest
of the pelvis
2. Hypotension
3. 3-mm pancreatic cystic lesion, likely representing an
intraductal papillary mucinous neoplasm (IPMN), recommend ___ year
follow-up MRI as clinically indicated.
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 ___ on
___ for a pelvic fracture you sustained in a fall at your
house. Because the fracture is in a part of your pelvis that
does not bear weight (the iliac crest, commonly called the "hip
bone"), the orthopedic team did not think an operation was
necessary.
In the emergency department you had an episode of low blood
pressure caused by the amount of pain medication you were given.
You spent a short time in the medical intensive care unit
(MICU). Once your condition was stable, you were transferred to
the medical floor.
On the medical floor, you experienced pain from your hip,
nausea, and abdominal pain. Because an ultrasound of your liver
raised concern for a biliary stricture, an MRCP (magnetic
resonance cholangio-pancreatography) was done to examine the
ducts more closely. This showed dilation of the common bile
duct. An ERCP (endoscopic retrograde cholangiopancreatography)
was performed which showed a narrowing and you had a
sphincterotomy which means they dilated the narrowing.
Your recovery from the ERCP was complicated by your development
of acute pancreatitis. To treat this you were given IV fluids
and asked to rest your bowels.
You became a bit short of breath from the IV fluids you were
given.
Finally, because your blood levels of tacrolimus were low, with
the advice of your Hepatology team, we increased your dose of
tacrolimus.
You are being discharged to a rehabilitation facility to help
you regain your strength and mobility.
You will continue to take enoxaprain as DVT prophylaxis till you
follow up with your orthopedic doctor
___ you for allowing us to participate in your care! We wish
you all the best.
Followup Instructions:
___
|
10685894-DS-36
| 10,685,894 | 27,221,752 |
DS
| 36 |
2148-09-16 00:00:00
|
2148-09-19 15:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
confusion, unsteady gait
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___, h/o acocholic cirrhosis s/p liver transplant in ___ on
tacrolimus, chronic low back pain, p/w 1 week of confusion, gait
difficulty, and abdominal pain. Arrived from rest house where
patient was reportedly having difficulty walking with right
lower extremity weakness yestserday.
In ED, patient was afebrile, code stroke called for weakness,
but CT head negative. Neuro consulted, did not find focal neuro
deficits and signed off. UA grossly positive for infection, Cr
at 1.8 (baseline 1.0). Patient started on IV ceftriaxone and
given fluids. Transferred to floor for further management.
This morning, patient reported story of confusion, instability x
1 week, endorsed confusion accompanying previous URIs, denies
facial droop, unilateral weakness, dysarthria. Abdominal pain
began epigastrically and spread to suprapubic region. Patient
also endorsed dysuria, frequency, denied any blood in urine,
change in bowel movements, pain with bowel movements, melena, or
BRBPR. Denied acute back pain different from chronic low back
pain. Also denied fevers/chills, nausea/vomiting, headache,
lightheadedness.
Past Medical History:
- Alcoholic cirrhosis s/p Liver transplant (___) on prograf
- Osteoporosis ___ steroid use, s/p humerus fx ___
- h/o RUE and RLE Thrombophlebitis
- RLE DVT ___ on coumadin until s/p IVC filter ___, now off
warfarin
- h/o left foot cellulitis
- Chronic low back pain
- HTN
- Asthma/COPD
- Hyperlipidemia
- GERD
- Depression
- vertebral compression fractures
Past Surgical History:
- s/p Cholecystectomy ___
- s/p Orif rt hip fx
- s/p Bl prosthetic hips
- s/p ventral hernia repair
Social History:
___
Family History:
Mother with hx of CVA and seizure, sister with breast cancer,
Father died of lung cancer.
No family history of kidney disease.
Physical Exam:
ADMISSION:
Vitals: T 98.1 HR 68 BP 104/64 RR 18 95% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: bilateral lower extremity excoriated rashes
DISCHARGE:
Vitals: Tm 98.0, Tc 98.0, BP 110s/60s, HR 71-85, RR 18, O2 99%RA
Exam:
General- Alert, oriented x 3, no acute distress
Remained of exam unchanged.
Pertinent Results:
=============== LABS ON ADMISSION ==================
___ 04:47PM BLOOD WBC-7.4 RBC-4.37 Hgb-12.8 Hct-39.6 MCV-91
MCH-29.3 MCHC-32.3 RDW-14.5 RDWSD-47.8* Plt ___
___ 04:47PM BLOOD Neuts-57.7 ___ Monos-9.4 Eos-6.0
Baso-0.5 Im ___ AbsNeut-4.24 AbsLymp-1.92 AbsMono-0.69
AbsEos-0.44 AbsBaso-0.04
___ 04:47PM BLOOD Glucose-112* UreaN-30* Creat-1.5* Na-143
K-4.7 Cl-109* HCO3-25 AnGap-14
___ 04:47PM BLOOD ALT-15 AST-22 AlkPhos-89 TotBili-0.3
___ 04:47PM BLOOD Albumin-4.0 Calcium-9.8 Phos-4.0 Mg-2.1
___ 04:47PM BLOOD ___ PTT-30.0 ___
___ 04:47PM BLOOD Lipase-36
___ 08:55PM BLOOD Ammonia-54
___ 04:47PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:56PM BLOOD Glucose-99 Lactate-1.2 Na-142 K-4.7
Cl-108 calHCO3-23
___ 10:43PM BLOOD tacroFK-4.4*
=============== LABS ON DISCHARGE ==================
___ 06:55AM BLOOD WBC-5.5 RBC-4.48 Hgb-12.8 Hct-40.0 MCV-89
MCH-28.6 MCHC-32.0 RDW-14.0 RDWSD-45.3 Plt ___
___ 06:55AM BLOOD Glucose-81 UreaN-17 Creat-1.0 Na-141
K-4.1 Cl-108 HCO3-21* AnGap-16
___ 06:55AM BLOOD ALT-16 AST-23 AlkPhos-90 TotBili-0.4
___ 06:55AM BLOOD Calcium-9.1 Phos-3.0 Mg-2.1
___ 06:55AM BLOOD tacroFK-3.4*
=============== IMAGING ==================
1. CT head with contrast (___)
No acute intracranial process. MRI is more sensitive for the
detection of acute infarction.
2. Chest X-Ray (___)
No acute intrathoracic process.
3. AP Pelvis and Hip (___)
No evidence of fracture.
4. Liver/Gallbladder U/S (___)
No evidence of portal vein thrombosis. The CBD is mildly
prominent at 6 mm, but is smaller than on the prior study.
=============== MICROBIOLOGY ==================
___ 6:45 pm URINE
URINE CULTURE (Preliminary):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
___ h/o alcoholic cirrhosis s/p liver transplant in ___ on
tacrolimus who p/w 1 week of confusion, gait difficulty, and
abdominal pain with UA grossly positive for infection.
# urinary tract infection
Patient presented with 1 week of dysuria and abdominal pain. UA
was grossly positive, so IV ceftriaxone was started in the ED.
When urine sensitivities showed multi-resistant E. coli, patient
was transitioned to PO nitrofurantoin given suspician for simple
cystitis. Given concern of nitrofurantoin's low blood and kidney
penetration and patient's immunosuppressed status, she was
observed overnight. She was discharged the next morning after
being clinically stable and well-appearing with plans to
complete 14 day course of appropriate antibiotics.
# confusion and weakness
Patient presented with 1 week of confusion, gait instability,
reported right lower extremity weakness. Code stroke was called
on arrival to ED, but CT head was negative and neurology did not
find any focal neurological deficits. Confusion and weakness
likely secondary to urinary tract infection and resolved with
antibiotics. Sedating home medications, cyclobenzaprine and
alprazolam were held. Patient alert and oriented, back to
neurological baseline at time of discharge.
# unsteady gait
Evaluated by neurology and thought to be unlikely due to stroke.
Urinary tract infection, confusion, and weakness may have
contributed, but patient also likely deconditioned with chronic
low back and hip pain. At time of discharge, patient's gait was
much improved, and she was able to ambulate to bathroom by
herself with walker. ___ evaluated and recommended continued
ambulation with walker when patient returns to rest house.
# acute kidney injury, resolved
Patient's creatinine had bumped to 1.8 from baseline of 1.0.
Resolved after a liter of fluids in the ED. Creatinine remained
stable and at baseline for the rest of the hospitalization.
# s/p liver transplant in ___ on tacro
Patient's LFTs were normal on admission, and there was no
evidence of decopmensated cirrhosis. Given her negative history
of cirrhosis, her rifaximin and lactulose were discontinued. She
remained alert and oriented without e/o encephalopathy. Her
tacrolimus levels were within target goal throughout the
admission.
# bedbugs
Patient has a history of cutaneous reactions to bedbugs. She was
treated symptomatically on home regimen of hydroxyzine,
tacrolimus 1% lotion, and added sarna lotion for itch.
#Transitional Issues:
1. New Medications: Nitrofurantoin 100mg Q12H (___)
- Macrobid chosen due to multiple drug resistances of E. coli in
urine. Other option would be meropenem.
- OF NOTE: nitrofurantoin does not have good kidney, blood
penetration; please monitor patient for abdominal pain, back
pain, fevers, chills, malaise. If symptoms develop, please have
patient reevaluated by a physician.
2. Medications stopped:
- Lactulose and rifaxamin stopped given no cirrhosis in
transplanted liver. Miralax started for bowel regimen in its
place.
3. Gait instability: patient should walk with assistance of
walker
4. Code: FULL
5. Contact: ___ (son): ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
3. Calcium Carbonate 500 mg PO BID
4. Citalopram 40 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Magnesium Oxide 400 mg PO DAILY
8. Metoprolol Tartrate 50 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Omeprazole 40 mg PO DAILY
11. Simvastatin 5 mg PO QPM
12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
13. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
14. TraZODone 100 mg PO QHS:PRN insomnia
15. Vitamin D 800 UNIT PO DAILY
16. HydrOXYzine 25 mg PO Q6H:PRN itch
17. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID rash
18. Alendronate Sodium 70 mg PO QWEEK
19. ALPRAZolam 0.25 mg PO TID:PRN anxiety
20. Cyclobenzaprine 10 mg PO TID:PRN muscle pain
21. Lactulose 15 mL PO DAILY constipation
22. Loratadine 10 mg PO DAILY
23. Rifaximin 550 mg PO BID
24. Tacrolimus 0.5 mg PO Q12H
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
3. Citalopram 40 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. HydrOXYzine 25 mg PO Q6H:PRN itch
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 40 mg PO DAILY
9. Simvastatin 5 mg PO QPM
10. Tacrolimus 0.5 mg PO Q12H
11. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
12. TraZODone 100 mg PO QHS:PRN insomnia
13. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID rash
14. Vitamin D 800 UNIT PO DAILY
15. Sarna Lotion 1 Appl TP QID:PRN itch
RX *camphor-menthol Apply to affected skin four times daily
Disp #*1 Bottle Refills:*0
16. Alendronate Sodium 70 mg PO QWEEK
17. ALPRAZolam 0.25 mg PO TID:PRN anxiety
18. Cyclobenzaprine 10 mg PO TID:PRN muscle pain
19. Loratadine 10 mg PO DAILY
20. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
21. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth
every 12 hours Disp #*26 Capsule Refills:*0
RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth
twice daily Disp #*26 Capsule Refills:*0
22. Calcium Carbonate 500 mg PO BID
23. Magnesium Oxide 400 mg PO DAILY
24. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Urinary tract infection
Altered mental status
Acute kidney injury
Secondary Diagnoses:
Chronic hip and back pain
Cutaneous reaction to bed bugs
S/p liver transplant in ___
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 were having confusion,
difficulty walking, and pain with urination. Your urine tests
came back showing that you had a urinary tract infection. We
treated this infection with an IV antibiotic (ceftriaxone) and
switched you to an oral antibiotic (Macrobid) before you were
discharged. You should continue to take this antibiotic until
___.
Your kidney function was slightly worse than usual when you came
in - we thought this was due to dehydration. We gave you fluids
and your kidnye function returned to normal. Because of your
weakness and confusion, there was also a concern that you had a
stroke, but your head imaging did not show a stroke. We are glad
you are feeling back to your normal self and your pain with
urination has resolved.
It was a pleasure taking care of you! We wish you all the best!
Followup Instructions:
___
|
10685894-DS-38
| 10,685,894 | 27,175,179 |
DS
| 38 |
2149-04-12 00:00:00
|
2149-04-12 16:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left acetabular fracture, UTI, ___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of orthotopic liver transplantation for
alcoholic cirrhosis in ___, steroid-mediated osteoporosis,
COPD, h/o MDR E coli UTI presents with a fall and left
acetabulum fracture, found to have ___ and UTI.
She was recently admitted from ___ for CAP, COPD
exacerbation, and EColi UTI. She was treated with prednisone
taper, azithromycin, and cefpodoxime after urine culture
resulted EColi (R to cipro/Bactrim only) to complete 8-day
course ending ___. She was discharged home with services.
She returns today after a fall yesterday. On ___, she was
walking outside her rest home with her son when she fell onto
her left hip on the cement after her "leg gave out. She denies
any preceding symptoms, dizziness, fever, chills, nausea,
vomiting, chest pain, dyspnea, syncope, abdominal pain,
diarrhea, constipation. No head strike or LOC.
In the ED, initial vitals: T98.6 HR71 BP121/73 RR16 100% RA.
Notable labs-
UA lg leuks, +nit, 23 WBC, many bact, 0 epi, 4 RBC.
WBC 10.3 from 12.4 on discharge. K 5.0. BUN/Cr ___ from
___ on discharge. Lactate 0.9. BLOOD CULTURE WAS NOT DRAWN
UNTIL AFTER ABX.
Notable imaging-
-CT pelvis revealed new focal sharp cortical irregularity
involving the anterior wall of the acetabulum, concerning for
acute fracture.
She was given:
-___ 15:12 PO Acetaminophen 1000 mg
-___ 15:12 PO/NG OxycoDONE (Immediate Release) 5 mg
-___ 18:16 IV Piperacillin-Tazobactam 4.5 g
Consults:
-Hepatology
-admit to et
-full infectious work up urine culture blood culture, cxr
-check tacro trough 1 hour pre morning dose
-check liver function tests and inr
-social consult for placement
-Orthopedics
-Non-operative
-WBAT
-Please obtain Judet views
-Plan for follow up with ___ clinic in ___ weeks
-dispo and pain control per ED
On the floor, she has no acute complaints. She does report
dysuria for past 2 days but does not think it is related to her
fall. She reports no PO intake since her fall.
Past Medical History:
- Alcoholic cirrhosis s/p Liver transplant (___) on tacrolimus
- H/o MDR UTI
- Osteoporosis ___ steroid use, s/p humerus fx ___
- h/o RUE and RLE Thrombophlebitis
- RLE DVT ___ on coumadin until s/p IVC filter ___, now off
warfarin
- h/o left foot cellulitis
- Chronic low back pain
- Hypertension
- Asthma/COPD
- Hyperlipidemia
- GERD
- Depression
- vertebral compression fractures
- Orthotopic cadaver liver transplant ___ ___
- Right unipolar hemiarthroplasty for right femoral neck fx
___ ___
- ORIF of left hip intertrochanteric hip fracture ___
___
- Removal of prominent screw and replacement with shorter screw
and bursectomy ___
- Ventral hernia repair with mesh ___
Social History:
___
Family History:
Mother with hx of CVA and seizure, sister with breast cancer,
Father died of lung cancer.
No family history of kidney disease.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T98.3 118/66 78 20 100RA
GEN: Woman appearing stated age, no acute distress, occasionally
grimaces due to hip pain
HEENT: No scleral icterus, MMM
HEART: RRR, no murmurs, normal S1 S2
LUNGS: Clear, no wheezes or rales, normal air movement
ABD: Normal BS, NT ND, not distended
EXT: Left hip tender to palpation, no erythema or bruising
NEURO: Alert, oriented, pleasant, no asterixis
SKIN: Multiple eczematous patches
DISCHARGE PHYSICAL EXAM:
VS: 98.5 ___ 120s-120s/40s-80s 20 95-98%RA
GENERAL: NAD, interactive, sitting in chair
SKIN: Left chest, bilateral UEs, bilateral distal LEs, right
popliteal area with dry plaques with fine scale c/w atopic
dermatitis, improved with clobetasol
HEENT: sclerae anicteric, MMM
LUNGS: CTAB
HEART: RRR, S1 and S2, no m/r/g
ABDOMEN: BS+, soft, NT, ND
EXTREMITIES: No ___ edema, Pt able to move LLE toes, ankle, knee,
hip. Sensation same on RLE and LLE.
NEURO: A&Ox3, Grossly Intact
Pertinent Results:
==Admission Labs==
___ 02:12PM BLOOD WBC-10.3* RBC-4.53 Hgb-13.4 Hct-41.8
MCV-92 MCH-29.6 MCHC-32.1 RDW-14.4 RDWSD-48.8* Plt ___
___ 02:12PM BLOOD Neuts-70.3 Lymphs-15.0* Monos-9.5 Eos-4.4
Baso-0.3 Im ___ AbsNeut-7.24* AbsLymp-1.54 AbsMono-0.98*
AbsEos-0.45 AbsBaso-0.03
___ 02:12PM BLOOD ___ PTT-29.9 ___
___ 02:12PM BLOOD Glucose-105* UreaN-26* Creat-1.3* Na-142
K-5.0 Cl-109* HCO3-25 AnGap-13
___ 02:12PM BLOOD Albumin-3.9 Calcium-9.5 Phos-3.4 Mg-2.1
___ 02:12PM BLOOD ALT-13 AST-23 AlkPhos-93 TotBili-0.4
___ 03:30PM URINE Color-Yellow Appear-Clear Sp ___
___ 03:30PM URINE Blood-NEG Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 03:30PM URINE RBC-4* WBC-23* Bacteri-MANY Yeast-NONE
Epi-0
___ 03:30PM URINE CastHy-3*
___ 03:30PM URINE WBC Clm-RARE Mucous-RARE
==Microbiology==
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
___. ___ REQUESTED FOSFOMYCIN SENSITIVITIES
___.
FOSFOMYCIN = SUSCEPTIBLE.
FOSFOMYCIN sensitivity testing performed by ___
___.
cefepime sensitivity testing performed by ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
Blood Cultures ___ Pending
==Imaging==
TECHNIQUE: AP view of the pelvis. AP view of the bilateral
hips. AP view of
the distal left femur.
COMPARISON: ___ right hip films.
FINDINGS:
BILAT HIPS (AP,LAT & AP PELVIS) ___
Right sided hip hemiarthroplasty is seen. Prior ORIF of the
left femur is noted. There is no perihardware lucency or
fracture. Pubic symphysis and SI joints are unremarkable. Soft
tissues are unremarkable.
IMPRESSION: No fracture.
CT PELVIS ORTHO W/O C ___
1. New focal sharp cortical irregularity involving the anterior
wall of the left acetabulum, concerning for an acute fracture.
2. Healed right iliac bone fractures.
3. Colonic diverticulosis with no evidence of acute
diverticulitis.
PELVIS W/JUDET VIEWS (3V) ___
Patient is status post partially imaged right hip arthroplasty.
The patient is also status post ORIF of the left femur,
partially imaged. From fracture of the anterior wall of the
left acetabulum is subtly seen, better assessed on preceding CT.
Subtle irregularity of the left superior pubic ramus is
concerning for nondisplaced fracture. Sacrum is partially
obscured by overlying bowel gas. There is no widening of the
pubic symphysis or sacroiliac joints.
CHEST XRAY ___
No acute cardiopulmonary process.
ABDOMNIAL US ___
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with alcoholic cirrhosis s/p OLT
___ // please evaluate OLT
TECHNIQUE: Grey scale, color and spectral Doppler ultrasound
images of the abdomen were obtained.
COMPARISON: Abdominal ultrasound ___
FINDINGS:
Liver echotexture evaluation is limited. There is no evidence of
focal liver lesions or biliary dilatation. There is no ascites,
right pleural effusion or sub- or ___ fluid
ollections/hematomas. Common bile duct measures 10 mm in width.
The spleen measures 11.3 cm and has normal echotexture.
The right and left kidneys are normal appearance with the right
measuring 10.5 and the left measuring 11.2 cm.
DOPPLER: The main hepatic arterial waveform is within normal
limits, with prompt systolic upstrokes and continuous antegrade
diastolic flow. Peak systolic velocity in the main hepatic
artery is 58.9. Appropriate arterial waveforms are seen in the
right hepatic artery and the left hepatic artery with resistive
indices of 0.78, and 0.81, respectively. The main portal vein,
right and left portal veins are patent with hepatopetal flow
with normal waveform. Appropriate flow is seen in the hepatic
veins and the IVC.
KIDNEYS: The right kidney measures 10.5 cm. The left kidney
measures 11.3 cm. Normal cortical echogenicity and
corticomedullary differentiation is seen bilaterally. There is
no evidence of masses, stones, or hydronephrosis in the kidneys.
IMPRESSION:
Patent hepatic vasculature with appropriate waveforms.
==Liver Labs==
___ 02:12PM BLOOD ALT-13 AST-23 AlkPhos-93 TotBili-0.4
___ 07:18AM BLOOD ALT-103* AST-194* CK(CPK)-37 AlkPhos-139*
TotBili-1.1
___ 07:00AM BLOOD ALT-78* AST-74* AlkPhos-120* TotBili-0.4
___ 07:05AM BLOOD ALT-60* AST-49* LD(LDH)-281* AlkPhos-111*
TotBili-0.3
___ 07:18AM BLOOD GGT-39*
___ 02:12PM BLOOD Albumin-3.9 Calcium-9.5 Phos-3.4 Mg-2.1
___ 07:18AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.8
___ 07:00AM BLOOD Albumin-3.0* Calcium-8.5 Phos-3.3 Mg-1.9
___ 07:05AM BLOOD Albumin-3.1* Calcium-8.7 Phos-3.2 Mg-1.8
___ 07:18AM BLOOD tacroFK-3.7*
___ 07:00AM BLOOD tacroFK-3.0*
___ 07:05AM BLOOD tacroFK-2.7*
==Discharge Labs==
___ 07:05AM BLOOD WBC-4.5 RBC-3.86* Hgb-11.3 Hct-36.7
MCV-95 MCH-29.3 MCHC-30.8* RDW-14.4 RDWSD-50.1* Plt ___
___ 07:05AM BLOOD Neuts-58.0 ___ Monos-10.2 Eos-6.8
Baso-0.7 Im ___ AbsNeut-2.63# AbsLymp-1.09* AbsMono-0.46
AbsEos-0.31 AbsBaso-0.03
___ 07:05AM BLOOD Glucose-90 UreaN-15 Creat-0.9 Na-139
K-4.5 Cl-107 HCO3-23 AnGap-14
___ 07:05AM BLOOD Albumin-3.1* Calcium-8.7 Phos-3.2 Mg-1.8
___ 07:05AM BLOOD ALT-60* AST-49* LD(LDH)-281* AlkPhos-111*
TotBili-0.3
___ 07:05AM BLOOD tacroFK-2.7*
Brief Hospital Course:
Ms. ___ is a ___ female with a history of liver
transplant in ___, atopic dermatitis, osteoporosis, several E
coli UTIs who presented to ___ after a fall. During the fall
she fractured her left acetabulum. She was seen by orthopedic
surgery and the fracture was felt to be non-operative. She was
also found to have a UTI. She was initially started on
piperacillin-tazobactam (___) given her history of
drug resistant E coli UTIs. She was transitioned to oral
Nitrofurantoin 100 mg twice daily on ___. She will continue
on this medication through ___ to complete a 10 day course.
She is being discharged to a rehabilitation facility to continue
to work on mobility after her fracture.
# Nondisplaced left acetabular fracture: The pt presented to the
hospital after a fall durnig which she got a nondisplaced left
acetabular fracture. Orthopedic surgery saw pt and fracture was
felt to be nonoperative. She was permitted bear weight as
tolerated and worked with ___ throughout her hospital course.
Her pain was managed with acetaminophen 500 mg Q6H and oxycodone
2.5 mg PO Q6H PRN. She will follow up with orthopedic surgery
on ___ (10:40 am x-ray, 11 am appointment).
# UTI: Pt related dysuria for two days prior to admission and
her UA is consistent with a UTI. She has previously had MDR E
Coli UTI. Presumptive speciation on ___ time was E. Coli.
She started on piperacillin-tazobactam given previous MDR E Coli
(D1 ___ and based on sensitivities transitioned to
nitrofurantoin 100 mg BID on ___. She will continue on this
through ___ to complete a ___: Cr on admission was 1.3 (baseline 0.9). This was likely
prerenal azotemia in the setting of volume depletion after fall.
She had an abdominal US showing no kidney abnormalities. Her
Cr was trended and she got IVF as needed. Cr 0.9 on discharge.
# Alcoholic Cirrhosis s/p OLT ___: Pt doing well from OLT
standpoint without any liver complaints this hospitalization.
LFTs were elevated, thought to be a stress response. Abdominal
US showed patent hepatic vasculature. She continued tacrolimus
0.5 mg Q12H and TMP-SMX prophylaxis. Her LFTs were trended.
# Atopic Dermatitis: Pt with AD on chest, UEs, LEs. She was
using triamcinolone on these lesions with some benefit prior to
admission. She was also using ketoconazole cream on her toes
for possible tinea pedis. Given that she had several eczematous
patches, she was treated with clobetasol 0.05% ointment BID to
lesions (D1: ___ and TAC was held. She continued with
ketoconazole. It would be reasonable to consider topical
tacrolimus (Protopic) 0.1% ointment to affected areas BID to
control current lesions, once controlled, use every 3 days
ongoing.
# Depression: Continued home citalopram and alprazolam
# HTN: Continued metoprolol succinate 50 mg daily
# GERD: Continued omeprazole 40 mg daily
# HLD: Continued simvastatin 5 mg QPM
# Osteoporosis: Continued alendronate 70 mg each ___,
Vitamin D 800 IU/day, Ca Carbonate 500 mg BID
# Insomnia: Continued trazodone 100 mg QHS PRN insomnia
# Chronic back pain: Continued home cyclobenzaprine, APAP,
tramadol
Transitional Issues:
-Pt has orthopedic surgery follow up ___ (10:40 am x-ray, 11
am appointment)
-Pt discharged on nitrofurantoin (macrobid) 100 mg BID through
___ to complete 10 day course for E coli UTI
-Pt had transaminitis in hospital. LFTs downtrending on
discharge.
-Pt discharged with clobetasol BID for eczema. She will continue
this through ___ and will then resume her preadmission
triamcinolone therapy.
-If needed for eczema, it would be reasonable to consider
topical tacrolimus (Protopic) 0.1% ointment to affected areas
BID to control current eczematous lesions, once controlled, use
topical tacrolimus 0.1% ointment every 3 days ongoing as
outpatient
-Please follow up pending ___ blood cultures that are
pending
-Contact: ___ (son/HCP) ___
-Code: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Calcium Carbonate 500 mg PO BID
3. Citalopram 40 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. HydrOXYzine 25 mg PO Q6H:PRN itch
7. Loratadine 10 mg PO DAILY
8. Magnesium Oxide 400 mg PO DAILY
9. Metoprolol Succinate XL 50 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 40 mg PO DAILY
12. Sarna Lotion 1 Appl TP QID:PRN itch
13. Simvastatin 5 mg PO QPM
14. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
15. Tacrolimus 0.5 mg PO Q12H
16. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
17. TraZODone 100 mg PO QHS:PRN insomnia
18. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID rash
19. Vitamin D 800 UNIT PO DAILY
20. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
21. Alendronate Sodium 70 mg PO QWED
22. ALPRAZolam 0.25 mg PO TID:PRN anxiety
23. Cyclobenzaprine 10 mg PO TID:PRN muscle pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
3. Alendronate Sodium 70 mg PO QWED
4. ALPRAZolam 0.25 mg PO TID:PRN anxiety
5. Calcium Carbonate 500 mg PO BID
6. Citalopram 40 mg PO DAILY
7. Cyclobenzaprine 10 mg PO TID:PRN muscle pain
8. Docusate Sodium 100 mg PO BID
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
10. HydrOXYzine 25 mg PO Q6H:PRN itch
11. Loratadine 10 mg PO DAILY
12. Magnesium Oxide 400 mg PO DAILY
13. Metoprolol Succinate XL 50 mg PO DAILY
14. Omeprazole 40 mg PO DAILY
15. Sarna Lotion 1 Appl TP QID:PRN itch
16. Simvastatin 5 mg PO QPM
17. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
18. Tacrolimus 0.5 mg PO Q12H
19. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
20. TraZODone 100 mg PO QHS:PRN insomnia
21. Vitamin D 800 UNIT PO DAILY
22. Benzonatate 100 mg PO TID:PRN Cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times daily
Disp #*30 Capsule Refills:*0
23. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
Please only use through ___ and then return to using
triamcinolone. Do not apply to face.
RX *clobetasol 0.05 % Apply to eczema patches twice daily. Do
not apply to face. Please use through ___ twice a day
Refills:*0
24. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 8
Days
RX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1
capsule(s) by mouth twice a day Disp #*13 Capsule Refills:*0
25. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every 4
hours Disp #*10 Tablet Refills:*0
26. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary Diagnoses:
Left acetabular fracture
Urinary tract infection (complicated)
Acute kidney injury
Secondary Diagnoses:
Atopic Dermatitis
Post Liver Transplant
Transaminitis
GERD
Depression
Hyperlipidemia
Hypertension
Osteoporosis
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 came to the hospital after a fall. You broke a bone in your
left hip called the acetabulum. You did not require surgery and
you will now go to a rehabilitation facility to continue to get
stronger.
You were also found to have an infection in your urine. You
will continue on antibiotics (macrobid) twice daily through
___.
You will follow up with orthopedic surgery on ___. You will
have an x-ray done at 10:40 am and your appointment will be at
11 am.
You were also given clobetasol ointment, a strong steroid, for
your eczema. Please apply this twice per day only to the eczema
patches through ___. On ___, you may return to using your
triamcinolone as you were before coming to the hospital. You
should also avoid putting either of these medications on your
face.
Thank you for allowing us to participate in your care.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10685894-DS-39
| 10,685,894 | 26,379,847 |
DS
| 39 |
2149-06-01 00:00:00
|
2149-06-01 19:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with a PMH significant for an
OLT (___), multiple MDR UTIs, osteoporosis and recent traumatic
left acetabulum fracture (treated non-operatively) who presents
from her assisted living with malaise.
Mrs ___ states that on ___ she awoke with malaise and felt
generally weak in her lower extremities. She says her legs
simply "gave out" on her on all attempts to ambulate since then.
She has had no falls, no head strike. She does report ongoing
urinary symptoms for years, which consist of u/f. These have not
changed significantly within the recent days/weeks. Denies any
nausea, vomiting, fevers, chills. Her main symptom other than
her legs/generalized weakness is that she has felt fatigued and
spent more time in bed sleeping over the past three days. She is
still maintaining appropriate food and fluid intake. No change
in BMs. No chest pain, dyspnea, cough. On interview, she is very
pleasant and says she feels just fine as she is lying in bed. No
other acute symptoms.
ED COURSE:
In the ED, initial vitals were: 0 98.5 64 101/52 18 95% RA
Labs notable for dirty UA, creatinine of 1.2; lactate 1.7
RUQUS and CXR without significant findings.
Patient was given single dose of pip/tazo
Vitals prior to transfer were 98.0 95 99/61 18 97% RA
Past Medical History:
- Alcoholic cirrhosis s/p Liver transplant (___) on tacrolimus
- H/o MDR UTI
- Osteoporosis ___ steroid use, s/p humerus fx ___
- h/o RUE and RLE Thrombophlebitis
- RLE DVT ___ on coumadin until s/p IVC filter ___, now off
warfarin
- h/o left foot cellulitis
- Chronic low back pain
- Hypertension
- Asthma/COPD
- Hyperlipidemia
- GERD
- Depression
- vertebral compression fractures
- Orthotopic cadaver liver transplant ___ ___
- Right unipolar hemiarthroplasty for right femoral neck fx
___
- ORIF of left hip intertrochanteric hip fracture ___
___
- Removal of prominent screw and replacement with shorter screw
and bursectomy ___ ___
- Ventral hernia repair with mesh ___ ___
Social History:
___
Family History:
Mother with hx of CVA and seizure, sister with breast cancer,
Father died of lung cancer.
No family history of kidney disease.
Physical Exam:
>> ADMISSION PHYSICAL EXAM:
Vitals: 97.8 120/66 67 16 96/RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: RRR, 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
Back: diffusely tender across back, slightly worse around L CVA
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: 99.2 ___ 95-100% RA
General: Seated comfortably in bed, no acute distress
HEENT: Sclera anicteric, EOMI, PERRL. Poor dentition. MMM,
oropharynx clear.
CV: Distant heart sounds. RRR, normal S1 + S2.
Lungs: clear bilaterally with good air movement throughout.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Back: no CVAT
GU: No foley
Ext: Warm, well perfused, no edema. Legs very thin.
Neuro: CNII-XII intact, ___ strength upper/lower extremities.
Skin: several ~4cm patches of clustered, excoriated papules on
erythematous base, predominantly on extensor surfaces (RUE, LUE,
L calf, R foot, back).
Pertinent Results:
>> ADMISSION LABS:
___ 03:50PM BLOOD WBC-7.0 RBC-4.36 Hgb-12.6 Hct-39.5 MCV-91
MCH-28.9 MCHC-31.9* RDW-14.7 RDWSD-48.8* Plt ___
___ 03:50PM BLOOD Neuts-58.7 ___ Monos-8.4 Eos-5.1
Baso-0.6 Im ___ AbsNeut-4.12 AbsLymp-1.88 AbsMono-0.59
AbsEos-0.36 AbsBaso-0.04
___ 05:29AM BLOOD ___ PTT-28.1 ___
___ 03:50PM BLOOD Glucose-104* UreaN-27* Creat-1.2* Na-140
K-4.8 Cl-108 HCO3-22 AnGap-15
___ 03:50PM BLOOD ALT-14 AST-34 AlkPhos-93 TotBili-0.4
___ 05:29AM BLOOD Albumin-3.6 Calcium-9.1 Phos-2.9 Mg-1.7
___ 05:29AM BLOOD tacroFK-6.2 (**not a true trough - drawn
at 8h)
___ 03:58PM BLOOD Lactate-1.7
.
>> DISCHARGE LABS:
___ 05:12AM BLOOD WBC-5.7 RBC-4.05 Hgb-11.6 Hct-36.3 MCV-90
MCH-28.6 MCHC-32.0 RDW-14.3 RDWSD-46.0 Plt ___
___ 05:12AM BLOOD Glucose-93 UreaN-13 Creat-1.1 Na-141
K-4.6 Cl-104 HCO3-25 AnGap-17
___ 05:12AM BLOOD ALT-12 AST-18 AlkPhos-81 TotBili-0.3
___ 05:12AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.6
.
>> OTHER RESULTS:
___ LIVER OR GALLBLADDER US (SINGL; DUPLEX DOPP ABD/PEL)
1. Patent hepatic vasculature with appropriate waveforms.
2. Mild right renal pelviectasis, new since ___.
___ CXR
The lungs are clear. There is no edema, effusion, or
pneumothorax. The
cardiomediastinal silhouette is within normal limits.
Atherosclerotic
calcifications are noted the aortic arch. Old healed right
lateral rib
fracture is again seen. Vertebroplasty changes are noted in the
lumbar spine.
___ Renal U/S
1. No hydronephrosis.
2. Small bilateral simple renal cysts.
Brief Hospital Course:
___ year old woman with a PMH significant for an OLT (___),
multiple MDR UTIs, osteoporosis and recent traumatic left
acetabulum fracture (treated non-operatively) who presents from
her assisted living with malaise, found to have a UTI.
.
>> ACTIVE ISSUES:
# UTI: Pt presented with a history of MDR E. coli, several days
of generalized weakness, U/A with +nitrites and 16 WBCs, and L
CVA tenderness. Notably, she was afebrile and without
leukocytosis. UCx grew E. coli with similar resistance profile
to past isolates, sensitive to Zosyn, meropenem, ertapenem, and
fosfomycin. She was initially started on Zosyn, then
transitioned to meropenem per ID recommendations. A midline
catheter was placed, and she was discharged on ertapenem to
complete a 10-day course of ___ (last day ___.
# Cr increase: Cr was 1.3 on admission. Suspected prerenal so
bolused 1L LR. Decreased to 1.1 by discharge; this may reflect
new baseline.
# Cirrhosis s/p OLT ___: No acute issues during this admission.
Continued Bactrim and tacro. Tacro trough was drawn, found to be
6.2 but does not reflect true trough - was drawn at 8 hours.
Will continue 1.0mg QAM/0.5mg QPM as she did at home with close
follow-up.
.
>> CHRONIC ISSUES:
# Nondisplaced left acetabular fracture: no issues during this
hospitalization.
# Atopic Dermatitis: Improved with home clobetasol, sarna lotion
# Depression/Anxiety: continued home citalopram and alprazolam
# HTN: continued home Metoprolol Succinate XL 50 mg PO DAILY
# GERD/Gastritis: continued home Omeprazole 40 mg PO DAILY
# HLD: continued home Simvastatin 5 mg PO QPM
# Osteoporosis: Continued Vitamin D 800 IU/day, Ca Carbonate 500
mg BID
# Insomnia: continued home TraZODone 100 mg PO QHS:PRN insomnia
# Chronic Back Pain: continued home Cyclobenzaprine, Tramadol.
Add Tylenol PRN.
# COPD: Continued home fluticasone, albuterol
.
>> TRANSITIONAL ISSUES:
[] check tacro trough prior to next appointment in transplant
clinic
[] consider fosfomycin for UTI suppression
[] has not been seen for follow up of acetabular fracture in
orthopedics clinic yet. Please ensure she follows up with them.
# CODE: Full
# CONTACT: ___ (son/HCP) ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
2. ALPRAZolam 0.25 mg PO TID:PRN anxiety
3. Calcium Carbonate 500 mg PO BID
4. Citalopram 40 mg PO DAILY
5. Cyclobenzaprine 10 mg PO TID:PRN muscle pain
6. Docusate Sodium 100 mg PO BID
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. HydrOXYzine 25 mg PO Q6H:PRN itch
9. Loratadine 10 mg PO DAILY
10. Magnesium Oxide 400 mg PO DAILY
11. Metoprolol Succinate XL 50 mg PO DAILY
12. Omeprazole 40 mg PO DAILY
13. Sarna Lotion 1 Appl TP QID:PRN itch
14. Simvastatin 5 mg PO QPM
15. Tacrolimus 0.5 mg PO QPM
16. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
17. TraZODone 100 mg PO QHS:PRN insomnia
18. Vitamin D 800 UNIT PO DAILY
19. Benzonatate 100 mg PO TID:PRN Cough
20. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
21. Multivitamins 1 TAB PO DAILY
22. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
23. Tacrolimus 1 mg PO QAM
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
2. ALPRAZolam 0.25 mg PO TID:PRN anxiety
3. Benzonatate 100 mg PO TID:PRN Cough
4. Calcium Carbonate 500 mg PO BID
5. Citalopram 40 mg PO DAILY
6. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
7. Cyclobenzaprine 10 mg PO TID:PRN muscle pain
8. Docusate Sodium 100 mg PO BID
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
10. HydrOXYzine 25 mg PO Q6H:PRN itch
11. Loratadine 10 mg PO DAILY
12. Magnesium Oxide 400 mg PO DAILY
13. Metoprolol Succinate XL 50 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Omeprazole 40 mg PO DAILY
16. Sarna Lotion 1 Appl TP QID:PRN itch
17. Simvastatin 5 mg PO QPM
18. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
19. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
20. TraZODone 100 mg PO QHS:PRN insomnia
21. Vitamin D 800 UNIT PO DAILY
22. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
RX *sodium chloride 0.9 % 0.9 % 10 ml IV DAILY Disp #*20
Applicator Refills:*0
23. Outpatient Lab Work
Please draw labs for tacrolimus levels on ______
1 hours before her dose.
Fax to Dr. ___ office at ___
24. Tacrolimus 1 mg PO QAM
25. Tacrolimus 0.5 mg PO QPM
26. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose
daily x 8 days starting ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
Pyelonephritis
SECONDARY:
Cirrhosis
Chronic lower back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege to care for you here at ___.
1. Why was I here?
-You came in because of weakness and pain in your back.
2. What was done?
-Urine tests showed you had another urinary tract infection.
-We started treatment with antibiotics through your veins.
-We placed an IV (called a midline) in your arm for antibiotics
at home.
3. What should I do next?
- You will continue antibiotics through your veins for 8 more
days
- Please keep follow up with all your doctors as ___.
We wish you the best,
Your ___ Team
Followup Instructions:
___
|
10685894-DS-40
| 10,685,894 | 22,549,877 |
DS
| 40 |
2149-06-16 00:00:00
|
2149-06-17 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:
Malaise
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs ___ is a ___ year old woman with a PMH
significant for an OLT (___), multiple MDR UTIs, osteoporosis
and recent traumatic left acetabulum fracture (treated
non-operatively) who was recently admitted to UTI and ___
placement, is now readmitted with RUE pain and a new ventous
thrombosis. Mrs ___ was recently hospitalized a ___ for a
moderate-resistant UTI from ___. She had a midline
placed for 8 days of antibiotics and she completed her course on
___. Midline was kept in place. She no longer complains of
urinary symptoms. However, 3 days PTA she began to develop pain
in her right arm and pain in her RUQ wrapping around to her
back. No right arm swelling. She has seen no erythema or
drainage. She reports decreased appetite and nausea but no
vomiting. She has baseline soft stools. She denies fever but
reports chills. No dysuria but baseline urinary frequency. She
denies chest pain and shortness of breath. She reports feeling
tired. She took tramadol for pain without improvement. For her
ongoing symptoms, she reported to the ED. ED COURSE:
- Initial VS: 99.6 67 97/62 16 95% RA - Exam notable for mild
tenderness to palpation at RUE ___ site without erythema or
edema, 2+ radial pulse. Tenderness to palpation in the RUQ
around to the right CVA. - Labs notable for WBC 10.4, HCO3 19
lactate 0.8. LFTs nl
- Abdominal U/S normal. LUE U/S with complete thrombosis of the
basilic vein from the antecubital fossa to the junction with the
subclavian vein. - Patient was given IV morphine
- VS prior to transfer: 8 98.9 97/45 16 RA
Past Medical History:
- Alcoholic cirrhosis s/p Liver transplant (___) on tacrolimus
- H/o MDR UTI
- Osteoporosis ___ steroid use, s/p humerus fx ___
- h/o RUE and RLE Thrombophlebitis
- RLE DVT ___ on coumadin until s/p IVC filter ___, now off
warfarin
- h/o left foot cellulitis
- Chronic low back pain
- Hypertension
- Asthma/COPD
- Hyperlipidemia
- GERD
- Depression
- vertebral compression fractures
- Orthotopic cadaver liver transplant ___ ___
- Right unipolar hemiarthroplasty for right femoral neck fx
___ ___
- ORIF of left hip intertrochanteric hip fracture ___
___
- Removal of prominent screw and replacement with shorter screw
and bursectomy ___ ___
- Ventral hernia repair with mesh ___ ___
- RUE DVT
Social History:
___
Family History:
Mother with hx of CVA and seizure, sister with breast cancer,
Father died of lung cancer.
No family history of kidney disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: RRR, 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
Back: diffusely tender across back, slightly worse around L CVA
GU: No foley Ext: WWP 2+ pulses, no clubbing, cyanosis no ___
edema. RUE PICC/midline site has some swelling around it, no
erythema or drainage. Minimally TTP. No palpable cords or
swelling between elbow or shoulder. Neurovascularly intact
distally to elbow.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
DISCHARGE
PHYSICAL EXAM:
Vitals: 98.3 114-117/59-63 ___ 20 98%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, NCAT, poor dentition
CV: RRR, distant heart sounds
Lungs: CTAB
Abdomen: Soft, nontender, non-distended, no rebound or
guarding.
Back: nontender across R flank
GU: No foley
Ext: no clubbing, cyanosis no ___ edema. RUE Minimally TTP. No
palpable cords or swelling between elbow or shoulder.
Neuro: A&Ox3, grossly normal, moving all extremities, gait with
walker.
Psych: Odd affect
Pertinent Results:
ADMISSION LABS:
___ 08:50PM BLOOD WBC-10.4*# RBC-3.94 Hgb-11.4 Hct-34.9
MCV-89 MCH-28.9 MCHC-32.7 RDW-13.8 RDWSD-44.5 Plt ___
___ 08:50PM BLOOD Neuts-68.4 Lymphs-15.2* Monos-11.7
Eos-3.7 Baso-0.4 Im ___ AbsNeut-7.11*# AbsLymp-1.58
AbsMono-1.22* AbsEos-0.38 AbsBaso-0.04
___ 11:11PM BLOOD ___ PTT-23.1* ___
___ 08:50PM BLOOD Glucose-104* UreaN-18 Creat-1.1 Na-135
K-4.2 Cl-102 HCO3-19* AnGap-18
___ 08:50PM BLOOD ALT-13 AST-19 AlkPhos-95 TotBili-0.4
___ 04:30AM BLOOD Albumin-3.3* Calcium-8.7 Phos-3.3 Mg-1.8
___ 04:30AM BLOOD tacroFK-5.0
___ 08:59PM BLOOD Lactate-0.8
IMAGING & STUDIES:
Rib Xray ___:
IMPRESSION:
There are several old healed rib fractures in the upper right
chest with no pneumothorax. Of incidental note are several
kyphoplasty procedures at L1-L2 and an IVC filter.
RUQ ___:
IMPRESSION:
1. Patent hepatic vasculature with appropriate waveforms.
2. Moderate intrahepatic biliary duct dilation with minimal
pneumobilia is unchanged since ___, but not well visualized on
the interim ultrasounds. MRCP is recommended for further
evaluation.
3. Simple renal cysts. Otherwise, normal renal ultrasound.
RECOMMENDATION(S): MRCP.
CXR ___:
IMPRESSION:
The right PICC terminates in the right axillary vein, unchanged
since ___. No new opacity concerning for pneumonia.
RUE Ultrasound ___
IMPRESSION:
1. No evidence of deep vein thrombosis in the right upper
extremity.
2. Complete thrombosis of the basilic vein from the antecubital
fossa to the junction with the subclavian vein. RUQUS ___:
1. Patent hepatic vasculature with appropriate waveforms. 2.
Simple renal cysts. Otherwise, normal renal ultrasound.
Brief Hospital Course:
Mrs ___ is a ___ year old woman with a PMH
significant for an OLT (___), multiple MDR UTIs, osteoporosis
and recent traumatic left acetabulum fracture (treated
non-operatively) who was recently admitted with MDR UTI, who was
discharged on IV antibiotics requiring PICC placement, was
admitted with RUE pain and a new venous thrombosis.
ACUTE ISSUES
# RUE Thrombosis: Pt presented with pain and swelling in RUE,
found to have thrombosis of basilic vein from antecubital fossa
to subclavian junction. Given the proximal extent of the lesion
there his a significant risk for extension into the subclavian
vein and deeper structure, the clot was managed as a DVT.
Midline pulled ___ and patient was started on heparin then
transitioned to lovenox for bridge to coumadin. She was
initially started on warfarin 5mg qday on ___, increased to
7.5mg on ___. Previously was on 10mg qday warfarin but elected
to titrate slowly given possible medication effects.
# RUQ pain, RESOLVED: Patient presented with 3 days of RUQ and R
flank pain. LFTs were stable and white count resolved without
intervention. RUQ US showed stable duct dilation from previous.
Rib films ___ did not show new fracture.
# Anemia: Baseline hgb ~11.5. No signs/sx of bleeding
CHRONIC ISSUES
# Alcoholic Cirrhosis s/p OLT ___: Pt doing well from OLT
standpoint without any liver complaints this hospitalization.
LFTs and abdominal exam normal. Continued tacrolimus and Bactrim
prophylaxis
# Nondisplaced left acetabular fracture: Pain control PRN
# Depression/Anxiety: continued home citalopram and alprazolam
# HTN: Metoprolol Succinate XL 50 mg PO DAILY
# GERD/Gastritis: Omeprazole 40 mg PO DAILY
# HLD: Simvastatin 5 mg PO QPM
# Osteoporosis: Continued alendronate 70 mg each ___,
Vitamin D 800 IU/day, Ca Carbonate 500 mg BID
# Insomnia: TraZODone 100 mg PO QHS:PRN insomnia
# Chronic Back Pain: continued home regimen Cyclobenzaprine,
APAP PRN, Tramadol.
# COPD. fluticasone, albuterol
# Atopic Dermatitis
TRANSITIONAL ISSUES:
=================
- patient discharged on lovenox ___ daily until INR
therapeutic
- patient discharged on warfarin 7.5mg daily, INR 1.2
- Will need outpatient titration of warfarin and discontinuation
of lovenox once INR is therapeutic.
- ___ to check INR twice weekly and fax to Liver Transplant
Center at ___. Next INR check ___
- plan for anticoagulation for 3 months, last day ___
# CODE: Full
# CONTACT: ___ (son/HCP) ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
2. ALPRAZolam 0.25 mg PO TID:PRN anxiety
3. Benzonatate 100 mg PO TID:PRN Cough
4. Calcium Carbonate 500 mg PO BID
5. Citalopram 40 mg PO DAILY
6. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
7. Cyclobenzaprine 10 mg PO TID:PRN muscle pain
8. Docusate Sodium 100 mg PO BID
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
10. HydrOXYzine 25 mg PO Q6H:PRN itch
11. Loratadine 10 mg PO DAILY
12. Magnesium Oxide 400 mg PO DAILY
13. Metoprolol Succinate XL 50 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Omeprazole 40 mg PO DAILY
16. Sarna Lotion 1 Appl TP QID:PRN itch
17. Simvastatin 5 mg PO QPM
18. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
19. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
20. TraZODone 100 mg PO QHS:PRN insomnia
21. Vitamin D 800 UNIT PO DAILY
22. Tacrolimus 1 mg PO QAM
23. Tacrolimus 0.5 mg PO QPM
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
2. ALPRAZolam 0.25 mg PO TID:PRN anxiety
3. Benzonatate 100 mg PO TID:PRN Cough
4. Calcium Carbonate 500 mg PO BID
5. Citalopram 40 mg PO DAILY
6. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
7. Cyclobenzaprine 10 mg PO TID:PRN muscle pain
8. Docusate Sodium 100 mg PO BID
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
10. HydrOXYzine 25 mg PO Q6H:PRN itch
11. Loratadine 10 mg PO DAILY
12. Magnesium Oxide 400 mg PO DAILY
13. Metoprolol Succinate XL 50 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Omeprazole 40 mg PO DAILY
16. Sarna Lotion 1 Appl TP QID:PRN itch
17. Simvastatin 5 mg PO QPM
18. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
19. Tacrolimus 1 mg PO QAM
20. Tacrolimus 0.5 mg PO QPM
21. TraZODone 100 mg PO QHS:PRN insomnia
22. Vitamin D 800 UNIT PO DAILY
23. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram/dose 17 gram by mouth daily
Refills:*0
24. Warfarin 7.5 mg PO DAILY16
RX *warfarin 2.5 mg 3 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
25. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
26. Enoxaparin Sodium 120 mg SC Q24H
Start: Today - ___, First Dose: First Routine
Administration Time
RX *enoxaparin 120 mg/0.8 mL 0.8 mL SC daily Disp #*14 Syringe
Refills:*0
27. Outpatient Lab Work
ICD 10: I82.6
Please check ___, PTT, INR and Cr
Please fax to: ___
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Primary:
extensive catheter associated clot, provoked
Secondary:
history of liver transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were seen at ___ for your arm pain. You were found to have
a clot in your arm where your midline catheter was. The midline
was removed and you were started on a blood thinner. Please take
warfarin every day, as directed by the Transplant Clinic. You
will also need to use lovenox (enoxaparin) injections once a day
until your INR is between ___. You will need to have your INR
checked twice a week. You will need to be on Coumadin for 3
months total.
It has been a pleasure taking care of you and we wish you all
the best,
Your ___ Care Team
Followup Instructions:
___
|
10685894-DS-41
| 10,685,894 | 26,772,496 |
DS
| 41 |
2149-07-05 00:00:00
|
2149-07-05 22:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R Hip Pain, R Back Pain
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
Ms. ___ is a ___ with PMH significant for OLT (___),
multiple MDR UTIs, osteoporosis and recent traumatic left
acetabulum fracture (treated non-operatively) who was recently
admitted for a UTI and PICC placement, now with RUE pain and a
new venous thrombosis diagnosed on her most recent admission
(___) who now presents with R hip pain. Patient was in her
usual state of health until this past ___ when she noted the
sudden onset of severe R hip pain. The pain was so severe that
she could barely move or sleep. She reports that the pain starts
in the right flank/back area and radiates down into her leg to
mid-shin. She denies trauma to the leg or back. She tried doses
of her home tramadol and Flexeril without improvement. She has a
history of urinary incontinence (estimates for the last ___
years). She denies any new lower extremity weakness or loss of
sensation (patient has chronic neuropathy). She also reports
dysuria, frequency, and urgency with suprapubic pain for the
last ___ days. Denies fever, chills, N/V, joint pain, rash.
In the ED, initial vitals were: pain 10, 99.5, 72, 98/52, 16,
98% RA Exam notable for: suprapubic tenderness and R hip pain
with movement Labs notable for: INR 5.3, Cr 1.3 (baseline
0.9-1.0), lactate 0.9, UA grossly positive with >182 WBCs/Lg
leuks/few bacteria/6 epis. Hip xray showed expected
post-operative changes without new fracture, dislocation or
hardware failure. Patient was given: 1L IVF, IV morphine 4mg x1,
IV meropenem 500mg x1, PO diazepam 5mg x1 with some improvement
in her pain. Hepatology was consulted and recommended admission
to ET.
Vitals prior to transfer: pain 6, 98.7, 79, 96/42, 18, 95% RA On
the floor, patient reports ongoing ___ leg pain which she
describes as spasm/achy. After her pain medications, her pain
level goes to a ___. A tolerable pain level for her is a
___. Patient is intermittently tearful throughout the
evaluation.
ROS:
(+) 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:
- Alcoholic cirrhosis s/p Liver transplant (___) on tacrolimus
- H/o MDR UTI
- Osteoporosis ___ steroid use, s/p humerus fx ___
- h/o RUE and RLE Thrombophlebitis
- RLE DVT ___ on coumadin until s/p IVC filter ___, now off
warfarin
- h/o left foot cellulitis
- Chronic low back pain
- Hypertension
- Asthma/COPD
- Hyperlipidemia
- GERD
- Depression
- vertebral compression fractures
- Orthotopic cadaver liver transplant ___ ___
- Right unipolar hemiarthroplasty for right femoral neck fx
___
- ORIF of left hip intertrochanteric hip fracture ___
___
- Removal of prominent screw and replacement with shorter screw
and bursectomy ___
- Ventral hernia repair with mesh ___
- RUE DVT
Social History:
___
Family History:
Mother with hx of CVA and seizure, sister with breast cancer,
Father died of lung cancer.
No family history of kidney disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital Signs: 98.1, 102/37, 81, 18, 95% RA
General: Alert, oriented, intermittently tearful
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD. Poor dentition. CV:
Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops Lungs: Clear to auscultation bilaterally, no wheezes,
rales, rhonchi Abdomen: Soft, mild TTP in the suprapubic region,
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. TTP to the right thigh not in a specific dermatomal
distribution. No overlying erythema. Neuro: CNII-XII intact, ___
strength upper and left lower extremities. Patient unable to
participate in strength or ROM testing for RLE. Decreased
sensation in ___ bilaterally consistent with past neuropathy, 2+
reflexes bilaterally, gait deferred.
DISCHARGE EXAM:
Vital Signs: 97.6-98.8 BP 96-111/55-61 HR ___ RR 18 96-100%RA
General: Alert, conversant
HEENT: NCAT, edentulous
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, NTND, no organomegaly
Ext: Warm, well perfused, no clubbing, cyanosis or edema.
Nontender over R hip. Able to actively move both legs. No
overlying erythema/effusion.
Pertinent Results:
ADMISSION LABS:
___ 08:35PM BLOOD WBC-8.9 RBC-4.05 Hgb-11.5 Hct-35.8 MCV-88
MCH-28.4 MCHC-32.1 RDW-13.8 RDWSD-44.6 Plt ___
___ 08:35PM BLOOD Neuts-68.4 Lymphs-17.4* Monos-11.5
Eos-2.3 Baso-0.2 Im ___ AbsNeut-6.10 AbsLymp-1.56
AbsMono-1.03* AbsEos-0.21 AbsBaso-0.02
___ 08:35PM BLOOD ___ PTT-58.8* ___
___ 08:35PM BLOOD Glucose-97 UreaN-19 Creat-1.3* Na-136
K-4.4 Cl-102 HCO3-23 AnGap-15
___ 08:35PM BLOOD ALT-10 AST-23 AlkPhos-92 TotBili-0.4
___ 08:35PM BLOOD Albumin-3.6 Calcium-9.0 Phos-3.2 Mg-1.7
___ 01:40PM BLOOD CRP-155.8*
___ 08:40AM BLOOD tacroFK-3.0*
___ 11:13AM BLOOD ___ Temp-37.8 pO2-42* pCO2-49*
pH-7.35 calTCO2-28 Base XS-0 Intubat-NOT INTUBA
___ 10:12PM BLOOD Lactate-0.9
DISCHARGE LABS:
___ 04:50AM BLOOD WBC-6.2 RBC-3.46* Hgb-9.9* Hct-30.3*
MCV-88 MCH-28.6 MCHC-32.7 RDW-13.3 RDWSD-42.0 Plt ___
___ 04:50AM BLOOD ___ PTT-35.8 ___
___ 04:50AM BLOOD Glucose-94 UreaN-15 Creat-0.7 Na-140
K-4.5 Cl-102 HCO3-28 AnGap-15
___ 04:50AM BLOOD ALT-20 AST-17 AlkPhos-122* TotBili-<0.2
___ 04:50AM BLOOD Calcium-8.9 Phos-2.3* Mg-2.0
___ 04:50AM BLOOD tacroFK-2.3*
LFTs:
___ 08:35PM BLOOD ALT-10 AST-23 AlkPhos-92 TotBili-0.4
___ 08:20AM BLOOD ALT-119* AST-238* AlkPhos-194*
TotBili-0.6
___ 10:55AM BLOOD ALT-117* AST-200* AlkPhos-193*
TotBili-0.5
___ 07:40AM BLOOD ALT-71* AST-67* AlkPhos-169* TotBili-0.4
___ 07:45AM BLOOD ALT-47* AST-32 AlkPhos-145* TotBili-0.3
___ 04:15AM BLOOD ALT-36 AST-23 AlkPhos-132* TotBili-0.3
___ 05:00AM BLOOD ALT-32 AST-22 AlkPhos-133* TotBili-0.3
MICROBIOLOGY:
___ 8:10 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination with mixed skin/genital flora. Clinical
significance of isolate(s) uncertain. Interpret with caution.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
FOSFOMYCIN SUSCEPTIBLE
SENSITIVITIES: MIC expressed in MCG/ML
________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
IMAGING & STUDIES:
___ ERCP:
Mild narrowing was noted at the anastomosis. Balloon sweeps
were performed from the hilum. No stones, sludge or pus was
seen.
The 8.5 mm balloon was withdrawn through the anastomosis
without resistance. Mild resistance was noted as the 11.5 mm
balloon was withdrawn through the anastomosis.
Given near normal LFTs and lack of resistance to withdrawal of
a 8.5 mm balloon, a stent was not placed.
Otherwise normal ercp to third part of the duodenum
___ Renal US:
IMPRESSION:
Bilateral simple renal cysts. No hydronephrosis or
nephrolithiasis
identified.
___ Abd US:
IMPRESSION:
1. Patent hepatic vasculature with appropriate waveforms.
2. Persistent mild extra and intra hepatic biliary ductal
dilatation and pneumobilia. Patient is planned for followup
MRCP.
___ CT R hip:
IMPRESSION:
No acute fracture.
No large joint effusion.
No evidence of hardware complication.
Chronic healed fracture of the right iliac wing.
___ HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) RIGHT
IMPRESSION: Postsurgical changes at both hips without evidence
of fracture, dislocation or hardware failure.
___ CHEST (SINGLE VIEW)
FINDINGS:
AP portable supine view of the chest. The lungs are clear. No
focal consolidation or supine evidence for effusion or
pneumothorax. Cardiomediastinal silhouette is normal. Imaged
bony structures are intact. A chronic appearing right upper rib
cage deformity is noted. IMPRESSION: No pneumonia.
Brief Hospital Course:
Ms. ___ is a ___ with PMH significant for OLT (___),
multiple MDR UTIs, osteoporosis, DVT from midline on Coumadin,
and recent traumatic left acetabulum fracture (treated
non-operatively) who now presents with R hip pain in setting of
supratherapeutic INR and UTI, also developed fever and
transaminitis.
#Transaminitis: Patient had acute increase in ALT, AST, and Alk
Phos AM of ___. Unclear precipitant but did have low-grade
fever night before. RUQ showed intra hepatic biliary ductal
dilatation. ERCP was unremarkable. Simvastatin was held. Her
LFTs improved.
#Encephalopathy: Patient has had waxing/waning mental status
consistent with delirium and correlating with administration of
pain medications. Improved with cessation of deliriogenic
medications.
#Fever: Patient has known UTI and unclear source of
transaminitis but spiking on meropenem, which E coli in urine
should be susceptible to. There was concern for cholangitis
given abnormal LFTs in the setting of fever and prior need for
biliary stenting. CMV, EBV, lyme negative. She was treated with
vancomycin (___) and meropenem for 7 day course
#R HIP PAIN: Unclear etiology, differential is broad and
includes new hip fx given h/o osteoporosis, bleed ___
supratherapeutic warfarin, RLE DVT, MSK/spasm, sciatica, and
radiculopathy. Hip xray without evidence of fracture or hardware
failure. RLE without edema or erythema to suggest DVT. CT showed
no acute fracture or collection. Ativan, gabapentin, flexeril
were trialed but discontinued due to delirium. Pain medications
were minimized due to concerning mental status while on them.
Pain resolved without intervention.
#E coli UTI: Patient has history of MDR UTI and received a dose
of meropenem in the ED. Currently without signs of sepsis. CVA
tenderness concerning for pyelo, although patient does not have
leukocytosis or other signs of infection outside report of
dysuria, frequency, and suprapubic pain. She was treated with IV
meropenem 500mg q6h (d1 = ___ for ___ coli UTI was
sensitive to fosfamycin, can consider prophylaxis if recurrence.
Recommend outpatient urology follow-up for urodynamic studies
and non-antibiotic prophylaxis evaluations.
___: likely prerenal secondary to dehydration. Received 1L IVF
in the ED and an additional 500cc on the floor. Resolved after
fluids. Bactrim was discontinued.
#RUE DVT/SUPRATHERAPEUTC INR: treated with warfarin as above.
INR 5.3 on admission. Patient is being treated for RUE
midline-associated DVT. Coumadin was held during
hospitalization. She was restarted on warfarin at 4mg with
lovenox bridge. INR on discharge was 1. Goal INR ___.
#H/O ETOH CIRRHOSIS S/P ORTHOTOPIC LIVER TRANSPLANT: Liver
transplanted in ___. Immunosuppression regimen includes
tacrolimus. She was taking SS Bactrim daily, which was
discontinued. She missed her tacrolimus dose the evening of
___.
#?ASTHMA/COPD: continue home inhalers: albuterol, fluticasone
#HLD: continue home simvastatin
#ANXIETY/DEPRESSION: continued home citalopram. Initially held
home alprazolam in the setting of receiving diazepam for muscle
spasm; this was also held for delirium.
#CHRONIC LBP: pain meds as above
#GERD: continue home omeprazole
#INSOMNIA: held home trazodone for delirium, was restarted at
lower dose
#CHRONIC CONSTIPATION: continue home bowel regimen
TRANSITIONAL ISSUES:
===================
- For anticoagulation, patient was discharged on Lovenox as
bridge to Coumadin
- Will need outpatient titration of warfarin and discontinuation
of lovenox once INR is therapeutic.
- ___ to check INR twice weekly and fax to Liver Transplant
Center at ___
- Would benefit from urologic evaluation for recurrent UTIs
# CODE: full code
# CONTACT: son ___, ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
2. ALPRAZolam 0.25 mg PO TID:PRN anxiety
3. Benzonatate 100 mg PO TID:PRN Cough
4. Calcium Carbonate 500 mg PO BID
5. Citalopram 40 mg PO DAILY
6. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
7. Cyclobenzaprine 10 mg PO TID:PRN muscle pain
8. Docusate Sodium 100 mg PO BID
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
10. HydrOXYzine 25 mg PO Q6H:PRN itch
11. Loratadine 10 mg PO DAILY
12. Magnesium Oxide 400 mg PO DAILY
13. Metoprolol Succinate XL 50 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Omeprazole 40 mg PO DAILY
16. Sarna Lotion 1 Appl TP QID:PRN itch
17. Simvastatin 5 mg PO QPM
18. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
19. Tacrolimus 1 mg PO QAM
20. Tacrolimus 0.5 mg PO QPM
21. TraZODone 100 mg PO QHS:PRN insomnia
22. Vitamin D 800 UNIT PO DAILY
23. Polyethylene Glycol 17 g PO DAILY:PRN constipation
24. Warfarin 6 mg PO DAILY16
25. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
2. Benzonatate 100 mg PO TID:PRN Cough
3. Calcium Carbonate 500 mg PO BID
4. Citalopram 40 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. HydrOXYzine 25 mg PO Q6H:PRN itch
8. Loratadine 10 mg PO DAILY
9. Magnesium Oxide 400 mg PO DAILY
10. Metoprolol Succinate XL 50 mg PO DAILY
11. Tacrolimus 1 mg PO Q12H
12. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
13. TraZODone 50 mg PO QHS:PRN insomnia
14. Warfarin 4 mg PO DAILY16
RX *warfarin [Coumadin] 2 mg 2 tablet(s) by mouth daily Disp
#*20 Tablet Refills:*0
15. Vitamin D 800 UNIT PO DAILY
16. Sarna Lotion 1 Appl TP QID:PRN itch
17. Omeprazole 40 mg PO DAILY
18. Polyethylene Glycol 17 g PO DAILY:PRN constipation
19. Multivitamins 1 TAB PO DAILY
20. Enoxaparin Sodium 80 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 80 mg/0.8 mL 80 mg sc every twelve (12) hours
Disp #*20 Syringe Refills:*0
21. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
22. Cyclobenzaprine 10 mg PO TID:PRN muscle pain
23. Simvastatin 5 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
MDR E. Coli UTI
Hip Pain
Transaminitis
Secondary diagnosis:
Toxic Metabolic encephalopathy
___
known DVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were seen at ___ for your severe hip pain. You were also
found to have a UTI. Additionally, you were noted to have an
elevation in your liver tests. We treated your UTI with
antibiotics. For your liver tests, we did an ERCP due to concern
for infection, but no infection or blockage was noted and your
liver tests improved. Your back pain improved without
intervention. You had some confusion with pain medications, so
these were scaled back. We held your Coumadin because of your
procedure. You are being given lovenox until you are therapeutic
on your Coumadin.
See below for a complete list of your meds.
We wish you the best,
Your ___ Team.
Followup Instructions:
___
|
10685894-DS-43
| 10,685,894 | 29,319,625 |
DS
| 43 |
2149-08-03 00:00:00
|
2149-08-05 11:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Right hip pain
Major Surgical or Invasive Procedure:
___ Angiography
History of Present Illness:
___ with alcoholic liver disease s/p liver transplant, prior
right partial hip replacement, Hx DVT on warfarin and lovenox,
recently hospitalized on ___ for hip pain and R hip tap now
presenting with R thigh pain and edema.
Recent admission on ___ for acute on chronic R hip pain. Had
extensive work up : including joint aspiration on ___ (rule out
septic arthritis, however with significant e/o hemarthrosis,
calculated hematocrit ~20) and A CT scan of the hip on ___ that
was
negative for fracture, hematoma, or hardware misalignment .
On this admission, patient reports acute onset of R medial thigh
swelling and ___ pain last night. The swelling and pain has
prevented her from walking. Notes some associated tingling,
which she has at baseline, but no weakness. No lightheadedness,
syncope. Some palpitations, but no CP, SOB. Of note patient
reports that she "falls all the time at home." Of note, although
she is incontinent of urine she says she hasn't urinated x1 day.
In the ED, initial vital signs were:
97.4; 104; 89/59; 18; 98% RA
On arrival, pt was triggered for hypotension.
- Exam notable for: leg and groin swelling.
- Labs were notable for.
CBC: 13.3>8.4/27.1<368
___: 20.2 PTT: 35.8 INR: 1.8
Bicarb 20
BUN/Cr ___
Normal LFTs
- Studies performed include
CTA ___:
1. Large hematoma within the proximal medial right thigh,
measuring up to 16.2 cm, with a hematocrit level suggesting
recent bleeding. No evidence of pseudoaneurysm or active
extravasation, and the source of bleeding is not identified.
2. Status post right hip hemiarthroplasty and left proximal
femur fixation without evidence of hardware complication or
fracture.
- Patient was given:
IV Fentanyl Citrate 25 mcg
IV Kcentra 2120 Units
IV Acetaminophen IV 1000 mg
- Vitals on transfer: 93; 113/59; 20; 98%
Past Medical History:
- Alcoholic cirrhosis s/p Liver transplant (___) on tacrolimus
- H/o MDR UTI
- Osteoporosis ___ steroid use, s/p humerus fx ___
- h/o RUE and RLE Thrombophlebitis
- RLE DVT ___ on coumadin until s/p IVC filter ___, now off
warfarin
- h/o left foot cellulitis
- Chronic low back pain
- Hypertension
- Asthma/COPD
- Hyperlipidemia
- GERD
- Depression
- vertebral compression fractures
- Orthotopic cadaver liver transplant ___ ___
- Right unipolar hemiarthroplasty for right femoral neck fx
___
- ORIF of left hip intertrochanteric hip fracture ___
___
- Removal of prominent screw and replacement with shorter screw
and bursectomy ___ ___
- Ventral hernia repair with mesh ___ ___
- RUE DVT
Social History:
___
Family History:
Mother with hx of CVA and seizure, sister with breast cancer,
Father died of lung cancer.
No family history of kidney disease.
Physical Exam:
On Admission:
Vitals- 98.4 PO 124 / 89 97 18 99 RA
GENERAL: AOx3, NAD
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. No
conjunctival pallor, dry mucous membranes, poor dentition.
NECK: No cervical lymphadenopathy.
CARDIAC: Distant heart sounds. Regular rhythm, normal rate, no
murmurs/gallops. No JVD.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, crackles
BACK: no CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, w/ tenderness to
deep palpation in all four quadrants, but especially in the
central abdomen.
EXTREMITIES: R medial thigh w/ large, tense edema, ecchymosis on
inferior thigh extending to R buttock
NEUROLOGIC: CN2-12 intact. + b/l tremor, +Asterixis. Stregnth
of lower ext limited by pain. Normal sensation. Patient unable
to walk due to pain, uses walker at baseline.
On discharge:
Vitals: 98.6, 100-115/52-63, 85-100, ___, 97-98% on RA
GENERAL: AOx3, NAD
HEENT: Normocephalic, atraumatic. Extraocular muscles intact.
No conjunctival pallor, moist mucous membranes, poor dentition.
CARDIAC: Distant heart sounds. Regular rhythm, normal rate, no
murmurs/gallops.
LUNGS: Clear to auscultation. No wheezes, crackles
BACK: no CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, w/ mild
tenderness to deep palpation diffusely.
EXTREMITIES: R medial thigh w/ edema, ecchymosis on inferior
thigh extending to R lateral leg and buttock. Appears to be
softer and less TTP as compared with yesterday. Full ROM of toes
with good strength. DP 2+ and equal, warm b/l.
NEUROLOGIC: CN2-12 intact. + b/l tremor. Stregnth of lower ext
limited by pain. Normal sensation.
Pertinent Results:
On Admission:
___ 09:19AM BLOOD WBC-13.3*# RBC-3.06* Hgb-8.4* Hct-27.1*
MCV-89 MCH-27.5 MCHC-31.0* RDW-15.0 RDWSD-48.1* Plt ___
___ 09:19AM BLOOD Neuts-87.3* Lymphs-8.0* Monos-3.7*
Eos-0.1* Baso-0.3 Im ___ AbsNeut-11.59*# AbsLymp-1.06*
AbsMono-0.49 AbsEos-0.01* AbsBaso-0.04
___ 09:19AM BLOOD ___ PTT-35.8 ___
___ 09:19AM BLOOD Glucose-150* UreaN-27* Creat-1.5* Na-138
K-5.0 Cl-105 HCO3-20* AnGap-18
___ 09:19AM BLOOD Albumin-3.2* Calcium-9.0 Phos-3.9 Mg-1.6
CBCs:
___ 09:19AM BLOOD WBC-13.3*# RBC-3.06* Hgb-8.4* Hct-27.1*
MCV-89 MCH-27.5 MCHC-31.0* RDW-15.0 RDWSD-48.1* Plt ___
___ 04:00PM BLOOD WBC-17.1* RBC-3.76* Hgb-10.5* Hct-32.3*
MCV-86 MCH-27.9 MCHC-32.5 RDW-14.9 RDWSD-46.2 Plt ___
___ 12:12AM BLOOD WBC-15.9* RBC-3.03* Hgb-8.5* Hct-26.3*
MCV-87 MCH-28.1 MCHC-32.3 RDW-15.1 RDWSD-47.8* Plt ___
___ 07:45AM BLOOD WBC-13.8* RBC-2.94* Hgb-8.4* Hct-24.9*
MCV-85 MCH-28.6 MCHC-33.7 RDW-15.4 RDWSD-46.9* Plt ___
___ 01:18PM BLOOD WBC-13.5* RBC-2.82* Hgb-7.9* Hct-24.6*
MCV-87 MCH-28.0 MCHC-32.1 RDW-15.2 RDWSD-48.4* Plt ___
___ 07:10PM BLOOD WBC-12.9* RBC-2.63* Hgb-7.3* Hct-23.0*
MCV-88 MCH-27.8 MCHC-31.7* RDW-15.1 RDWSD-48.0* Plt ___
___ 01:10AM BLOOD WBC-11.8* RBC-2.78* Hgb-7.9* Hct-24.5*
MCV-88 MCH-28.4 MCHC-32.2 RDW-14.7 RDWSD-47.1* Plt ___
___ 06:00AM BLOOD WBC-10.2* RBC-2.66* Hgb-7.6* Hct-23.6*
MCV-89 MCH-28.6 MCHC-32.2 RDW-14.7 RDWSD-47.8* Plt ___
___ 03:13PM BLOOD WBC-10.5* RBC-2.70* Hgb-7.9* Hct-24.0*
MCV-89 MCH-29.3 MCHC-32.9 RDW-14.9 RDWSD-47.7* Plt ___
___ 08:49PM BLOOD WBC-9.8 RBC-2.71* Hgb-7.8* Hct-24.2*
MCV-89 MCH-28.8 MCHC-32.2 RDW-15.0 RDWSD-47.7* Plt ___
___ 08:49PM BLOOD WBC-9.8 RBC-2.71* Hgb-7.8* Hct-24.2*
MCV-89 MCH-28.8 MCHC-32.2 RDW-15.0 RDWSD-47.7* Plt ___
___ 03:45PM BLOOD WBC-9.1 RBC-2.47* Hgb-6.9* Hct-22.8*
MCV-92 MCH-27.9 MCHC-30.3* RDW-15.2 RDWSD-50.9* Plt ___
___ 07:02AM BLOOD WBC-8.0 RBC-2.50* Hgb-7.2* Hct-22.7*
MCV-91 MCH-28.8 MCHC-31.7* RDW-15.1 RDWSD-49.1* Plt ___
___ 03:02PM BLOOD WBC-7.9 RBC-2.56* Hgb-7.2* Hct-23.6*
MCV-92 MCH-28.1 MCHC-30.5* RDW-15.2 RDWSD-49.7* Plt ___
On Discharge:
___ 03:02PM BLOOD WBC-7.9 RBC-2.56* Hgb-7.2* Hct-23.6*
MCV-92 MCH-28.1 MCHC-30.5* RDW-15.2 RDWSD-49.7* Plt ___
___ 07:02AM BLOOD Glucose-100 UreaN-14 Creat-1.0 Na-139
K-4.4 Cl-107 HCO3-23 AnGap-13
___ 07:02AM BLOOD Calcium-8.5 Phos-4.2# Mg-1.8
Imaging:
___ Right Femoral Angiography:
FINDINGS:
1. Patent right profunda, external iliac and visualized
portions of the SFA.
2. No pseudoaneurysm or definitive active extravasation
identified from the interrogated vessels in the right thigh.
3. Hyperemia in the medial right thigh.
4. Patent left common femoral artery.
IMPRESSION:
No active hemorrhage was identified.
___ RUE U/S:
IMPRESSION:
Follow-up ultrasound demonstrates recanalization of the right
basilic vein, with residual, chronic thrombus in the right
basilic vein, with resolution of previously seen thrombus in the
right axillary vein.
___ CTA RLE:
IMPRESSION:
1. Large hematoma within the proximal medial right thigh,
measuring up to 16.2 cm, with a hematocrit level suggesting
recent bleeding. No evidence of pseudoaneurysm or active
extravasation, and the source of bleeding is not identified.
2. Status post right hip hemiarthroplasty and left proximal
femur fixation
without evidence of hardware complication or fracture.
Brief Hospital Course:
Ms. ___ is a ___ F with EtOH cirrhosis s/p liver txp in ___,
and a recent admission for abdominal and hip pain, presenting
with R hip swelling and pain, determined on CT to be a hematoma,
w/ no active extravasation. Patient's anticoagulation was
reversed with Kcentra, Coumadin was stopped, and she was given
3u pRBCs. However, her Hb continued to trend down and therefore
she underwent angiogram on ___. However, no source of bleed was
identified on agiogram. Patient remained hemodynamically stable,
and obtained serial hb/hct which remained stablex3, indicating
that bleeding had stopped. Of note, patient had RUE Ultrasound
to evaluate for clot given she had previous clot in the setting
of previous PICC line. Clot burden was improved, but she
continued to have residual clot. Given falls, the risk of
Coumadin was felt to be too high and anticoagulation was not
resumed. She was discharged to a rehab facility, with plan to
follow up in transplant clinic in ___ weeks.
#R hematoma: The exact etiology was not clear, although it is
possible she had trauma to her Right thigh in the setting of one
of her recurrent falls. On presentation, pt had downtrending
H/H, requiring 3U PRBCs over the course of her hospitalization.
She was given K-centra in the ED as above, and she received
vitamin K as well. Pt was evaluated by vascular surgery and
general surgery who did not feel that her hematoma needed
drainage. Pt underwent angiography on ___, which did not show
any active bleeding. Her Hct stabilized on ___ and ___, and
the swelling/pain on her Right thigh improved significantly,
although she continued to have significant ecchymosis along her
Right posterior thigh and Right buttock. She was discharged
WITHOUT warfarin, and it was felt that, given her recurrent
falls, the risk of Coumadin in her outweighed the risk of PE
from her residual clot burden (see below). Pt's pain was managed
with oxycodone 10mg PO Q6H PRN. H/H at discharge was 7.2/23.6.
___: On presentation, pt's Cr was 1.5 (baseline ~1). ___ felt
to be prerenal in the setting of blood loss. Her Cr improved
with IVF and blood transfusions and was 1.0 at the time of
discharge.
#H/o EtOH cirrhosis s/p liver transplant in ___: Pt was
continued on home tacrolimus while in house, and her tacrolimus
levels remained ___.
#Hx RUE DVT I/s/o PICC: As above, pt's INR was reversed in the
setting of bleeding. RUE U/S showed some residual clot in the
Right basilic vein, improved from prior. Given the relatively
low risk of PE from this clot, and her high risk of bleeding and
falling, a decision was made to stop anticoagulation.
#HTN: Pt's home metoprolol was initially held in the setting of
bleeding. It was restarted at the time of discharge.
#asthma: Pt was continued on home albuterol and fluticasone
inhalers
#Depression: Continue home citalopram
#Constipation: Continued home docusate and senna PRN
#Eczema: Continued home triamcinolone and clobetasol creams and
hydroxyzine for itching
#HLD: Continued home simvastatin
#Insomnia: Continued home trazadone as needed for sleep
#osteoporosis: Continued home calcium, vitamin D
#CODE: Full
#CONTACT: Son ___ (HCP): ___ (home), ___
(cell)
Transitional issues
-Recheck hemoglobin and hematocrit on ___ to ensure
stability (Hgb 7.2 on the day of discharge).
-hold Coumadin, patient will have f/u in liver transplant clinic
which will determine if she should continue
-lovenox discontinued
-continue oxycodone 10 mg q6h PRN for pain control
-check circumferential right thigh measurement and right groin
for signs of enlarging hematoma (original ~16 cm)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
2. Calcium Carbonate 500 mg PO TID
3. Citalopram 40 mg PO DAILY
4. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID:PRN
itching rash
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Fluticasone Propionate 110mcg 1 PUFF IH BID
7. HydrOXYzine 25 mg PO Q6H:PRN itching
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Omeprazole 40 mg PO DAILY
11. Polyethylene Glycol 17 g PO DAILY
12. Sarna Lotion 1 Appl TP QID:PRN itch
13. Simvastatin 5 mg PO QPM
14. Tacrolimus 1 mg PO Q12H
15. TraZODone 50 mg PO QHS:PRN insomnia
16. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID:PRN itching
rash
17. Vitamin D 800 UNIT PO DAILY
18. Warfarin 5 mg PO DAILY16
19. Gabapentin 200 mg PO TID
20. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
21. Enoxaparin Sodium 80 mg SC Q12H
Discharge Medications:
1. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 10 mg 1 tablet(s) by mouth q6h PRN Disp #*16
Tablet Refills:*0
2. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth BID PRN Disp
#*14 Tablet Refills:*0
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
4. Calcium Carbonate 500 mg PO TID
5. Citalopram 40 mg PO DAILY
6. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID:PRN
itching rash
7. Docusate Sodium 100 mg PO BID:PRN constipation
8. Fluticasone Propionate 110mcg 1 PUFF IH BID
9. Gabapentin 200 mg PO TID
10. HydrOXYzine 25 mg PO Q6H:PRN itching
11. Metoprolol Succinate XL 50 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Omeprazole 40 mg PO DAILY
14. Polyethylene Glycol 17 g PO DAILY
15. Sarna Lotion 1 Appl TP QID:PRN itch
16. Simvastatin 5 mg PO QPM
17. Tacrolimus 1 mg PO Q12H
18. TraZODone 50 mg PO QHS:PRN insomnia
19. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID:PRN
itching rash
20. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary Diagnosis:
Hematoma
Secondary Diagnosis:
___
Chronic R Hip pain
ETOH cirrhosis s/p liver transplant
Hx DVT
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 being involved in your care
Why you were here:
-you came in because you developed swelling and pain in you
right leg
What we did while you were here:
-we got some imaging of your leg and determined that you had a
bleed in your thigh
-we reversed your anticoagulation, and stopped your Coumadin
-we did a procedure called an angiogram to look for a bleed, but
could not find an active source of bleeding
Your next steps:
-please follow up with the transplant clinic on ___
-do not take Coumadin unless told otherwise
-continue to work with your physical therapist at rehab to
regain strength and mobility in your leg
We wish you well,
Your ___ Care Team
Followup Instructions:
___
|
10685894-DS-45
| 10,685,894 | 29,555,582 |
DS
| 45 |
2151-03-15 00:00:00
|
2151-03-15 22:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Rash
Major Surgical or Invasive Procedure:
EGD ___
Colonoscopy ___
History of Present Illness:
___ is a ___ yo woman with PMH significant for
orthotopic liver transplant (on tacrolimus) and multi-drug
resistant UTI who presented to the ED with bilateral ___ rash.
Patient reports a history of eczema since childhood that was
well-controlled, typically presenting with occasional lesions on
the medial aspect of her elbow. One month prior to admission,
she
developed a self-reported "eczema flare" on her bilateral lower
extremities, particularly on her ankles and dorsal aspect of
knees. She described this rash as clustered, erythematous,
raised
bumps associated with significant pruritus. Despite
hydrocortisone cream and PO antibiotics prescribed by her PCP,
the rash continued to spread to her entire ___, as well as
stomach, back, and arms, prompting her to present to the ED. She
endorses some chills and night sweats, but denies fever.
She also described an unrelated episode of burning with
urination
2 days prior to admission, but reports that this has since
resolved and denies any current dysuria or urinary frequency.
She
reports a history of intermittent perineal pain and dysuria.
In the ED, initial vital signs were notable for 98.5 | 60 |
131/66 | 16 | 95% RA. Exam notable for erythematous, warm,
slightly swollen ___ with flakey patches and associated
excoriation. Abdominal exam notable for suprapubic tenderness.
Labs were notable for low albumin 3.3, elevated lipase 65. Trace
leukocytes, 10 WBC, and few bacteria on UA. Patient was given
NS,
PO oxycodone, and IV vanc.
Consults: Derm, Transplant Hepatology. Dermatology recommended
Cefazolin given concern for SSTI and clobatesol. Likelihood of
secondary syphilis was felt to be low.
Vitals on transfer: 98.1 | 136/72 | 60 | 16 | 95% RA
Upon arrival to the floor, the patient was laying in bed and
pleasantly conversant. She continues to endorse ___ pain
bilaterally.
Review of Systems:
Complete ROS obtained and is otherwise negative.
Past Medical History:
- in ___ she has a heart attack in ___ s/p cath with no
intervention.
- Alcoholic cirrhosis s/p Liver transplant (___) on tacrolimus
- H/o MDR UTI
- Osteoporosis ___ steroid use, s/p humerus fx ___
- h/o RUE and RLE Thrombophlebitis
- RLE DVT ___ on coumadin until s/p IVC filter ___, now off
warfarin
- h/o left foot cellulitis
- Chronic low back pain
- Hypertension
- Asthma/COPD
- Hyperlipidemia
- GERD
- Depression
- vertebral compression fractures
- Orthotopic cadaver liver transplant ___ ___
- Right unipolar hemiarthroplasty for right femoral neck fx
___
- ORIF of left hip intertrochanteric hip fracture ___
___
- Removal of prominent screw and replacement with shorter screw
and bursectomy ___ ___
- Ventral hernia repair with mesh ___ ___
- ___ DVT
Social History:
___
Family History:
Mother with hx of CVA and seizure, sister with breast cancer,
Father died of lung cancer.
No family history of kidney disease.
Physical Exam:
ADMISSION PHYSICAL
==================
VITALS: Afebrile, Stable
GENERAL: Alert and interactive. In no acute distress.
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally; gaze conjugate. Sclera anicteric and
without injection. Moist mucous membranes.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally w/ end-expiratory
wheezes. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended. Mildly tender to
deep palpation in suprapubic region.
EXTREMITIES: Mild 1+ edema in RLE. No clubbing, cyanosis. Pulses
DP/Radial 2+ bilaterally.
SKIN: Large brown scaly plaques on anterior and medial surface
of
both RLE and LLE. TTP. Erythematous papules on bilateral arms,
abdomen, and left lateral thigh. No palmar/plantar lesions.
NEUROLOGIC: No gross deficits. AOx3.
DISCHARGE PHYSICAL
==================
VITALS: 24 HR Data (last updated ___ @ 740)
Temp: 98.1 (Tm 100), BP: 134/69 (134-163/60-76), HR: 69
(51-69), RR: 18, O2 sat: 98% (94-98), O2 delivery: Ra, Wt: 132.2
lb/59.97 kg
GENERAL: NAD
HEENT: NC/AT, anicteric sclerae, MMM, poor dentition
CARDIAC: RRR, no M/R/G
LUNGS: CTAB, no IWOB
ABDOMEN: soft, NTND, +BS
EXTREMITIES: Mild 1+ edema in RLE. No clubbing, cyanosis. Pulses
DP/Radial 2+ bilaterally.
SKIN: Large brown scaly plaques on anterior and medial surface
of
both RLE and LLE -markedly improved. Erythematous papules on
bilateral arms, abdomen, and left lateral thigh - improved.
NEUROLOGIC: No gross deficits. AOx3.
Pertinent Results:
ADMISSION LABS
==============
___ 08:38PM BLOOD WBC-5.9 RBC-3.97 Hgb-11.8 Hct-36.3 MCV-91
MCH-29.7 MCHC-32.5 RDW-14.4 RDWSD-48.5* Plt ___
___ 08:38PM BLOOD Neuts-48.3 ___ Monos-11.9
Eos-12.6* Baso-0.5 Im ___ AbsNeut-2.84 AbsLymp-1.55
AbsMono-0.70 AbsEos-0.74* AbsBaso-0.03
___ 08:38PM BLOOD Plt ___
___ 08:38PM BLOOD Glucose-97 UreaN-21* Creat-1.1 Na-145
K-4.6 Cl-107 HCO3-26 AnGap-12
___ 08:38PM BLOOD ALT-8 AST-15 AlkPhos-79 TotBili-0.3
___ 08:38PM BLOOD Lipase-65*
___ 08:38PM BLOOD Albumin-3.3* Calcium-9.5 Phos-3.1 Mg-1.7
___ 04:57AM BLOOD tacroFK-5.0
___ 10:45PM BLOOD Lactate-1.0
___ 11:30PM URINE Color-Straw Appear-Clear Sp ___
___ 11:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR*
___ 11:30PM URINE RBC-2 WBC-10* Bacteri-FEW* Yeast-NONE
Epi-1
___ 11:30PM URINE Mucous-RARE*
MICRO/PERTINENT RESULTS
=======================
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
RPR ___: Non-Reactive
Blood Cultures ___: Pending - No Growth to Date
STUDIES
=======
Right Lower Extremity Doppler Ultrasound ___
No evidence of deep venous thrombosis in the right lower
extremity veins.
EGD ___
Esophagus:
Mucosa: A salmon colored island was seen and biopsied at 33 cm.
A regular Z line was seen at 35 cm.
Stomach:
Mucosa: Normal mucosa was noted. Two cold forceps biopsies were
performed for histology at the stomach body. Two cold forceps
biopsies were performed for histology at the stomach antrum.
Duodenum:
Mucosa: Normal mucosa was noted. Two cold forceps biopsies were
performed for histology at the duodenal bulb. Four cold forceps
biopsies were performed for histology at the D2.
Impression:
A salmon colored island was seen and biopsied at 33 cm.
A regular Z line was seen at 35 cm.
Normal mucosa in the stomach. Two cold forceps biopsies were
performed for histology at the stomach body. Two cold forceps
biopsies were performed for histology at the stomach antrum.
Normal mucosa in the duodenum. Two cold forceps biopsies were
performed for histology at the duodenal bulb. Four cold forceps
biopsies were performed for histology at the D2.
Colonoscopy ___
Findings:
Mucosa: Quality of preparation: ___ 2 + 3 + 2. DRE: Normal.
The colonoscope inserted through the anus and under direct
visualization advanced to the terminal ileum. The appendiceal
orifice was identified. Color, texture, mucosa and anatomy of
the colon were carefully examined. Terminal ileum: Normal.
Cecum: A small polyp was seen and removed (see below). Ascending
colon: Normal. Transverse colon: Normal. Descending colon:
Normal. Sigmoid colon: A small polyp was seen and removed (see
below). Multiple diverticula were seen. Rectum: Normal. TI and
random colon biopsies were taken. Cold forceps biopsies were
performed for histology throughout the whole colon. Four cold
forceps biopsies were performed for histology at the terminal
ileum.
Protruding Lesions: A single sessile 1 mm polyp of benign
appearance was found in the cecum. A single-piece polypectomy
was performed using a cold forceps. The polyp was completely
removed. A single sessile 10 mm polyp of benign appearance was
found in the sigmoid colon. A single-piece polypectomy was
performed using a hot snare. The polyp was completely removed.
Impression:
Quality of preparation: ___ 2 + 3 + 2. DRE: Normal. The
colonoscope inserted through the anus and under direct
visualization advanced to the terminal ileum. The appendiceal
orifice was identified. Color, texture, mucosa and anatomy of
the colon were carefully examined.
Terminal ileum: Normal.
Cecum: A single sessile 1 mm polyp of benign appearance was
found in the cecum. A single-piece polypectomy was performed
using a cold forceps. The polyp was completely removed.
Ascending colon: Normal.
Transverse colon: Normal.
Descending colon: Normal.
Sigmoid colon: A single sessile 10 mm polyp of benign appearance
was found in the sigmoid colon. A single-piece polypectomy was
performed using a hot snare. The polyp was completely removed.
Multiple diverticula were seen.
Rectum: Normal.
Cold forceps biopsies were performed for histology throughout
the whole colon. Four cold forceps biopsies were performed for
histology at the terminal ileum
DISCHARGE LABS
==============
___ 04:46AM BLOOD WBC-10.5* RBC-3.97 Hgb-11.8 Hct-35.1
MCV-88 MCH-29.7 MCHC-33.6 RDW-14.0 RDWSD-45.2 Plt ___
___ 04:46AM BLOOD ___ PTT-28.7 ___
___ 04:46AM BLOOD Glucose-106* UreaN-21* Creat-0.9 Na-141
K-4.7 Cl-104 HCO3-24 AnGap-13
___ 04:46AM BLOOD ALT-10 AST-19 AlkPhos-86 TotBili-0.4
___ 04:46AM BLOOD Calcium-9.0 Phos-3.1 Mg-1.6
___ 04:46AM BLOOD tacroFK-3.8*
Brief Hospital Course:
___ female with a history of alcoholic cirrhosis status
post OLT in ___ on tacrolimus, eczema, hypertension,
depression, hyperlipidemia, asthma, chronic pain syndrome, and
MDR UTI who presented with one month history of b/l ___ rash
concerning for eczematous eruption with superimposed cellulitis.
ACTIVE ISSUES:
# Eczematous eruption complicated by right lower extremity
cellulitis
The patient had a self-reported history of eczema and is
followed in ___ clinic who presented with a history of
pruritic skin rash and widespread scaly plaques most consistent
with a pruritic eczematous eruption. Given erythema, edema, and
TTP of R>L ___, eczema flare was also likely complicated by
superimposed cellulitis. Dermatology was consulted and
recommended topical steroids (clobetasol 0.05% ointment twice
daily), aggressive emollient use and cefazolin for 10 days. The
patient's wound culture later grew coagulase-positive staph and
she was transitioned to cephalexin as she remained stable
without other infectious signs or symptoms. Secondary syphilis
was considered but thought to be unlikely and an RPR was
nonreactive. Given her asymmetric right > left lower extremity
swelling, a lower extremity doppler ultrasound was ordered but
was negative for DVT.
# Alcoholic Cirrohosis s/p OLT (___)
The patient's LFTs were baseline admission and continued to
remain so. She was continued on her home dose of tacrolimus 0.5
mg twice daily and her Keppra levels were trended daily. As she
was admitted as an inpatient, she underwent screening EGD and
colonoscopy on ___ to avoid loss of follow-up.
# H/o MDR E. Coli UTI
Patient had history of MDR-E coli UTI sensitive only to
meropenem, gentamicin, nitrofurantoin, and zosyn. Although she
was found to have WBC and bacteria on UA and initially had mild
suprapubic tenderness to palpation, she was afebrile with normal
WBC and did not endorse any current urinary symptoms such as
dysuria, increased frequency, increased urgency, or back pain.
She had been previously evaluated as an outpatient and
infectious disease clinic for this finding but was due to have
further workup of persistent perineal pain thought to be related
to postmenopausal atrophic vaginitis and complex pain syndrome
with OB/GYN. Given lack of symptoms, broad-spectrum antibiotics
were deferred during her hospitalization. She was closely
monitored for signs of infection and urinary symptoms.
CHRONIC ISSUES:
# Chronic Pain
The patient was continued on oxycodone 5 mg twice daily as
needed and gabapentin 300 mg twice daily.
# HTN
The patient remained normotensive since admission. She was
continued on home lisinopril 2.5 mg daily and furosemide 20 mg
daily.
# Asthma
Her O2 sats stable were on admission and she denied any recent
asthma flares. The patient was continued on albuterol every 4
hours as needed and fluticasone twice daily.
# Depression
The patient was continued on citalopram 40 mg daily.
# HLD
The patient was continued on atorvastatin 80 mg nightly.
# Insomnia
The patient was continued on trazodone 100 mg nightly as needed.
# Hx MI s/p cath
The patient was continued on aspirin 81 mg daily and metoprolol
XL 50 mg daily.
TRANSITIONAL ISSUES
===================
[]Tamiflu: Continue taking Tamiflu 75 mg once daily for 10 days
(last day ___
[]Cephalexin: Continue taking 500 mg every 6 hours for 10 total
days of treatment (last day ___
[]Clobetasol: continue using twice daily until ___. Patient to
followup in ___ clinic on ___.
[]Tacrolimus: NO changes, continue 0.5mg very 12 hours
[]Esophagus, Stomach, Colon Biopsies: Please followup with GI
office for pathology results, patient will be notified by GI
office
[]History of MDR E. Coli UTI: deferred treatment give lack of
symptoms, patient should follow-up with OB/GYN to rule out
chronic pain component
#CODE: Full (presumed)
#CONTACT: ___ (son) Phone: ___
___ on Admission:
1. Lisinopril 2.5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Citalopram 40 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Gabapentin 300 mg PO BID
7. HydrOXYzine 25 mg PO Q6H:PRN itching
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 40 mg PO BID
10. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain -
Moderate
11. Polyethylene Glycol 17 g PO DAILY
12. TraZODone 50 mg PO QHS:PRN insomnia
13. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID:PRN itching
rash
14. Vitamin D 800 UNIT PO DAILY
15. Calcium Carbonate 500 mg PO TID
16. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID:PRN
itching rash
17. Ferrous Sulfate 325 mg PO DAILY
18. Fluticasone Propionate 110mcg 1 PUFF IH BID
19. Metoprolol Succinate XL 50 mg PO DAILY
20. Tacrolimus 0.5 mg PO Q12H
21. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
Discharge Medications:
1. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours
Disp #*12 Capsule Refills:*0
RX *cephalexin 500 mg 1 capsule(s) by mouth four times a day
Disp #*8 Capsule Refills:*0
2. OSELTAMivir 75 mg PO DAILY
RX *oseltamivir 75 mg 1 capsule(s) by mouth daily Disp #*5
Capsule Refills:*0
RX *oseltamivir 75 mg 1 capsule(s) by mouth daily Disp #*2
Capsule Refills:*0
3. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
RX *clobetasol 0.05 % affected area on both legs twice daily
Refills:*0
4. TraZODone 100 mg PO QHS:PRN insomnia
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Calcium Carbonate 500 mg PO TID
9. Citalopram 40 mg PO DAILY
10. Ferrous Sulfate 325 mg PO DAILY
11. Fluticasone Propionate 110mcg 1 PUFF IH BID
12. Furosemide 20 mg PO DAILY
13. Gabapentin 300 mg PO BID
14. HydrOXYzine 25 mg PO Q6H:PRN itching
RX *hydroxyzine HCl 25 mg 1 by mouth every six (6) hours Disp
#*30 Tablet Refills:*0
15. Lisinopril 2.5 mg PO DAILY
16. Metoprolol Succinate XL 50 mg PO DAILY
17. Multivitamins 1 TAB PO DAILY
18. Omeprazole 40 mg PO BID
19. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain -
Moderate
20. Polyethylene Glycol 17 g PO DAILY
21. Tacrolimus 0.5 mg PO Q12H
RX *tacrolimus [Prograf] 0.5 mg 1 capsule(s) by mouth every
twelve (12) hours Disp #*60 Capsule Refills:*0
22. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID:PRN
itching rash
23. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
=================
Eczema flare complicated by right lower extremity cellulitis
Influenza exposure
Chronic pain syndrome
Alcoholic cirrhosis status post orthotopic liver transplant
(___)
Secondary Diagnoses
===================
Hypertension
Asthma
Depression
Hyperlipidemia
Insomnia
History of MI status post cath
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 in the hospital!
Why was I admitted to the hospital?
-You came to the hospital because you had an eczema flareup and
a superficial infection in your right leg
What happened while I was admitted to the hospital?
-You were seen by the dermatologists who recommended steroid
creams as well as an antibiotic for 10 days because of possible
infection in your right leg
-Your infection workup showed a bacterial infection in your
right leg that was treated with an antibiotic
An ultrasound of your right leg did not show any signs of a
blood clot
Your IV antibiotic was converted to an oral antibiotic that you
can take after you leave the hospital
-During a social group meeting, a visitor was found to have the
flu and so you were given a medication to prevent you from
developing the flu
-You also underwent a screening EGD and colonoscopy as you were
due for both
-Your lab numbers were closely monitored and you were continued
on your home medications
What should I do after I leave the hospital?
-Please continue taking all of your medications as prescribed,
details below
-Keep all of your appointments as scheduled
We wish you the very best!
Your ___ Care Team
Followup Instructions:
___
|
10685894-DS-46
| 10,685,894 | 22,662,636 |
DS
| 46 |
2151-04-30 00:00:00
|
2151-04-30 18:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
pruritic rash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o F with history of liver transplant on tacrolimus, MDR
UTI, prior DVT no longer on anticoagulation, chronic pain, who
presents for evaluation of recurrent pruritic bilateral lower
extremity rash. She was recently admitted from ___ to ___
for eczematous eruption c/b cellulitis (wound cx with coag +
staph), treated initially with IV cefazolin and then
transitioned to cephalexin to complete 10 day course. She states
that her cellulitis initially resolved with treatment. However,
on ___, she started noticing small eruptions again, which
she admits to scratching. They have progressed since then and
she now notes areas of open skin with clear, non-purulent
drainage on her bilaterally lower extremities. She also has rash
on her arms and chest, although they are without drainage. She
states the rash is both itchy and painful. No fever, chills,
N/V/D, myalgias, dysuria. She has not tried any new medications
or any new topicals. She was supposed to be using steroid creams
but has not. She has been using eucerin cream twice a day. She
had an appointment with dermatology on the ___ but did
not attend.
She also notes about 1 week of cough associated with mild
dyspnea, wheezing and increased sputum production. She has been
out of albuterol for about 1 month but feels that she needs it.
No associated chest pain, palpitations or diaphoresis.
Past Medical History:
Medical History:
- Alcoholic cirrhosis s/p orthotopic liver transplant (___) on
tacrolimus
- MI s/p cath at ___ with no intervention.
- H/o MDR UTI
- Severe eczema
- Osteoporosis ___ steroid use, s/p humerus fx ___
- h/o RUE and RLE Thrombophlebitis
- RLE DVT ___ on coumadin until s/p IVC filter ___, now off
AC
- h/o left foot cellulitis
- Chronic low back pain
- Hypertension
- Asthma/COPD
- Hyperlipidemia
- GERD
- Depression
- vertebral compression fractures
Surgical History:
- Orthotopic cadaver liver transplant ___ ___
- Right unipolar hemiarthroplasty for right femoral neck fx
___ ___
- ORIF of left hip intertrochanteric hip fracture ___
___
- Removal of prominent screw and replacement with shorter screw
and bursectomy ___ ___
- Ventral hernia repair with mesh ___
Social History:
___
Family History:
Mother with hx of CVA and seizure, sister with breast cancer,
Father died of lung cancer.
No family history of kidney disease.
Physical Exam:
ADMISSION EXAM:
VS: 98.1 ___
GENERAL: Alert and interactive. In no acute distress.
Chronically ill appearing
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally. Sclera anicteric and
without injection. Moist mucous membranes.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally w/ end-expiratory
wheezes. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended. Mildly tender to
deep palpation in suprapubic region.
EXTREMITIES: Trace edema bilaterally. No clubbing, cyanosis.
Pulses
DP/Radial 2+ bilaterally.
SKIN: Large brown scaly plaques on anterior and medial surface
of both RLE and LLE. TTP. Erythematous papules on bilateral
arms,
abdomen, and left lateral thigh. No palmar/plantar lesions.
Clear drainage and excoriations of lower extremity lesions.
Hyperpigmented excoriated bodies diffusely on chest, back. legs,
arms.
NEUROLOGIC: No gross deficits. AOx3.
DISCHARGE EXAM:
GENERAL: Thin frail older woman in NAD.
HEENT: No icterus or injection. Poor dentition.
CV: RRR, no murmurs.
RESP: Normal work of breathing. CTAB.
ABD: Soft, NDNT.
NEURO: Alert, oriented, attentive, no deficits.
SKIN: Erythematous plaques and excoriations on bilateral distal
and proximal ___, improving since admission. No purulence or
fluctuance.
Pertinent Results:
ADMISSION LABS:
___ 08:05PM BLOOD WBC-8.4 RBC-4.42 Hgb-13.3 Hct-40.5 MCV-92
MCH-30.1 MCHC-32.8 RDW-14.6 RDWSD-49.2* Plt ___
___ 08:05PM BLOOD Neuts-58.3 ___ Monos-9.2
Eos-11.6* Baso-0.7 Im ___ AbsNeut-4.88 AbsLymp-1.68
AbsMono-0.77 AbsEos-0.97* AbsBaso-0.06
___ 08:05PM BLOOD Glucose-96 UreaN-16 Creat-1.2* Na-144
K-4.5 Cl-104 HCO3-25 AnGap-15
___ 05:29AM BLOOD ALT-11 AST-15 AlkPhos-83 TotBili-0.3
___ 05:29AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.7
___ 05:29AM BLOOD tacroFK-3.0*
DISCHARGE LABS:
___ 05:28AM BLOOD WBC-5.9 RBC-4.14 Hgb-12.4 Hct-37.4 MCV-90
MCH-30.0 MCHC-33.2 RDW-14.1 RDWSD-46.6* Plt ___
___ 05:28AM BLOOD Glucose-117* UreaN-20 Creat-1.0 Na-138
K-5.0 Cl-100 HCO3-25 AnGap-13
___ 05:28AM BLOOD ALT-10 AST-18 LD(LDH)-203 AlkPhos-89
TotBili-0.4
___ 05:28AM BLOOD tacroFK-2.5*
MICRO:
WOUND CULTURE (Preliminary):
STAPH AUREUS COAG +. SPARSE GROWTH.
Blood Culture, Routine (Pending):
STUDIES:
CXR ___
No signs of pneumonia.
Brief Hospital Course:
BRIEF SUMMARY:
===============
___ woman with a history of alcoholic cirrhosis s/p OLT
in ___ on tacrolimus, severe eczema, CAD, admitted for the
second time in several weeks for severe eczematous skin eruption
with superimposed cellulitis. She improved quickly with topical
steroids and oral antibiotics and was discharged the next day to
her rest home with close Dermatology f/u.
ACTIVE ISSUES:
===============
# Severe eczematous eruption:
# Cellulitis:
Patient presented with recurrent pruritic erythematous plaques
on her lower extremities. Dermatology was consulted last
admission and recommended topical steroids, emollients, and oral
antibiotics. She acknowledged she had not adhered to these
therapies. She was restarted on topical clobetasol and
emollients, as well as empiric cephalexin for presumed
superimposed cellulitis. Wound cultures last admission grew MSSA
and she again had no purulence to suggest MRSA/antibiotic
failure. Her symptoms rapidly improved and she was discharged
with close Dermatology follow-up.
# Acute renal failure:
Cr on presentation was 1.2 from baseline 0.9 and rapidly
normalized with 500cc IVF, consistent with mild prerenal ___.
CHRONIC ISSUES:
================
# History of Orthotopic Liver Transplant (___):
Graft function remained stable and she was continued on
tacrolimus 0.5mg BID.
# Asthma/COPD:
# Tobacco use:
Patient reported shortness of breath and had mild wheezing on
admission. She reported running out of her home inhalers, and
her symptoms rapidly resolved once these were restarted. She was
encouraged to quit smoking.
# Chronic pain:
Gabapentin was discontinued at patient's request since she finds
this ineffective and her pain did not sound neuropathic.
# Coronary artery disease with h/o MI:
# Hypertension:
# Dyslipidemia:
Patient has a history of MI that was medically managed. She had
no signs of ischemia or heart failure. Her home aspirin, statin,
beta-blocker, lisinopril, and furosemide 20mg were continued.
# Depression:
Continued citalopram 40 mg daily.
# Insomnia:
Continued trazodone 100 mg nightly as needed.
TRANSITIONAL ISSUES:
=========================
- Discharged on a 2-week course of clobetasol and cephalexin.
Please encourage adherence and Dermatology follow up.
- Gabapentin was discontinued at patient's request since
ineffective. Monitor pain and consider alternate topical vs.
systemic agents.
Name of health care ___
Relationship:son
Phone ___
Cell ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D 800 UNIT PO DAILY
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Calcium Carbonate 500 mg PO BID
6. Citalopram 40 mg PO DAILY
7. Furosemide 20 mg PO DAILY
8. Gabapentin 300 mg PO TID
9. TraZODone 100 mg PO QHS insomnia
10. Tacrolimus 0.5 mg PO Q12H
11. Lisinopril 2.5 mg PO DAILY
12. Metoprolol Succinate XL 50 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Omeprazole 40 mg PO BID ___ esophagus
15. HydrOXYzine 25 mg PO Q6H:PRN itching
16. Ferrous GLUCONATE 324 mg PO DAILY
17. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
18. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of
breath
19. Benzonatate 100 mg PO TID:PRN cough
20. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
21. Milk of Magnesia 15 mL PO DAILY:PRN constipation
22. Fluticasone Propionate NASAL 2 SPRY NU BID:PRN congestion
23. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
24. Lactulose 15 mL PO BID:PRN constipation
Discharge Medications:
1. Cephalexin 500 mg PO Q6H
2. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID Duration:
2 Weeks
3. Hydrocerin 1 Appl TP QID
4. TraZODone 100 mg PO QHS:PRN insomnia
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
7. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 80 mg PO QPM
10. Benzonatate 100 mg PO TID:PRN cough
11. Calcium Carbonate 500 mg PO BID
12. Citalopram 40 mg PO DAILY
13. Ferrous GLUCONATE 324 mg PO DAILY
14. Fluticasone Propionate NASAL 2 SPRY NU BID:PRN congestion
15. Furosemide 20 mg PO DAILY
16. HydrOXYzine 25 mg PO Q6H:PRN itching
17. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of
breath
18. Lactulose 15 mL PO BID:PRN constipation
19. Lisinopril 2.5 mg PO DAILY
20. Metoprolol Succinate XL 50 mg PO DAILY
21. Milk of Magnesia 15 mL PO DAILY:PRN constipation
22. Multivitamins 1 TAB PO DAILY
23. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
24. Omeprazole 40 mg PO BID ___ esophagus
25. Tacrolimus 0.5 mg PO Q12H
26. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
#Severe eczema
#Cellulitis
#Acute renal failure
#Asthma/COPD
SECONDARY
#Liver transplant on chronic immunosuppression
#Coronary artery disease status post myocardial infarction
#Hypertension
#Dyslipidemia
#Depression
#Chronic pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___.
WHY YOU WERE ADMITTED:
- You had a severe skin rash from eczema and possibly a skin
infection ("cellulitis").
WHAT HAPPENED WHILE YOU WERE HERE:
- We gave you a steroid cream and antibiotics and your rash got
better.
WHAT TO DO WHEN YOU LEAVE THE HOSPTIAL:
- Please use your skin creams at least twice a day, every day.
- Take your antibiotics until you finish the entire bottle.
- Follow up with the skin experts and all your other doctors.
___ below for a list of your appointments.
We wish you all the best.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10685894-DS-48
| 10,685,894 | 23,226,438 |
DS
| 48 |
2152-08-02 00:00:00
|
2152-08-02 17:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ yo female with a history of alcoholic cirrhosis s/p
DDLT (___) on Tacrolimus, COPD, CAD with previous MI, DVT s/p
IVC filter not on Coumadin, and history of multidrug resistant
UTIs who presented with hypotension after a fall.
She was in her usual state of health until 3 days prior, when
she began experiencing full body aches, rigors, and dysuria. No
reported fevers. She also had a fall at around 0930 at her
living
facility, where her legs gave out and she fell onto her buttocks
onto a tile floor. A maintenance worker found her down. She has
been having frequent falls lately (~1 per month), and was
transported to an OSH where a CT showed a T1 fracture. She was
subsequently transferred to ___ ED.
Past Medical History:
- Alcoholic cirrhosis s/p orthotopic liver transplant (___) on
tacrolimus
- MI s/p cath at ___ with no intervention.
- H/o MDR UTI
- Severe eczema
- Osteoporosis ___ steroid use, s/p humerus fx ___
- h/o RUE and RLE Thrombophlebitis
- RLE DVT ___ on coumadin until s/p IVC filter ___, now off
AC
- h/o left foot cellulitis
- Chronic low back pain
- Hypertension
- Asthma/COPD
- Hyperlipidemia
- GERD
- Depression
- vertebral compression fractures
Surgical History:
- Orthotopic cadaver liver transplant ___ ___
- Right unipolar hemiarthroplasty for right femoral neck fx
___
- ORIF of left hip intertrochanteric hip fracture ___
___
- Removal of prominent screw and replacement with shorter screw
and bursectomy ___ ___
- Ventral hernia repair with mesh ___ ___
Social History:
___
Family History:
Mother with hx of CVA and seizure, sister with breast cancer,
Father died of lung cancer.
No family history of kidney disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
VS: 97.9 PO 128/74 L Lying 59bpm 16RR 91% Ra
GENERAL: Resting in hospital bed comfortably, in no apparent
distress. A hard collar is in place.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
mucus membranes slightly dry.
NECK: Deferred examination as hard collar in place
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB in anterior fields, no wheezes, rales, rhonchi,
breathing comfortably without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding
EXTREMITIES/BACK: no cyanosis, clubbing, or edema. Reporting
significant toe tenderness secondary to known fractures.
Tenderness along entirety of back centrally.
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused. She does have some minor skin
breakdown across
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 1212)
Temp: 97.4 (Tm 98.3), BP: 110/66 (110-154/66-79), HR: 81
(72-81), RR: 16 (___), O2 sat: 95% (94-96), O2 delivery: Ra,
Wt: 144 lb/65.32 kg
GENERAL: WD older woman chronically ill appearing in no apparent
distress. A hard collar is in place.
HEENT: PERRL, anicteric sclera.
NECK: Deferred examination as hard collar in place
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: mild wheezing bilaterally, no increased WOB on RA
ABDOMEN: nondistended, soft, nontender, no
rebound/guarding
EXTREMITIES/BACK: no ___ edema, legs appear symmetric.
previously:
Reporting significant toe tenderness secondary to known
fractures. Area of tenderness in right medial thigh, presence of
area of induration of ~3x3cm.
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused. She does have some minor skin
breakdown over her left hip.
Pertinent Results:
ADMISSION LABS:
==============
___ 03:18PM BLOOD WBC-10.9* RBC-4.00 Hgb-12.2 Hct-37.8
MCV-95 MCH-30.5 MCHC-32.3 RDW-14.0 RDWSD-47.8* Plt ___
___ 03:18PM BLOOD Neuts-69.8 Lymphs-18.2* Monos-8.1 Eos-2.9
Baso-0.5 Im ___ AbsNeut-7.59* AbsLymp-1.97 AbsMono-0.88*
AbsEos-0.31 AbsBaso-0.05
___ 03:18PM BLOOD ___ PTT-29.3 ___
___ 03:18PM BLOOD D-Dimer-1662*
___ 03:18PM BLOOD Glucose-98 UreaN-29* Creat-2.1*# Na-141
K-4.8 Cl-107 HCO3-22 AnGap-12
___ 03:18PM BLOOD ALT-16 AST-25 AlkPhos-85 TotBili-0.5
___ 03:18PM BLOOD proBNP-387*
___ 03:18PM BLOOD Albumin-3.8 Calcium-9.6 Phos-3.4 Mg-1.8
___ 08:22AM BLOOD tacroFK-5.1
___ 03:32PM BLOOD ___ pO2-29* pCO2-43 pH-7.38
calTCO2-26 Base XS--1
REPORTS:
========
___ CT Spine:
1. Mild superior endplate compression deformity at T1 vertebral
body. The
appearance suggests either a an acute or subacute fracture. No
retropulsion
or alignment abnormality.
2. Multilevel mild degenerative changes of the cervical spine.
___ Head CT:
No acute intracranial process.
___ ___:
Right posterior tibial vein thrombosis.
___ TTE:
Mild symmetric left ventricular hypertrophy with normal cavity
size, and
regional/global biventricular systolic function. No valvular
pathology or pathologic flow identified.
___ V/Q Scan
1. Low likelihood ratio V/Q scan for acute pulmonary
thromboembolism. 2. Multifocal ventilation defects that most
likely represent underlying airways disease.
MICRO:
======
Urine Culture: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES),
CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.
DISCHARGE LABS:
================
___ 07:02AM BLOOD WBC-6.3 RBC-3.59* Hgb-10.9* Hct-33.9*
MCV-94 MCH-30.4 MCHC-32.2 RDW-14.1 RDWSD-47.6* Plt ___
___ 07:02AM BLOOD Plt ___
___ 07:02AM BLOOD Glucose-86 UreaN-17 Creat-1.0 Na-137
K-5.3 Cl-102 HCO3-25 AnGap-10
___ 07:02AM BLOOD ALT-21 AST-31 AlkPhos-91 TotBili-0.4
___ 07:02AM BLOOD Albumin-3.5 Calcium-9.5 Phos-4.2 Mg-1.8
___ 07:02AM BLOOD tacroFK-2.3*
Brief Hospital Course:
PATIENT SUMMARY:
================
This is a ___ yo female with a history of alcoholic cirrhosis s/p
DDLT (___) on Tacrolimus, COPD, CAD with previous MI, DVT s/p
IVC filter not on Coumadin, and history of multidrug resistant
UTIs who presented with hypotension after a fall, found to also
have ___, RLE DVT and T1 fracture.
ACTIVE ISSUES
=============
#RLE DVT
Found to have RLE DVT on ___. Does have prior h/o DVT s/p IVC
filter, had been off anticoagulation at presentation. there was
initial concern for PE on presentation as well given concurrent
hypotension and mild hypoxemia, but V/Q scan was low probability
for PE. She was continued on a heparin drip for the DVT, which
was transitioned to lovenox ultimately. She will require
anticogaultion follow-up for her DVT, with careful monitoring
given her recent history of falls.
#Fall
Pt with a history of multiple falls, occurring once monthly to
once weekly. She lives at a ___ nursing facility due to
chronic back pain and poor mobility. Her falls appear to be
mechanical in nature. She does not have any significant
electrolyte derangements to explain her weakness; likely it is
secondary to her liver disease and general deconditioning. CT
head was negative on admission, but a T1 fracture was
identified. She worked with Physical Therapy while admitted, who
reccomended she be discharged to an ___ rehabilitation
facility given her weakness and deconditioning. She will require
a hard collar for her T1 fracture, and will follow up with
neurosurgery in 1 month regarding this issue.
___:
Patient presented with ___ with Cr. 2.1 (baseline 0.9-1.0). In
the setting of her hypotension, it is likely that this is
pre-renal in etiology. She was given fluids in the ED with
improvement in renal function. Her home lisinopril was held in
the setting of the ___ and was held at discharge given
hypotension on admission.
#Hypotension
Pt presented from OSH with hypotension to ___'s/___'s. She also
reported recent rigors/chills, which was concerning for
infectious etiology though infectious workup was negative.
Ultimately her hypotension was thought to be secondary to
hypovolemia with history of limited PO. Her motoprolol was held
due to her hypotension but resumed at lower dose prior to
discharge.
#EtoH Cirrhosis s/p transplant
Pt with a history of alcoholic cirrhosis s/p DDLT in ___. She
takes Tacrolimus 0.5 bid for immunosuppression (goal ___. Her
tacolimus level was monitored, and her regimen was unchanged.
#Recurrent UTI's
Patient reported symptoms of UTI (burning, urgency), but this
appears to be her baseline. U/A negative, UCx negative. She is
scheduled to see Dr. ___ in ___. There is no need for
prophylaxis per Dr. ___.
CHRONIC ISSUES
==============
# COPD: Continued home inhalers
# GERD: Continued home omeprazole
# Coronary artery disease with h/o MI
# Hypertension: Continued ASA, statin. Metoprolol dose decreased
due to hypotension and falls and lisinopril held at discharge.
Consider resuming lisinopril 2.5mg as outpatient if BP will
tolerate.
TRANSITIONAL ISSUES
===================
___ rehab length of stay anticipated < 30 days
[]F/u w/ neurosurgery in 1 month to assess need for continued
use of c-spine collar. ___ take off briefly for skin care.
[]Transitioned to lovenox prior to discharge. Would likely
recommend continuing for 3 months and then stopping (the patient
has an IVC filter in place currently) given risk of continuing
a/c long term in the setting of frequent falls.
[]Continued monitoring of tacrolimus levels, immunosuppression
[]Pt home gabapentin dose of 300mg TID down to 300mg BID; taper
as outpatient given frailty and patient unsure of why she is
taking medication
[]Assess need to re-start lisinopril, was stopped while
inpatient due to low blood pressure
[] Continue to assess need for tramadol and trazodone and if
appropriate please reduce dose or discontinue these medications
given history of falls.
#Code: FULL
#Contact: son ___ (___) Cell phone: ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atorvastatin 80 mg PO QPM
2. Citalopram 40 mg PO DAILY
3. Gabapentin 300 mg PO TID
4. Lactulose 15 mL PO BID:PRN constipation
5. Lisinopril 2.5 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Ranitidine 150 mg PO QHS
8. Tacrolimus 0.5 mg PO Q12H
9. TraZODone 300 mg PO QHS insomnia
10. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
DAILY
11. Aspirin 81 mg PO DAILY
12. TraMADol 50 mg PO BID:PRN Pain - Moderate
13. Pantoprazole 40 mg PO Q12H
14. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
15. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN allergies
16. HydrOXYzine 25 mg PO Q6H:PRN itch
17. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB
18. Milk of Magnesia 15 mL PO DAILY:PRN Constipation - Second
Line
19. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
20. Multivitamins 1 TAB PO DAILY
21. Vitamin D 800 UNIT PO DAILY
22. Calcium Carbonate 500 mg PO BID
23. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Enoxaparin Sodium 70 mg SC Q12H
2. Gabapentin 300 mg PO BID
3. Metoprolol Succinate XL 12.5 mg PO DAILY
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Calcium Carbonate 500 mg PO BID
9. Citalopram 40 mg PO DAILY
10. Ferrous Sulfate 325 mg PO DAILY
11. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN allergies
12. HydrOXYzine 25 mg PO Q6H:PRN itch
13. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation
inhalation DAILY
14. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB
15. Lactulose 15 mL PO BID:PRN constipation
16. Milk of Magnesia 15 mL PO DAILY:PRN Constipation - Second
Line
17. Multivitamins 1 TAB PO DAILY
18. Pantoprazole 40 mg PO Q12H
19. Ranitidine 150 mg PO QHS
20. Tacrolimus 0.5 mg PO Q12H
21. TraMADol 50 mg PO BID:PRN Pain - Moderate
22. TraZODone 300 mg PO QHS insomnia
23. Vitamin D 800 UNIT PO DAILY
24. HELD- Lisinopril 2.5 mg PO DAILY This medication was held
due to low blood pressure. Do not start unless hypertensive.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
FINAL DIAGNOSES:
- Acute Kidney Injury
- Deep Vein Thrombosis
SECONDARY DIAGNOSES:
- EtoH Cirrhosis s/p transplant
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 ___,
___ were admitted to the hospital because ___ had a fall.
WHAT HAPPENED WHILE ___ WERE IN THE HOSPITAL?
- Your blood pressure was low, so ___ were given fluids through
an IV.
- A blood clot was found in your leg; ___ were given medications
to prevent the clot from getting bigger.
- Your kidneys were damaged from dehydration; the IV fluids
helped your kidney function.
- ___ improved and were ready to leave the hospital to an
inpatient rehab facility.
WHAT DO ___ NEED TO DO WHEN ___ 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 ___ 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 ___ 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 ___ the
best!
- Your ___ Care Team
Followup Instructions:
___
|
10686159-DS-7
| 10,686,159 | 20,186,641 |
DS
| 7 |
2133-08-29 00:00:00
|
2133-08-29 11:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
doxycycline
Attending: ___
Chief Complaint:
___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI:
___ is a ___ right-handed man with a history
of
MI status post stent, hypercholesterolemia, well-controlled
hypertension, who presents as a transfer from an outside
hospital
with a right frontal intraparenchymal hemorrhage.
The history is obtained from the patient. He was driving at
around 1 ___ today when he experienced an acute onset, severe
headache and the frontal area. This was not associated with
loss
of consciousness. Maximal intensity was reached almost
immediately. There was no head strike. Although he almost got
into a car accident because he pressed the accelerator instead
of
the brake, he was able to drive safely the rest of the way home.
However, his wife thought he was acting a little odd, and given
the persistent headache, he was taken to an outside hospital.
He
underwent a CT which showed the right intraparenchymal
hemorrhage. He was subsequently transferred via med flight to
___ for further management.
The patient reports that he has had no significant weight loss,
or constitutional symptoms. Denies illicit substance use. He
does not believe he has had any cognitive issues. He reports
that his blood pressure is well controlled, and in fact his
primary care physician was trying to wean him off of his
atenolol. He he was told he has a benign skin cancer on top of
his head, and this is being followed by his PCP.
Past Medical History:
PMH/PSH:
Silent MI ___ years ago, status post stent. He was briefly on
aspirin and Plavix, but is no longer on Plavix
Hypertension, well controlled
Prediabetes
Hyperlipidemia
Social History:
SOCIAL HISTORY:
Former smoker quit ___ years ago, denies alcohol use, denies
illicit substance use. Used to work as a ___ currently
retired. Lives at home with his wife.
Physical Exam:
Admission
=========
PHYSICAL EXAMINATION
Vitals: T: 98 HR: 65 BP: 132/73 RR: 13 SaO2: 100% on
room air
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple. At the top
of his head, there is a small 0.5 cm in diameter verrucous
appearing lesion.
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Mildly inattentive, unable to
complete months of the year backward. He is able to perform
days
of the week backwards without hesitation. Speech is fluent with
full sentences, intact repetition, and intact verbal
comprehension. There is delayed response latencies. Naming
intact. Occasional paraphasias. No dysarthria. Normal prosody.
Able to register 3 objects and recall ___ at 5 minutes. No
apraxia. No evidence of hemineglect. No left-right confusion.
Able to follow both midline and appendicular commands.
- Cranial Nerves: PERRL 3->2 brisk. VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
[___]
L 5 5 5 5 ___ 5 5 5 5 5
R 5 5 5 5 ___ 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
Plantar response flexor bilaterally
- Sensory: No deficits to light touch, pin, or proprioception
bilaterally. No extinction to DSS.
- Coordination: No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait: Deferred
Discharge
=========
General physical examination:
General: Awake sitting up in chair, NAD
HEENT: NC/AT, no scleral icterus, no oropharyngeal lesions, neck
supple. At the top of his head, there is a small 0.5 cm in
diameter verucous appearing lesion.
___: RRR, warm and well perfused
Pulmonary: breathing comfortably on room air
Abdomen: NT, ND, no guarding
Extremities: Warm, no edema
Neurologic Examination:
Mental Status:
Awake and alert. oriented to self, date/month/year, and place.
Minimal delayed response latencies. Speaking in short
sentences but grammatically correct. Hypophonic. Naming and
repetition intact. No dysarthria. Remembered 3 objects after 3
minutes. Able to follow both midline and appendicular commands.
Cranial Nerves:
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry, decreased activation
on left. Trapezius strength ___ bilaterally. Tongue midline,
symmetric elevation and no dysarthria.
Motor:
Examination remarkable for left sided right deltoid 3, otherwise
all full.
Sensory:
No deficits to light touch.
Gait:
Deferred
Pertinent Results:
Admission
=========
___ 03:36AM BLOOD WBC-6.9 RBC-4.67 Hgb-14.0 Hct-42.8 MCV-92
MCH-30.0 MCHC-32.7 RDW-13.1 RDWSD-43.6 Plt ___
___ 03:36AM BLOOD Neuts-52.5 ___ Monos-13.9*
Eos-2.6 Baso-0.9 Im ___ AbsNeut-3.63 AbsLymp-2.03
AbsMono-0.96* AbsEos-0.18 AbsBaso-0.06
___ 03:36AM BLOOD ___ PTT-28.9 ___
___ 03:36AM BLOOD Glucose-90 UreaN-16 Creat-1.1 Na-141
K-4.9 Cl-102 HCO3-28 AnGap-11
___ 03:36AM BLOOD ALT-19 AST-31 AlkPhos-63 TotBili-0.6
___ 03:36AM BLOOD Lipase-53
___ 03:36AM BLOOD Albumin-4.0
___ 03:36AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:40AM BLOOD Lactate-1.3
Stroke Labs
===========
___ 11:04AM BLOOD %HbA1c-5.9 eAG-123
___ 08:05AM BLOOD Triglyc-108 HDL-60 CHOL/HD-3.2
LDLcalc-107
___ 08:05AM BLOOD TSH-0.85
IMAGING
=======
Noncontrast head CT performed at outside hospital Right frontal
lobar IPH measuring 10.7 cc, with associated mild ___
edema. There is a subarachnoid component to the hemorrhage. No
intraventricular extension. No midline shift, with local
mass-effect.
CTA head ___. Overall stable right frontal intraparenchymal hematoma, right
frontal subarachnoid hemorrhage, and mass effect since head CT
performed at 02:29. No new hemorrhage.
2. Patent anterior/posterior circulations, circle of ___, and
major
tributaries. No aneurysm seen.
CTA neck ___. Patent neck arteries. Mild atherosclerosis. No flow limiting
stenosis.
2. Emphysema
MRI ___. A 3 cm lesion in the anterior right frontal lobe and an
additional 0.5-cm lesion in the left parietal lobe demonstrating
T1 and T2 hyperintense with mild contrast enhancement and slow
diffusion are consistent with hemorrhagic products. Differential
considerations include underlying neoplastic processes such as
hemorrhagic metastatic lesions or melanoma, although amyloid
angiopathy could also be of consideration.
2. Intraparenchymal hematoma in the right frontal lobe is again
seen
demonstrating appropriate evolution measuring up to 4-cm. Again
an underlying lesion cannot be excluded.
3. Diffuse subarachnoid superficial siderosis is seen
bilaterally, with
additional punctate focus of low signal in the subcortical
region
within the left temporal lobe - likely sequelae of chronic
hemorrhage.
CT ABDOMEN ___
IMPRESSION:
1. No evidence of malignancy in the abdomen and pelvis.
2. Hepatic steatosis.
CT CHEST ___
RECOMMENDATION(S):
1. Evaluation of possible esophageal dysmotility.
2. Few nonspecific subpleural lung nodules, attention
___.
Thyroid US ___
Multiple colloid cysts. No suspicious thyroid nodules are
identified.
EEG preliminary reading: No seizure activity identified
MR SPECTROSCOPY ___
1. Nondiagnostic MR spectroscopy.
2. Large, stable intraparenchymal hemorrhage within the superior
lobule of the right frontal lobe, with surrounding vasogenic
edema, local mass effect, and 2-3 mm of leftward midline shift.
There is peripheral and central enhancement seen within this
area
of hemorrhage, with subtle increased perfusion along the
superior
margin. An underlying hemorrhagic lesion is not excluded, and
attention on ___ is recommended.
3. T1/T2 hyperintense lesion within the more inferior anterior
right frontal lobe demonstrating marginal enhancement along the
inferolateral and posteromedial aspects, and restricted
diffusion
centrally. Given the findings on DWI, this may represent an area
central necrosis, with abscess or tumefactive inflammatory
change
felt less likely.
4. Subarachnoid hemorrhage within the right frontal lobe sulci
and right sylvian fissure, similar in extent compared to the
recent CT examination.
5. Additional chronic findings as above.
Skin Biopsy
- Squamous cell carcinoma in situ; not seen at the examined
specimen margins.
- Associated hypertrophic actinic keratosis; not seen at the
examined specimen margins
Brief Hospital Course:
___ is a ___ right-handed man with a history
of
MI status post stent, hypercholesterolemia, well-controlled
hypertension, who presented with severe headache followed by odd
behavior found to have a right frontal intraparenchymal
hemorrhage on CT.
Initial neurologic exam notable for mild inattention, delayed
response latency, but otherwise non focal. Current neurologic
exam is notable for blunted affect, mild inattention, paucity of
speech, abulia and mild left deltoid weakness ___.
CTA showed patent vessels of the head and neck. Subsequent MRI
revealed a second right frontal lesion with some intrinsic blood
products as well as a small left parietal lesion. He also has
multiple hemorrhages at various ages. MRI spectroscopy was non
diagnostic. Given his delayed responses, EEG was performed and
did not show evidence of seizure activity. He was started on
keppra for seizure prophylaxis which will be continued until he
is followed up in clinic. Diagnostic workup also included CT
torso which did not reveal a primary malignancy but showed
pulmonary nodules. Biopsy of a skin lesion in his scalp was
benign. Thyroid ultrasound normal. Stroke risk factors assessed
with A1C of 5.9% and LDL 107. He was monitored and remained
normotensive off his ACE inhibitor, so we will defer resuming
this medication to his PCP.
At this time he will be discharged to rehab with a diagnosis of
cerebral amyloid angiopathy. We will order a repeat brain MRI
with contrast in 8 weeks and follow in neurology stroke clinic.
Transitional Issues:
# Continue keppra 1000mg PO q12 until seen in neurology clinic
# Holding home ACE until seen by PCP
# ___ MRI in 8 weeks
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 12.5 mg PO DAILY
2. Simvastatin 40 mg PO QPM
3. Aspirin 81 mg PO DAILY
Discharge Medications:
1. LevETIRAcetam 1000 mg PO BID
2. Simvastatin 40 mg PO QPM
3. HELD- Atenolol 12.5 mg PO DAILY This medication was held. Do
not restart Atenolol until follow up with PCP
___:
Extended Care
Facility:
___
___)
Discharge Diagnosis:
RT frontal intraparenchymal hemorrhage
Cerebral amyloid angiopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Hello Mr. ___,
It was a pleasure taking care of you at ___
___.
You were in the hospital after you had an episode of severe,
acute onset headache followed by odd behavior. In the hospital,
we performed imaging of your brain with a CT and you were found
to have a bleed in the right frontal area. We did an MRI of your
brain which showed evidence of other areas with old bleeds. This
is consistent with Cerebral Amyloid Angiopathy, a disease of
abnormal protein deposition in your blood vessels which
predisposes you to bleeding.
When you leave the hospital, you will be discharged to a
rehabilitation facility to work on your strength. Please
continue to take your blood pressure medications as prescribed,
and follow up
with your primary care doctor in the next ___ weeks. We have
held some of your prior blood pressure medications; if your
blood pressure remains high, your existing medications may need
to be increased or others may be restarted. We have given you
atorvastatin 40mg daily to treat high cholesterol. Your diabetes
will be treated with glipizide and metformin. You will need to
follow up in neurology stroke clinic with Dr. ___
please call ___ for an appointment.
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
Best wishes,
Your ___ team
Followup Instructions:
___
|
10686389-DS-15
| 10,686,389 | 23,662,250 |
DS
| 15 |
2180-09-06 00:00:00
|
2180-09-06 22:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Redness/pain of right hand
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ year old male with no PMH presenting with R
hand pain/redness/swelling going up towards armpit since last
night. He works for ___, was stocking and brushed R
hand against metal grate ___ days ago. Yesterday night noticed
pain in R forearm, this morning at 4:30am noticed skin red from
forearm in linear path towards R armpit. No fevers/chills,
N/V/D, difficulty tolerating po, numbness/tingling, pain with
joint movement.
In the ED, initial vs were 99.4 76 153/74 20 99% ra. Received
hand consult that reported the patient did not need surgical
intervention. Requested IV vanco and IV unasyn, obs in ED and
discharge home on bactrim/cefodroxil x 10 day course. He
revieved IV vanco 1 gram x1 (Q12 hours) and ceftriaxone 1gram IV
x1. On Reeval the patient's hand was not improving and he was
admitted to further IV antibiotics.
Transfer VS 98.5 66 144/94 18 99%.
On arrival to the floor, patient reports that he feels well and
that he no longer has pain in elbow and that his hand is feeling
much better than it was the day prior. He continues to deny
fever/chills, N/V, neck pain, headache, or any other symtpoms.
Past Medical History:
Drainage of para-tonsilar abscess at Mass Eye and Ear in ___
Social History:
___
Family History:
HTN in Father
DM2 in Maternal Aunt
Physical ___:
ADMISSION PHYSICAL EXAM:
VS: T:99.1, BP: 110/76 HR: 75, RR: 18, Sat:98% on RA
GEN: Alert, oriented, no acute distress, laying in bed
HEENT: NCAT, MMM, EOMI, sclera anicteric, OP clear
NECK: Supple, no JVD, no LAD
PULM: Good aeration, CTAB no w/r/rh
CV: RRR, normal S1/S2, no m/r/g
ABD: +BS, soft, NT/ND, no r/g
EXT: Right hand wrapped in ace wrap. Linear erythamous streaking
over the anterior arm extending up to the level of the axillia.
Full ROM of the elbow without pain, no swelling overlaing the
elbow. ___ ROM of the right shoulder. Mild tender shotty LAD in
the right axilla. Full ROM in digits with extention and flexion.
NEURO: CNs2-12 intact, motor function grossly normal
SKIN: See ext aboe. No other ulcers or lesions
DISCHARGE EXAM:
VS: T:99.0, BP: 126/68 HR: 57, RR: 18, Sat:97% on RA
GEN: Alert, oriented, no acute distress, sitting up in bed
HEENT: NCAT, MMM, EOMI, sclera anicteric, OP clear
NECK: Supple, no JVD, no LAD
PULM: Good aeration, CTAB no w/r/rh
CV: RRR, normal S1/S2, no m/r/g
ABD: +BS, soft, NT/ND, no r/g
EXT: Right hand wrapped in ace wrap. On takeing down wrapping,
decreased linear streaking and swelling. Full ROM of the elbow
without pain, no swelling overlaing the elbow. ___ ROM of the
right shoulder. Full ROM in digits with extention and flexion.
NEURO: CNs2-12 intact, motor function grossly normal
SKIN: See ext above. No other ulcers or lesions
Pertinent Results:
ADMISSION:
___ 01:30PM BLOOD WBC-9.5 RBC-5.12 Hgb-14.5 Hct-43.3 MCV-85
MCH-28.4 MCHC-33.5 RDW-12.9 Plt ___
___ 01:30PM BLOOD Plt ___
___ 01:30PM BLOOD Glucose-96 UreaN-20 Creat-0.8 Na-140
K-3.9 Cl-106 HCO3-24 AnGap-14
___ 01:41PM BLOOD Lactate-0.8
IMAGING:
Splint/bandage overlies the right hand, obscuring fine bony
detail and making detection for radiographic evidence of acute
osteomyelitis quite suboptimal. If high clinical concern for
such, consider removal and repeat radiographs over more advanced
imaging with MRI or nuclear medicine bone scan. No definite
acute fracture is seen.
DISCHARGE LABS:
___ 06:50AM BLOOD WBC-8.7 RBC-5.72 Hgb-16.2 Hct-48.9 MCV-86
MCH-28.3 MCHC-33.1 RDW-12.5 Plt ___
___ 06:50AM BLOOD Glucose-114* UreaN-15 Creat-0.9 Na-138
K-4.1 Cl-103 HCO3-23 AnGap-16
___ 06:50AM BLOOD Calcium-10.0 Phos-3.2 Mg-1.9
Brief Hospital Course:
Mr ___ is a ___ year old male with no significant PMHx who
presents with 1 day of worsening redness and swelling of his
right index finger. Concer for cellulitis and lymphadenitis.
#Cellulitis/Lymphadenitis:
Recieved 3 doses of IV vanco in ED and 1 gram of ceftriaxone
with improvement in his symptoms. He has improved on his current
regimen of vancomycin and ceftriaxone. He has full ROM of his
joints and was seen by plastics who do not feel that surgical
intervention is required. On the floor he was placed on
Vancomycin 1250mg IV Q12hours and Ceftriaxone 1 gram IV Q24
hours. There was no growth from the blood cultures and he
continued to improve. Following 48 hours of IV antibiotics it
was felt that he had improved enough to transition to PO
medications. He was placed on PO Bactrim DS 2 Tabs BID x10 days
and Cefadroxil 1000mg PO BID x10 days. He was discharged home
with close follow up.
Transitional Issues:
He will be seen 2 days after discharge as an outpatient to make
sure that he is improving on PO antibiotics.
The patient also does not have a PCP at time of admission. He
was scheduled with a PCP at time of 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 ___ mg PO Q6H:PRN pain
2. Sulfameth/Trimethoprim DS 2 TAB PO BID Duration: 10 Days
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 2
tablet(s) by mouth twice a day Disp #*40 Tablet Refills:*0
3. cefaDROXil *NF* 1000 mg Oral BID Duration: 10 Days
RX *cefadroxil 500 mg 2 capsule(s) by mouth twice a day Disp
#*40 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right hand cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr ___,
It was a pleasure taking care of you while you were in the
hospital. You were admitted for IV antibiotics for your
infection in your right hand. You did well with the antibiotics
and were transitioned to oral antibiotics and able to be
discharged home. Please follow up will all of your appointments.
Please complete your antibiotic course even if you start to feel
better before it's completed. Please seek medical attention if
you have fever/chills, worsening of the hand pain or swelling.
Please keep your hand elevated to help with the swelling. You do
not have to continue to wear the splint, but if it helps make
the hand feel better then you can continue to wear it.
Followup Instructions:
___
|
10686389-DS-16
| 10,686,389 | 22,443,998 |
DS
| 16 |
2185-12-07 00:00:00
|
2185-12-07 16:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
amoxicillin / azithromycin / amoxicillin
Attending: ___.
Chief Complaint:
CHIEF COMPLAINT: Chest pain
Major Surgical or Invasive Procedure:
___ Coronary angiography and left heart catheterization
with right radial access
History of Present Illness:
Mr. ___ is a ___ year old man with a prior history of
borderline hypertension and recurrent strep pharyngitis who
presents with sore throat, fevers, chills, nausea and vomiting
in addition to chest pressure.
He was in his usual state of health until ___ when he
worked all day inside of a very hot ___. He felt suddenly
lethargic, diaphoretic and tremulous, and subsequently had some
episodes of emesis and a headache. He had intenseThe following
day he felt slightly improved, but developed sore throat
consistent with prior strep pharyngitis infections. On ___ he
was still feeling tired and somewhat weak with a sore throat.
Around midnight on the morning of admission, he developed
substernal chest pain. This lasted an hour, but then returned an
hour lated and lasted until admission. He denied pleuritic or
positional pain.
He describes the sensation mostly as an irritation with some
heaviness and no radiation. Notably the pain was worse with deep
inspiration but was not positional. Given concern for inability
to eat or drink well and the heaviness in his chest, he
presented to the ED.
He has not had any sick contacts, recent travel, tick exposure,
new medications, illicit drugs. He has had knee pain related to
a meniscal tear and has been taking 600mg ibuprofen three times
daily.
EMERGENCY DEPARTMENT COURSE
In the ED initial vitals were:
- T: 97.0, HR: 74, BP: 124/83, O2: 100% RA
Exam notable for:
- Exam: +tonsillar exudates. +cervical adenopathy ttp. CV/Lung
exam wnl. Abd benign. wwp.
Images notable for:
- CXR with no acute intrathoracic process
EKG:
- ST Depression V1 and V3 with J point elevation in lateral
leads, nonspecific but could represent ischemia
- Posterior EKG with 1mm ST elevation in V7 and V8
Patient was given:
___ ___
___ 07:03IVKetorolac 15 mg
___ 07:03IVDexamethasone 10 mg
___ 07:47PO/NGSulfameth/Trimethoprim DS 1 TAB
___ 07:47PO/NGCephalexin 500 mg
___ 08:37PO/NGAspirin 324 mg
___ 08:41SLNitroglycerin SL .4 mg
___ 08:51IVFNS 1000 mLStopped (2h ___
___ 09:26PO/NGAtorvastatin 80 mg
___ 09:32IVHeparin 4000 UNIT
___ 09:32IVHeparinStarted 1000 units/hr
___ 09:40IV DRIPNitroglycerin (0.35-3.5 mcg/kg/min
ordered)Started 0.35 mcg/kg/min
___ 09:51IV DRIPNitroglycerinChanged to 0.5 mcg/kg/min
___ 10:03IV DRIPNitroglycerin Changed to 1 mcg/kg/min
___ 10:17IV DRIPNitroglycerinChanged to 1.5 mcg/kg/min
___ 10:34IV DRIPNitroglycerinChanged to 2 mcg/kg/min
Vitals on transfer to cath lab :
HR: 92, BP: 110/65, RR: 16, RR: 97% RA
On the floor
- Complete resolution of chest pain/pressure
- No dyspnea
Past Medical History:
- Recurrent infectious pharyngitis including two paratonsillar
abscesses requiring drainage
- Borderline hypertension without prior treatment
- Right arm cellulitis requiring hospitalization
- Microscopic hematuria
Social History:
___
Family History:
Mother: ___ disorder
Father: HTN, HLD
Brother: ___ use disorder
No family history of cardiomyopathy or sudden cardiac death
Physical Exam:
PHYSICAL EXAM ON ADMISSION
==========================
VS: T:98.0 BP:101/65, HR:73, RR:18: O2:95, RA
GENERAL: Tired appearing man speaking to us in no apparent
distress
HEENT: Pupils equal and reactive, no scleral icterus or
injection. Enlarged tonsils with bilateral tonsillar exudates.
Submandibular and cervical tenderness and mild swelling without
asymmetry or overt lymphadenopathy. Moist mucous membranes.
NECK: JVP ___ with some hepatojugular reflex.
CARDIAC: S1/S2 regular without murmurs, rubs or S3/S4. No rub in
forward leaning position.
LUNGS: Clear bilaterally.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm extremities without edema. R arm with radial
bandage. Good pulse and warm fingers with normal sensation and
movement.
PULSES: Strong pedal pulses.
PHYSICAL EXAM ON DISCHARGE
===========================
GENERAL: well appearing man in NAD, sitting up in bed
HEENT: Pupils equal and reactive, no scleral icterus or
injection. Enlarged erythemic tonsils with bilateral tonsillar
exudates R >L
Submandibular and cervical tenderness, though no notable
cervical or clavicular lymphadenopathy. MMM
NECK: JVP ___ with mild hepatojugular reflex.
CARDIAC: S1/S2 regular without murmurs, rubs or S3/S4.No rub
appreciated while sitting forward
LUNGS: Clear bilaterally, no crackles or wheezing noted
ABDOMEN: Soft, non-tender, non-distended, +BS
EXTREMITIES: Warm extremities without edema. R arm with intact
radial
bandage. Good pulse and warm fingers with normal sensation and
movement.
PULSES: Strong pedal pulses.
SKIN: Dry and intact
Pertinent Results:
ADMISSION LABS
=============
___ 06:09AM BLOOD WBC-13.5* RBC-4.79 Hgb-13.6* Hct-39.4*
MCV-82 MCH-28.4 MCHC-34.5 RDW-13.7 RDWSD-40.7 Plt ___
___ 06:09AM BLOOD Neuts-84.7* Lymphs-5.3* Monos-8.5
Eos-0.1* Baso-0.4 Im ___ AbsNeut-11.46* AbsLymp-0.72*
AbsMono-1.15* AbsEos-0.01* AbsBaso-0.05
___ 07:36PM BLOOD ___ PTT-25.7 ___
___ 06:09AM BLOOD Plt ___
___ 06:09AM BLOOD Glucose-121* UreaN-17 Creat-0.8 Na-137
K-3.6 Cl-100 HCO3-21* AnGap-16
___ 06:09AM BLOOD CK(CPK)-539*
___ 06:09AM BLOOD CK-MB-41* MB Indx-7.6* cTropnT-0.73*
___ 07:36PM BLOOD CK-MB-39* MB Indx-9.0* cTropnT-0.57*
___ 07:36PM BLOOD Calcium-9.3 Phos-2.5* Mg-2.0
___ 07:36PM BLOOD TSH-0.33
DISCHARGE LABS
=============
___ 07:45AM BLOOD WBC-13.5* RBC-4.77 Hgb-13.5* Hct-39.9*
MCV-84 MCH-28.3 MCHC-33.8 RDW-13.7 RDWSD-42.1 Plt ___
___ 07:45AM BLOOD Plt ___
___ 07:45AM BLOOD Glucose-106* UreaN-17 Creat-0.7 Na-142
K-3.9 Cl-105 HCO3-22 AnGap-15
___ 07:45AM BLOOD ALT-43* AST-53* LD(LDH)-346* AlkPhos-83
TotBili-0.4
___ 07:45AM BLOOD Calcium-9.6 Phos-3.3 Mg-2.0
MICROBIOLOGY
============
___ Blood Culture = Pending
___ Strep and viral throat swabs = Pending
REPORTS AND IMAGING STUDIES
=========================
___ TRANSTHORACIC ECHOCARDIOGRAM
The left atrium is mildly dilated. The right atrium is mildly
enlarged. There is no evidence for an atrial septal defect by
2D/color Doppler. The estimated right atrial pressure is ___
mmHg. There is normal left ventricular wall thickness with a
mildly increased/dilated cavity. There is mild global left
ventricular hypokinesis. No thrombus or mass is seen in the left
ventricle. Quantitative biplane left ventricular ejection
fraction is 42 %. Due to severity of mitral regurgitation,
intrinsic left ventricular systolic function may be lower. There
is no resting left ventricular outflow tract gradient. Tissue
Doppler suggests a normal left ventricular filling pressure
(PCWP less than 12mmHg). There is normal diastolic function.
Normal right ventricular cavity size with uninterpretable free
wall motion assessment. The aortic valve leaflets (3) appear
structurally normal. There is no aortic valve stenosis. There is
no aortic regurgitation. The mitral valve leaflets appear
structurally normal with no mitral valve prolapse. There is mild
[1+] mitral regurgitation. The tricuspid valve leaflets appear
structurally normal. There is mild [1+] tricuspid regurgitation.
The estimated pulmonary artery systolic pressure is normal.
There is a trivial pericardial effusion.
IMPRESSION: Normal left ventricular wall thickness with mild
cavity dilation and mild global systolic dysfunction c/w a
nonischemic cardiomyopathy or myocarditis. Mild mitral
regurgitation. Mild tricuspid regurgitation.
Compared with the prior TTE (images reviewed) of ___ ,
the findings are similar. Left ventricular cavity size was
underestimated on the prior study.
___ TRANSTHORACIC ECHOCARDIOGRAM
The left atrial volume index is mildly increased. The right
atrium is mildly enlarged. There is mild symmetric left
ventricular hypertrophy with a normal cavity size. There is
normal regional and global left ventricular systolic function.
Quantitative biplane left ventricular ejection fraction is 42 %.
There is no resting left ventricular outflow tract gradient.
Normal right ventricular cavity size with normal free wall
motion. The aortic sinus diameter is normal for gender with
normal ascending aorta diameter for gender. The aortic arch
diameter is normal. The aortic valve leaflets (3) appear
structurally normal.
There is no aortic valve stenosis. There is no aortic
regurgitation. The mitral valve leaflets appear structurally
normal with no mitral valve prolapse. There is mild [1+] mitral
regurgitation. The tricuspid valve leaflets appear structurally
normal. There is mild [1+] tricuspid regurgitation. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
IMPRESSION: Mild global left ventricular systolic dysfunction.
MIld mitral regurgitation.
___ LEFT HEART CATHETERIZATION AND CORONARY ANGIOGRAPHY
LV Systolic = 101
LVEDP = 21
HR = 109
AO Systolic 93
AO Diastolic 73
AO Mean 76
HR 86
Angiography report pending, preliminary is no significant
disease
Brief Hospital Course:
=================
SUMMARY STATEMENT
=================
Mr. ___ is a ___ year old man with a prior history of
borderline hypertension and recurrent strep pharyngitis who
presents with pharyngitis and chest pain and was found to have
ECG changes and troponin elevation consistent with
myopericarditis. A TTE revealed depressed LVEF of 40%. He did
not show evidence of hemodynamic compromise, heart failure
decompensation, conduction abnormality, or arrhythmia. His
troponins started downtrending within 12 hours of admission. He
was discharged on treatment for presumed bacterial pharyngitis
and pericarditis.
# CORONARIES: ___: NO CAD
# PUMP: LVEF 42%, global LV systolic dysfunction, mild MR
# RHYTHM: Sinus
==================
TRANSITIONAL ISSUES
==================
Discharge Weight: (___) 94.8kg (209lb)
Discharge Diuretic: None (written for lasix, but should only use
if directed)
Discharge Creatinine: 0.7
[ ] If he has symptoms of recurrent chest pain, it would be
reasonable to treat with colchicine in addition to ibuprofen.
Would avoid steroids until absolutely necessary.
[ ] Would consider elective tonsillectomy given recurrent strep
pharyngitis
[ ] LFTs elevated, possibly in the setting of acute viral
infection, but would repeat within 2 weeks as an outpatient
[ ] Patient was provided with furosemide 20mg tablets, but
should only take if instructed by a physician
[ ] Will have repeat TTE in heart failure clinic to re-evaluate
for improving systolic function
New Medications:
- Cephalexin 500mg twice daily through ___
- Ibuprofen 800mg three times daily x 7d, followed by
- Ibuprofen 400mg three times daily x 7d
- Ibuprofen 400mg PRN after this
- Torsemide 20mg PO, only to be taken if directed by physician
___: None
Discontinued Medications: None
====================
ACUTE MEDICAL ISSUES
====================
#Myopericarditis with global LV dysfunction (LVEF 40%)
Mr. ___ presented with clinical signs of pericarditis
(pleuritic chest pain) and ECG evidence of pericaridits as well.
Troponins were elevated confirming concomittant myocarditis. A
coronary angiography did not show coronary disease. Left heart
catheterization did show elevated LVEDP of 21, and a TTE showed
global LV dysfunction with LVEF 40%. He did not show signs of
hemodynamic compromise, heart failure decompensation, conduction
abnormality, or arrhythmia, despite evidence of elevated filling
pressures.
Etiology very likely to be related to recent pharyngitis
infection, especially given concurrent pericarditis. There is
case-report evidence of strep pharyngitis-associated myocarditis
and pericarditis. He received IV toradol and steroids, and was
started on a nitroglycerin and heparin gtt in the ED and his
chest pain resolved. He did not have recurrent chest pain.
Utox negative, few eosinophils on peripheral smear. Mild
presentation not consistent with giant cell myocarditis. No
other evidence of endocarditis. His cardiac biomarkers,
including CK-MB and troponin T, were downtrending during his
admission. Limited repeat TTE on the day of discharge showed
stable mild LV dysfunction. Review of his telemetry revealed on
occasional premature atrial depolarizations without any
sustained supraventricular or ventricular arrhythmias and no
evidence of heart block. For treatment of his pharyngitis and
myopericarditis:
- Keflex ___ PO twice daily through ___
- Ibuprofen 800mg three times daily x 7d
- Ibuprofen 400mg three times daily x 7d
- Ibuprofen 400mg PRN after this
- Strep culture and viral culture pending at discharge, but will
treat with 7d course of keflex for presumptive strep pharyngitis
given strong history of this
- Follow-up in heart failure clinic to be arranged after
discharge
- Low threshold to restart colchicine if recurrent pericarditis
symptoms
#Pharyngitis
Extended history of bacterial pharyngitis including two episodes
of peritonsillar abscess requiring drainage. Clear evidence of
pharyngitis on exam without evidence of abscess. Culture taken,
but after antibiotics already started. Will treat empirically
for bacterial infection with 7d course of keflex ___ twice
daily.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate
Discharge Medications:
1. Cephalexin 500 mg PO Q12H
RX *cephalexin 500 mg 1 capsule(s) by mouth twice daily Disp
#*11 Capsule Refills:*0
2. Furosemide 20 mg PO DAILY
Do not take unless instructed by doctor.
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*10 Tablet
Refills:*0
3. Ibuprofen 800 mg PO Q8H Duration: 7 Days
RX *ibuprofen 800 mg 1 tablet(s) by mouth three times daily Disp
#*21 Tablet Refills:*0
4. Ibuprofen 400 mg PO Q8H Duration: 7 Days
start after completing course of 800mg three times daily
RX *ibuprofen 400 mg 1 tablet(s) by mouth three times daily Disp
#*21 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
================
PRIMARY DIAGNOSIS
================
Myopericarditis
===================
SECONDARY DIAGNOSES
===================
Acute heart failure with reduced ejection fraction, not
decompensated
Pharyngitis
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 while you were admitted to ___
___.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were having throat pain and chest pain.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- We found that you have inflammation of the heart muscle, and
of the sack the surrounds the heart: this is called myocarditis
and pericarditis.
- Because your symptoms can be consistent with a heart attack,
we did a procedure to look at the vessels in the heart (coronary
angiography). This did not show any blockages or narrowing.
WHAT SHOULD YOU DO WHEN YOU GO HOME?
- You are still at risk for cardiac complications. If you have
difficult breathing, swelling in your legs, worsening fatigue,
feeling lightheaded, call a doctor right away. You need to call
___ or go to an emergency department if it feels like your heart
is beating strangely or too fast, or if you pass out at any
time.
- Do not do any exercise until you see a doctor who tells you
this is ok. Normal household activities are fine to do.
- Buy a scale and take your weight every morning after getting
up. If your weight goes up 3 pounds in a day or 5 pounds in a
week, call your doctor right away. Your weight when you left the
hospital was 209 pounds (94.8 kilograms).
- Carefully review the attached medication list.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10686447-DS-11
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2156-10-26 00:00:00
|
2156-10-26 12:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
"weird smells"
Major Surgical or Invasive Procedure:
___ - Stereotactic Brain Biopsy
History of Present Illness:
___ yo male patient who presents after "smelling things" and
HA and CT shows a right temporal lesion with surrounding edema.
He states his HA is now resolved as is the smell. He denies
N/V,
dizziness, and visual changes.
Past Medical History:
- LBP as above
- Dyslipidemia
- HTN
- Duodenal ulcer
- Pilonidal cyst, occasionally causing drainage
- Glaucoma
- S/p appendectomy
Social History:
___
Family History:
Lung CA
Son with cerebral palsy; otherwise nil neurological
Physical Exam:
On Admission
============
PHYSICAL EXAM:
O: T:97.3 BP: 137/77 HR:58 R:18 O2Sats:98% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: ___ EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 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: slight left tongue deviation
Motor: Normal bulk and tone bilaterally. No Slight left updrift.
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
============
On Discharge
============
Patient alert and oriented to person, place and time.
PERRL, EOMI, face symmetrical.
No pronator drift, moves all extremities
Incision is clean, dry and intact.
Pertinent Results:
Please see OMR for pertinent lab/imaging studies.
Brief Hospital Course:
___ presents to ED with "weird smells" and headache, with
non-contrast head CT concerning for right temporal brain lesion.
#Brain Lesion
The patient was admitted to the neurosurgical service to obtain
an MRI brain with/without contrast, CT torso for metastatic
workup, and for potential surgical planning. MRI brain revealed
multi-centric contrast enhancing mass in the right temporal
lobe. CT torso was negative for The patient had been initially
started on dexamethasone, but this was later held with intent to
maximize possibility of obtaining lesional tissue with intent to
biopsy the mass. Neuro-oncology and Radiation-oncology were
consulted. The patient was taken to the OR on ___ for biopsy,
which was uncomplicated, please see OMR for detailed operative
note. Intra-operative head CT after the procedure showed
expected post-operative changes without hemorrhage. The patient
was extubated in the operating room and transferred to PACU for
post-operative monitoring. The patient was transferred to the
floor and recovered until he was discharged on ___.
#AFib
On the evening of ___, the patient's cardiac telemetry alarmed
for new onset atrial fibrillation with RVR, confirmed on EKG.
The patient was asymptomatic. ___ was consulted, but
recommended no acute intervention and any anticoagulation
recommendations were deferred given planned biopsy. His
metoprolol dose was titrated to achieve rate control. An
echocardiogram was obtained, which showed an EF of 50%, with no
valvular or structural abnormalities. ___ evaluated the
patient for pre-operative risk stratification, and found him to
be a good medical candidate for surgery.
#Elevated BUN/Cr
On admission his BUN/Cr were noted to be elevated. He was given
IV fluid for hydration pre- and post-contrast for the CT torso.
His BUN/Cr was monitored over the course of his admission.
Medications on Admission:
metoprolol tartrate 25 mg QD
atorvastatin 20 mg QD
Omeprazole 1 cap QD
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
Do not exceed 4 grams in a 24 hour period.
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - First Line
3. Dexamethasone 2 mg PO Q12H
RX *dexamethasone 2 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Famotidine 20 mg PO Q12H
RX *famotidine 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. LevETIRAcetam 1000 mg PO BID
RX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
6. Senna 8.6 mg PO BID:PRN Constipation - Second Line
7. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*30 Tablet Refills:*0
8. Atorvastatin 20 mg PO QPM
9. Metoprolol Succinate XL 37.5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
brain lesion
cerebral compression
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Surgery
You underwent a biopsy. A sample of tissue from the lesion in
your brain was sent to pathology for testing.
Please keep your incision dry until your sutures/staples are
removed.
You may shower at this time but keep your incision dry.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
***Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
***You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may experience headaches and incisional pain.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Feeling more tired or restlessness is also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
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10686498-DS-8
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2135-09-03 05:50:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left-sided chest pain, abdominal pain.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is a ___ year old male without significant past
medical history
who presented to ___ via EMS status post fall. The patient was
painting while standing on a ladder when the ladder slipped from
under his feet, causing him to fall forward approximately ___
feet. He struck the ladder with the left-side of his chest and
sustained a small abrasion to his left cheek during the fall.
EMS arrived on the scene and found the patient to be alert and
oriented appropriately, complaining of pain localized to the
left chest wall with inspirations and abdominal pain. EMS
administered fentanyl 50mcg in the field and reported that the
patient had an oxygen saturation of 98% throughout
transportation.
Past Medical History:
Patient denies any significant past medical history.
Family History:
Non-contributory.
Physical Exam:
Constitutional: Mild distress secondary to pain
HEENT: Pupils 3mm and equal, round and reactive to light,
Extraocular muscles intact. No scalp or face tenderness to
palpation
No hemotympanum, Cervical collar in place. No jaw
malocculsion
Chest: Airway intact, breath sounds equal bilaterally,
Left-sided chest wall tenderness at the mid-axillary line,
inferior sternal tenderness to palpation. No crepitus.
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft,mild tenderness to palpation, Nondistended
Pelvic: Pelvis stable to compression
Extr/Back: Full range of motion of the upper extremities,
no evidence of trauma throughout the upper or lower
extremities. Strong distal pulses.
Skin: Left cheek abrasion, right anterior shin abrasion
Neuro: Speech fluent, ___ strength throughout the upper and
lower extremities bilaterally
Psych: Normal mood, Normal mentation
Pertinent Results:
___ 12:52PM BLOOD WBC-7.7 RBC-4.87 Hgb-14.5 Hct-43.5 MCV-89
MCH-29.9 MCHC-33.5 RDW-13.2 Plt ___
___ 12:52PM BLOOD ___ PTT-25.1 ___
___ 12:52PM BLOOD Plt ___
___ 12:52PM BLOOD ___
___ 02:49AM BLOOD Glucose-92 UreaN-15 Creat-0.9 Na-139
K-3.9 Cl-103 HCO3-28 AnGap-12
___ 05:34PM BLOOD Amylase-42
___ 12:52PM BLOOD Lipase-75*
___ 05:34PM BLOOD Lipase-50
___ 02:49AM BLOOD Calcium-9.1 Phos-4.3 Mg-1.9
___ 12:52PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Imaging:
___ Chest Radiograph (AP)
Single supine portable view of the chest was obtained. The
right
costophrenic angle is not completely included on the image.
Given this, there are relatively low lung volumes. No focal
consolidation, large pleural effusion, or evidence of
pneumothorax is seen. Cardiac and mediastinal silhouettes are
likely in part accentuated by the supine, AP technique. Rib and
sternal fractures better assessed on subsequent CT torso.
___ CT Abdomen/Pelvis with contrast
Small amount of intermediate-density fluid interdigitates along
the
mesentery in several locations, more confluent focus on the
right. There is additionally trace pelvic fluid and trace
perihepatic fluid. Stranding/fluid around the SMA and proximal
SMV. Constellation of findings are highly worrisome for
mesenteric injury. No active extravasation of IV contrast,
pneumoperitoneum, or bowel wall thickening, however bowel injury
can not be excluded.
2. Grade I subcapsular splenic laceration. No pseudoaneurysm
or active
extravasation of contrast.
3. Small amount of perihepatic fluid, without definite
parechymal injury
identified.
4. Nondisplaced mid-sternum fracture. Displaced anterior left
fifth and
sixth rib fractures. Nondisplaced anterior left seventh rib and
eighth rib fractures. No segmental rib fracture.
5. Small focus of air in the right paratracheal soft tissues
may represent a tracheal diverticulum. Focal mediastinal gas is
less likely as none is seen elsewhere.
___ CT Cervical Spine without contrast
1. No cervical spine fracture, acute alignment abnormality, or
prevertebral soft tissue abnormality.
2. Small focus of air in the right paratracheal soft tissues
may represent a tracheal diverticulum or, less likely, a focus
of mediastinal gas as none is seen elsewhere.
Brief Hospital Course:
Mr. ___ is a ___ year old male without significant past
medical history who was brought into the ED by EMS after falling
from ladder of approximately 12 feet. He reportedly struck the
ladder on his left chest. Patient was stable at time of
arrival. CT abd demonstrated a small amount of
intermediate-density fluid along the mesentery in several
locations in the right mid-abdomen with trace pelvic fluid and
trace perihepatic fluid with associated fat standing concerning
for possible mesenteric injury. No active extravation of
contrast was observed. Additional injuries included a
nondisplaced mid-sternum fracture, displaced anterior left fifth
and sixth rib fractures as well as nondisplaced anterior left
seventh rib and eighth rib fractures. Also noted was a small
focus of of air in the right paratracheal soft tissues may
represent possibly representing a diverticulum. Patient was
transfered to the ICU and made NPO with IVF in stable condition.
Input and output was closely monitored. Serial hematocrit
levels were monitored as well as serial abdominal exams. The
patient's hematocrit levels were stable and his abdominal exam
improved during the ICU stay. His pain was adequatedly
contolled with a PCA and use of an incentive spirometer was
encouraged. Mr. ___ remained stable from a pulmonary
stanpoint. The patient was transferred to the inpatient floor
on ___.
Mr. ___ was transitioned from a PCA to oral narcotic and
non-narcotic pain medications once taking adequate oral intake.
His pain was well controlled. He was hemodynamically stable and
afebrile. His hematocrit levels remained stable while
recovering on the trauma ward. He had no alterations in his
respiratory status and continued to oxygenate well on room air.
On ___, Mr. ___ was discharged home with a follow-up
appointment in the ___ clinic.
Medications on Admission:
None.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg 1 tablet(s) by mouth q6hr Disp #*50
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. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth q4hr
Disp #*80 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Grade 1 splenic laceration
Displaced left ___ anterior rib fractures
Non-displaced left ___ rib fractures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ on
___ after falling from a ladder and sustaining a laceration to
your spleen as well as multiple rib fractures. You were
initially sent to the ICU for closer observation and later
transferred to the inpatient floor to recover. You are now
doing well and ready to be discharged home with the following
discharge instructions:
Rib fractures can cause severe pain and subsequently cause you
to take shallow breaths because of the pain. You should take
your pain medicine as as directed to stay ahead of the pain
otherwise you won't be able to take deep breaths. If the pain
medication is too sedating, take half the dose and notify your
physician.
Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
Do NOT smoke.
Return to the ED right away for any acute shortness of breath,
increased pain or crackling sensation around your rips
(crepitus).
Narcotic pain medication can cause constipation. Therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible. Do not drive or operate heavy
machinery while you are taking narcotics. They can cause
drowsiness and impair your daily motor and cognitive function.
Resume any prior home medications. A prescription for pain
medication is being provided for home discharge. You may also
take over-the-counter acetaminophen (Tylenol) or ibuprofen
(Advil) as needed along with the narcotic pain medication. Over
time, you should need to take less narcotic (oxycodone) and
relieve your pain with the acetaminophen or ibuprofen. Do not
take more than the recommended dose (as stated on the medication
labeling) as they have their own unique side-effects.
A follow-up appointment with the ___ clinic has been made for
you (see below). If you have any concerns prior to that time,
please call our office.
Followup Instructions:
___
|
10686617-DS-5
| 10,686,617 | 29,656,062 |
DS
| 5 |
2114-01-22 00:00:00
|
2114-01-22 21:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Low back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ w/ no major PMH who has had worsening back
pain. He is ___ and ___ a pop in his sacral area about
two weeks ago. He started having some pain after that. He
continued along with his business working up until ___ when
he was doing more floor work and injured his back more when he
was bending over. He went to urgent care (TUES) at the ___
and was given given Flexeril w/ minimal improvement.
Went back to urgent care ___ of this week and back xray
demonstrated mild lumbar scoliosis with note made of
degenerative changes most pronounced at T11-T12. He was given
tylenol 3 and referred to ___ ED to have MRI. He notes that
his pain is focused in midline lumbo-sacral region, which is
constant, sharp, ___ intensity. He has bilateral pain that
radiates down buttocks and ant/post legs with movement or
flexion of ___. He denies numbness, paresthesias or weakness
of his lower extremities. No urinary or fecal incontinence. No
prior hx of low back injury or surgery. He does state that he
has had a distant blood on top of his stool previously, and
states that after ___, it was determined to be primarily
secondary to hemorrhoids. He also had gastritis/esophagitis.
In the ED, initial VS were: 98.0 80 117/82 18 99%
MRI showed no cord compromise or cord compression, although did
show L4-S1 disk bulging. He was given toradol, valium and
dilaudid PO. His pain improved with the dilaudid.
VS prior to transfer were: 97.6 73 118/71 18 99%
On arrival to the floor, the patient's vitals were: 98.2 124/79
68 18 99%RA. He was lying in bed comfortably, but visibly
uncomfortable with any movement. He was able to relay hx w/out
problem.
Past Medical History:
-Sleep apnea, obstructive
-h/o Medial Meniscus Tear
-ATRIAL FIBRILLATION
-ARTICULAR CARTILAGE DISORDER, UNSPEC SITE
-COLONIC ADENOMA
-HELICOBACTER PYLORI INFECTION
-GASTRITIS -
Social History:
___
Family History:
noncontributory
Physical Exam:
ADMISSION:
98.2 124/79 68 18 99%RA
GENERAL: lying in bed
HEENT: PERRL, EOMI
LUNGS: CTAB
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, no organomegaly
BACK: tenderness to palpation lower lumbar and sacral area, with
concomittant paraspinal tenderness
EXTREMITIES: No c/c/e, distal pulses intact.
Positive straight leg raise bilaterally. ___ motor strength
below knees, ___ upper leg strength, likely secondary to pain.
sensation intact b/l. Range of motion testing limited by pain.
NEUROLOGIC: A+OX3, CN II - XII w/out deficit. Brisk knee and
ankle reflexes b/l. Absence of Babinski sign b/l.
.
DISCHARGE:
VS: 98.4 125/79 71 18 93%RA
I/O: Did urinate this morning, and showered.
GENERAL: lying in bed, NAD, caucasian male looks stated age, red
hair, fair skin
HEENT: EOMI, Moist MM
LUNGS: CTAB
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS,
BACK:no tenderness to palpation lower lumbar and sacral area
EXTREMITIES: No c/c/e, distal pulses intact.
straight leg negative bilaterally.
___ motor strength below knees, ___ hip strengthn. Sensation
intact b/l. Range of motion full.
NEUROLOGIC: A+OX3, CN II - XII w/out deficit. Brisk knee and
ankle reflexes b/l. Absence of sign of Babinski b/l.
Pertinent Results:
ADMISSION AND DISCHARGE
___ 06:15AM BLOOD WBC-6.5 RBC-4.78 Hgb-13.8* Hct-41.8
MCV-88 MCH-28.9 MCHC-33.0 RDW-12.3 Plt ___
___ 11:45AM BLOOD Glucose-81 UreaN-21* Creat-0.8 Na-139
K-4.3 Cl-103 HCO3-27 AnGap-13
___ 06:15AM BLOOD Glucose-79 UreaN-21* Creat-0.9 Na-141
K-5.2* Cl-105 HCO3-29 AnGap-12
___ 11:45AM BLOOD CK(CPK)-117
___ 11:45AM BLOOD Calcium-9.3 Phos-3.5 Mg-2.1
STUDIES:
MRI OF C& T & L ___:
- C ___:
IMPRESSION: Minimal spondylosis at C3/4, C5-C6 and C6-C7 levels
with no
evidence of cervical spinal cord compression.
- T ___:
IMPRESSION: Mild degenerative changes throughout the thoracic
___,
consistent with Schmorl's nodes with no evidence of spinal canal
stenosis or
neural foraminal narrowing, there is no evidence of spinal cord
compression.
- L ___:
IMPRESSION: Mild degenerative changes throughout the lumbar
___, more
significant at L4-L5 and L5-S1 levels as described above. There
is no
evidence of significant spinal canal stenosis or cord
compression in the conus
medullaris.
Brief Hospital Course:
Mr. ___ is a ___ w/ no major PMH who heard a pop of the
lower back two weeks ago with associated low back pain, he
continued working for the next week. Comes in ___ after
worsening/unbearable pain, found to have L4-L5-S1 bulge on MRI,
no s/s of compression syndrome. Neuro + Ortho is not concerned
for compression.
.
## BACK PAIN: Significantly improved on day of discharge. No
concerning signs or symtpoms of cord compression, no implication
of cord compromise on MRI. Pain is likely secondary to lower
lumbo-sacral disk bulging, especially considering pt realized a
"pop" a week or two back, w/ worsening back pain w/ movement.
Pt was evaluated by Physical therapy on two subsequent days and
they recommended home outpatient ___.
- Pain was significantly improved with Tizanidine, Gabapentin,
Tylenol, Lidocaine patch and PRN Ultram. Pt did receive 2 doses
of 10mg Oxycodone PO, however, this was discontinued due to
strong sedation response as pt is opioid naive.
- On day of discharge pt was able to shower, ambulate, urinate,
tolerate full PO diet and move bowels on his own. He reported a
___ pain, although he was still not at his functional
baseline, subjectively.
- Pt was informed that he needs to follow up with an Atrius
___ doctor, and pain management specialists. Pt was
instructed to call his Atrius PCP, who was made aware that the
patient needs additional specialist visits. Pt already had a
standing physical rehab appointment for day after discharge.
Pt was instructed to AVOID all NSAIDs give h/o gastritis.
.
## TRANSITIONAL
- F.u with PCP, ___, pain management, ___
- Avoid all NSAIDs, discuss this with patient at every visit
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from Atrius.
1. Acetaminophen w/Codeine 1 TAB PO Q8H
2. Multivitamins 1 TAB PO DAILY
3. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
4. Ibuprofen 600 mg PO Q8H
5. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Multivitamins 1 TAB PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Docusate Sodium 200 mg PO BID
RX *Colace 100 mg 1 capsule(s) by mouth twice a day Disp #*60
Tablet Refills:*0
4. Lidocaine 5% Patch 1 PTCH TD DAILY
RX *lidocaine 5 % (700 mg/patch) keep patch on low back for 24
hours, off for 24 hours every other day Disp #*14 Not Specified
Refills:*0
5. Senna 1 TAB PO BID constipation
hold for loose stools
RX *senna 8.6 mg 2 tabs by mouth twice a day Disp #*56 Tablet
Refills:*0
RX *senna 8.6 mg 1 tab by mouth twice a day Disp #*28 Tablet
Refills:*0
6. Tizanidine 2 mg PO TID
RX *tizanidine 2 mg 2 capsule(s) by mouth three times a day Disp
#*84 Tablet Refills:*0
7. TraMADOL (Ultram) 50 mg PO BID low back pain
hold for respiration rate < 12
RX *tramadol 50 mg 1 tablet(s) by mouth twice a day Disp #*28
Tablet Refills:*0
8. Acetaminophen 500 mg PO Q6H
RX *acetaminophen 500 mg 1 tablet(s) by mouth four times a day
Disp #*28 Tablet Refills:*0
9. Outpatient Physical Therapy
Follow Up Provider:
___
Phone: ___
Fax: ___
ICD: 722.2
10. Gabapentin 300 mg PO BID
RX *gabapentin 300 mg 1 capsule(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Lumbar Disc Herniation (L4-L5 and L5-S1)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Thank you for chosing ___. You were admitted for severe low
back pain. In the ED an MRI of your ___ was done that showed
two disc bulges in the L4-L5-S1 area. There was no concern of
spinal canal damage. Neurology physicians were consulted who
were also not concerned for neurological effects. After
starting pain management we observed significant improvement in
your pain, and your functional capacity. Physical therapists
evaluated you on two days and recommended that you follow up
with a physical therapist in the outpatient setting. On the day
of discharge, you were able to sit, walk, shower and use the
bathroom on your own.
In addition to physical therapy, we recommend that you follow up
with your Primary care doctor, ___, and pain
management specialists. Your primary care doctor ___ coordinate
appointments with the other specialists.
Please make sure to avoid medications like Ibuprofen, Motrin,
Advil that have "NSAIDs" - these medications are commonly use to
relieve pain but can worsen your abdominal symptoms and increase
risk of bleeding.
MEDICATIONS:
START Gabapentin 300mg twice/day
START Tramadol 50mg four times / day (when pain not controlled)
START Lidocaine Patch place on lower back for 24 hours on, 24
hours off
START Tizanidine 2 mg three times / day
START Acetaminophen 500mg four times / day
START Senna 1 tab twice / day (for constipation)
START Colace Docusate Sodium 200 mg twice / day (for
constipation)
Followup Instructions:
___
|
10686640-DS-5
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DS
| 5 |
2147-08-05 00:00:00
|
2147-08-06 14:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Amoxicillin / Benzodiazepines / lisinopril /
irbesartan / valsartan / adhesive
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
Pacemaker extraction
History of Present Illness:
___ y/o F w/ hx of Syncope/SSS s/p right sided St. ___
pacemaker implant, hypothyroidism, fibromyalgia, transferred
from ___ for intractable back pain. The patient is
currently at a nursing facility for rehabilitation from recent
hospitalization for frequent falls. She has been improving
functionally and was being prepared for discharge home with ___,
but suffered a fall from a chair to the floor and landed on her
buttocks. The history is limited as the patient was in
considerable pain but there was no associated palpitations,
chest pain, shortness of breath or loss of consciousness. She
was taken to ___ were she underwent a CT scan of
her neck, lumbar spine, left hip, pelvis showed no signs of
fracture. Due to ___ despite multiple doses of narcotics, she
was transferred to ___ for further evaluation
In the ED, initial VS were 98.2 106 153/84 20 98%. Labs showed a
white count of 15 Neutrophisl of 15.6 CT abdomen showed no acute
process. She received tramadol, morphine, tylenol, ctx,
vancomycin. Heart rate trended down to ___ with IVF
Past Medical History:
1. Syncope/SSS s/p right sided St. ___ pacemaker implant in
___. Patient reports that this was her second device
implant. S/p generator change
2. Mild to moderate AS
3. s/p syncope ___ while at the gym, found hypertensive.
4. Hypertension with LVH
5. Hyperlipidemia
6. Sjogren's syndrome
7. PUD
8. fibromyalgia
9. Trochanteric bursitis, s/p steroid injections
10. Glaucoma
11. s/p hysterectomy/Oophorectomy
___. Urinary incontinence
13. Osteoporosis
14. Spinal stenosis s/p cervical laminectomy ___ years ago
15. GERD
16. Vertigo
Social History:
___
Family History:
Father with "heart problems", died at age ___
Physical Exam:
Admission exam:
VS: AFebrile, 132/69 92 93% RA
GENERAL: NAD. Eyes closed in pain. Opens with questions.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple, non-elevated JVP.
CARDIAC: RRR, normal S2, could not appreciate S1. ___ systolic
murmur heard best @ LUSB, radiation to carotids. No thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no rales or
cracklyes
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No peripheral edema, warm extremities. +2 DP
pulses. No femoral bruits.
BACK: No tenderness to palpation along the spine or paraspinal.
Pain appears to be provoked with papating right hip or left hip
but the pain is not reproducible
Neuro: Left lower extremity ___ strength limited by pain. ___
motion of the right lower extremity also limited due to pain. CN
II-XII intact.
.
Discharge exam
Vitals: 97.8 137/69 92 20 94-99ra
General: sleeping, wakes up with voice, held brief conversation
then fell back asleep
HEENT: NCAT, sclera clear, PERRLA, EOMI, OP clear
Neck: supple, no LAD, no elevated JVD
CV: RRR, soft systolic murmur, no rubs/gallops.
Lungs: CTAb anteriorly, no w/r/r
Abdomen: soft, NTND, NABS, no hsm
Ext: no ___ nodes, ___ spots, ___ lesions
Neuro: testing limited this am.
Pertinent Results:
Admission labs
==============
___ 10:02AM BLOOD WBC-15.6*# RBC-4.11* Hgb-12.5 Hct-38.8
MCV-95 MCH-30.3 MCHC-32.1 RDW-13.9 Plt ___
___ 10:02AM BLOOD Neuts-90.6* Lymphs-4.4* Monos-4.6 Eos-0.3
Baso-0.1
___ 10:02AM BLOOD Glucose-174* UreaN-25* Creat-0.7 Na-138
K-3.4 Cl-107 HCO3-22 AnGap-12
___ 10:10AM BLOOD Lactate-1.7
.
Pertinent results
=================
# TEE ___
There is biatrial enlargement. No atrial septal defect is seen
by 2D or color Doppler. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the aortic arch and in the descending thoracic aorta. There are
three aortic valve leaflets. The aortic valve leaflets are
severely thickened/deformed. There is a very tiny (0.1 x 0,2 cm)
mobile echodensity seen in the LVOT and likely originating from
he aortic valve (attachment not well visualized due to extensive
aortic cusp calcification and shadowing) (clips 55 and 24). No
aortic valve abscess is seen. There is severe aortic valve
stenosis (valve area 0.7cm2 by planimetry. Mild (1+) 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. There is moderate
functional mitral stenosis (mean gradient 7 mmHg) due to mitral
annular calcification. Mild to moderate (___) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of tricuspid regurgitation may be significantly UNDERestimated.]
There is no pericardial effusion.
IMPRESSION: Probable very small aortic valve vegetation. Severe
aortic stenosis by planimetry with mild aortic regurgitation.
Mild-moderate mitral regurgitation and moderate mitral stenosis
due to mitral annular calcification. Preserved biventricular
systolic function.
# MRI head ___
FINDINGS: The study is limited by significant motion artifact,
lack of
contrast and inability to obtain GRE sequence.
Multiple foci of restricted diffusion are present within the
right cerebellar
hemisphere, left occipital lobe, left parietal lobe, and both
frontal lobes,
compatible with acute infarcts. On FLAIR images, there are
confluent
regions of hyperintensity within the periventricular white
matter,
nonspecific, but likely the sequelae of chronic small vessel
ischemic disease.
No gross mass, mass effect, or midline shift is present. There
is no gross
intracranial hemorrhage.
IMPRESSION: Significantly supoptimal examination.
Multifocal supra- and infratentorial infarcts suggesting an
acute "shower" of
emboli from a central source, either bland or septic.
# ___ 9:15 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ ___
10:50AM.
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
# ___ 8:58 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. 10,000-100,000 ORGANISMS/ML..
Brief Hospital Course:
___ year old female with history of sick sinus syndrome s/p
right-sided St. ___ pacemaker implant, hypothyroidism,
fibromyalgia, aortic stenosis, transferred from ___
for intractable back pain, found to have high grade MRSA
bacteremia, course complicated by AV endocarditis leading to
removal of her permanent pacemaker, course also complicated by
multiple septic emboli to the brain.
ACTIVE ISSUES
------------
# MRSA septicemia, complicated by AV endocarditis s/p removal of
permanent pacemaker, also complicated by septic emboli to the
brain. Patient initially on a general medical service on the
floor. Gram positive cocci grew out from blood cultures soon
after admission. She presented with SIRS and was given broad
spectrum antibiotics in the ED. Given her pacemaker, the pocket
site was observed and felt to require removal. Her pacemaker
was subsequently removed, with surgical sutures removed prior to
discharge. Infectious disease was consulted and followed her
throughout her course. She underwent a TEE which showed concern
for a vegetation, and she was felt to have endocarditis. Repeat
TEE and TTE did not show the same vegetation. MRI Spine on ___
showed a focal area of enhacement near L5 without a drainable
fluid collection. She was felt to require followup MRI on ___.
CT surgery was consulted for evaluation, and felt not to be an
operative candidate. On ___, given her continued and
increasing delirium as described below, an MRI brain was
performed which showed concern for multiple foci of septic
emboli. Her neurological exam was without focal weakness,
though the patient was noted to be weak and deconditioned
throughout. She had slurred speech and slight left facial droop
that was still present, though improving, prior to discharge. ID
recommended daptomycin as patient continued to have positive
blood cultures while on vancomycin. Pt is to complete a 6 week
course of daptomycin with day 1 = ___. She has follow-up
MRI of head and back scheduled on ___, as well as outpatient ___
clinic follow-up. She will require weekly creatine kinase
levels to be drawn. There are numerous pending blood cultures
at the time of discharge, which will need to be followed up.
# Cardiogenic shock: Patient had poor perfusion evidenced by
increasing lactate and decreased UOP on admission. Cardiogenic
shock was the most likely etiology as evidenced by elevated JVP,
peripheral edema, pulmonary edema, and ScvO2 of 36%. At the time
of event, she had no leukocytosis or fevers making septic shock
much less likely despite being previously bacteremic.
Differential diganosis for cardiogenic shock in this patient
includes tricuspid regurgitation from pacer lead extraction,
aortic stenosis, pericardial effusion, and NSTEMI. Bedside TTE
did not show evidence of pericardial effusion. The most likely
explanation for her shock was a combination of new severe
tricuspid regurgitation from pacer lead extraction in
combination with severe aortic stenosis, resulting in
significantly reduced cardiac output. This is furthur
complicated by her sick sinus syndrome and inability to mount an
increased heart rate to improve cardiac output. She was placed
on a norepinephrine gtt and transferred to the MICU for further
care on ___. Cardiology was consulted and followed along.
After diuresis, she improved. Review of her TEE x2 and TTE
resulted in an aortic area of 1.0cm with a gradient of about 26.
CT surgery was consulted who evaluated her and felt her not to
be a surgical candidate unless she acutely decompensated. The
patient did not required CT surgery intervetion, and her blood
pressure stabilized prior to discharge.
# Urinary tract infection - patient was noted to have bacteria
and large leukocytes on ___. She was started on IV
ceftriaxone and is to finish a 7 day course of this medication
with day 1 = ___.
# Hypoxemic respiratory failure: Secondary to bilateral pleural
effusions and pulmonary edema after volume resuscitation. She
did well on on BiPAP, and eventually was downtitrated to Face
Mask, nasal cannula, and then room air. She was also much
improved after gentle diuresis. She had good oxygen saturation
on room air prior to discharge.
# Delirium: Initial toxic encephalopathy thought to be due from
persistent bacteremia, later acute delirium secondary to
prolonged hospital. Patient received quetiapine, olanzapine and
haloperidol with minimal effect. She was intermittently
agitated and screaming at times during her hospital stay, and
pulled out her Dobhoff tube x2. Patient was with waxing and
waning delirium, usually alert and oriented during the morning
but confused in the afternoon and evening. As above, on ___, an
MRI of her brain showed multiple foci of likely septic emboli.
On discharge, she still has waxing and wanning mental status as
she continues to have poor sleep at night, but overall, her
mental status is much improved. She was discharged on 25 mg of
quetiapine at night.
# Acute kidney injury: BUN/Cr elevated to > 20, initially
consistent with pre-renal azotemia in setting of poor PO intake.
Creatinine was monitored daily and downtrended after fluid
resucitation and then with gentle diuresis. Creatinine returned
to baseline prior to discharge.
# Back pain: No evidence of bony defects or fracture on CT scan.
MRI L-spine was with enhancing focus as described above, with
follow-up MRI to be done on ___.
INACTIVE ISSUES
--------------
# Hypertension: patient was continued on her home medications
# Hypothyroidism: patient was continued on her home
levothyroxine
# Hyperlipidemia: patient was continued on her home pravastatin
TRANSITIONAL ISSUES
------------------
# patient to continue to be seen at ___ clinic
# patient will need weekly CK while on daptomycin
# patient has follow up MRI of L spine to be done on ___
# patient to see cardiology ___ clinic after she finishes 6 weeks
course of antibiotics, to determine if she will require another
pacemaker
# patient will need continuous ___ and OT assistance to regain
strength and functioning
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Losartan Potassium 100 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Pravastatin 40 mg PO DAILY
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. Atovaquone Suspension 750 mg PO DAILY
9. PredniSONE 20 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Lidocaine 5% Patch 1 PTCH TD QAM
4. Losartan Potassium 100 mg PO DAILY
5. Pravastatin 40 mg PO DAILY
6. Carvedilol 3.125 mg PO BID
7. Docusate Sodium 100 mg PO BID
8. Polyethylene Glycol 17 g PO DAILY
9. QUEtiapine Fumarate 25 mg PO QHS
10. Senna 8.6 mg PO BID
11. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
12. Multivitamins 1 TAB PO DAILY
13. Acetaminophen 1000 mg PO Q8H
14. CeftriaXONE 1 gm IV Q24H Duration: 7 Days
15. Daptomycin 400 mg IV Q24H Duration: 6 Weeks
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
MRSA septicemia
AV endocarditis
cerebral embolic infarct
Secondary Diagnosis
Hypertension
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (___
or cane).
Mental Status: Confused - sometimes.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You came because of back pain. This
was most likely due to the fall. X-rays at the outside hospital
did now show any fractures. Here we found that you had a blood
stream infection. MRI showed multiple lesions from infected
collections that came from your heart. Because your heart
valves were infected, we had to remove your pacemaker. You
tolerated the procedure well. You were started on antibiotics
and you will continue to receive treatment for a total of 6
weeks. The infection has made you weak, and we are therefore
transitioning your care to a care facility, where you will work
with physical therapiest and an occupational therapist to help
you regain your strength.
Followup Instructions:
___
|
10686753-DS-3
| 10,686,753 | 25,727,867 |
DS
| 3 |
2145-07-03 00:00:00
|
2145-07-10 11:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
nitroglycerin / Tylenol / Chantix
Attending: ___.
Chief Complaint:
shortness of breath, productive cough
Major Surgical or Invasive Procedure:
Bronchoscopy and endobronchial ultrasound with fine needle
aspiration
History of Present Illness:
___ with > 120 py smoking history, oropharyngeal squamous cell
carcinoma s/p chemo-radiation ___ ___ and placement of PEG tube (___) for nutrition
presenting with dyspnea. Gets care mostly at ___ , but
thoracic surgery f/u @ ___. Seen on ___ for evaluation of
a FDG-avid 8mm right upper lobe lung nodule, concerning for
either primary lung cancer or metastatic disease. Seen again on
___, when he had a CPET ___ (pt cancelled prior appts
for rib pain after a fall)
notable for 74% predicted VO2 (average surgical risk). Follow
up CT scan in ___ at ___ notable for increase in
size of the RUL nodule to 11mm, the development of two
additional nodules (18mm and 13mm), and mediastinal and right
hilar lymphadenopathy.
Now he presented to OSH ED for evaluation of subjective SOB on
exercion, CT PE was done - notable for negative PE but
significantly narrowed RUL takeoff, worsening hilar
lymphadenopathy with post-obstructive component. Transferred to
___ and IP consulted.
In the ED, initial vitals were: 97.1 88 113/77 18 97% RA
- Labs were significant for INR 6.5.
- The patient was given oxycodone 60mg and 1L NS.
Vitals prior to transfer were: 98 84 116/80 18 95% RA
Upon arrival to the floor, denies SOB, CP. Reports that he has
been eating for ___ months and has not needed PEG tube. Reports
2d of cough, with no fever, chills. Cough has been intermittent
and productive of whitish sputum.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
- oropharyngeal squamous cell carcinoma s/p chemo-radiation
___
___ ___
- HTN
- MI ___
- Hyperthyroidism
- Hyperlipidemia
- CAD
- Hx of ETOH abuse
PAST SURGICAL HISTORY:
- placement of PEG tube ___
- Suspension Microlaryngoscopy with biopsy (___)
- Tonsillectomy
- bilateral eyelid surgery
- cardiac stents x2 (___)
- CABG (___)
Social History:
___
Family History:
none
Physical Exam:
ADMISSION:
Vitals: 97.9 128/68 86 18 100RA
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: upper airways sounds on upper half b/l, more prominent
on R side, no focal absent lung sounds
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding, PEG tube in place
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:
Vitals: Tc 97.9 Tm 98.3 HR ___, BP 100-110s/50-60s, RR 18 SpO2
100% RA
General: thin, bi-temporal wasting, alert, oriented, no acute
distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRLA.
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: rhoncherous BS on R side, no focal absent lung sounds
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding, PEG tube in place
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: grossly normal motor and sensation.
Pertinent Results:
ADMISSION
===================
___ 09:20PM BLOOD WBC-7.8 RBC-3.63* Hgb-11.6* Hct-33.8*
MCV-93 MCH-32.0 MCHC-34.3 RDW-14.1 RDWSD-47.7* Plt ___
___ 09:20PM BLOOD Neuts-79.1* Lymphs-6.4* Monos-13.0
Eos-0.0* Baso-0.3 Im ___ AbsNeut-6.19* AbsLymp-0.50*
AbsMono-1.02* AbsEos-0.00* AbsBaso-0.02
___ 09:20PM BLOOD Glucose-120* UreaN-12 Creat-0.7 Na-137
K-3.8 Cl-96 HCO3-25 AnGap-20
___ 06:00AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.8
___ 09:43PM BLOOD Lactate-3.8*
PERTINENT RESULTS
===================
___ 09:43PM BLOOD Lactate-3.8*
___ 09:16AM BLOOD Lactate-1.8
___ 06:08PM BLOOD ___ pO2-111* pCO2-56* pH-7.28*
calTCO2-27 Base XS--1 Comment-PERIPHERAL
IMAGING
===================
___ CXR
No comparison. Isolated right upper lobe parenchymal opacities,
combined to pleural thickening and enlargement of the right
hilus. The changes are characterized in substantially more
detailed on the CT examination from ___. Normal
appearance of the cardiac silhouette. Mild elongation of the
descending aorta.
MICROBIOLOGY
===================
___ 3:05 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
___ 9:20 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
PATHOLOGY
==================
FNA from EBUS ___ - pending
DISCHARGE LABS
===================
___ 06:05AM BLOOD WBC-6.8 RBC-3.26* Hgb-10.1* Hct-31.8*
MCV-98 MCH-31.0 MCHC-31.8* RDW-14.3 RDWSD-50.2* Plt ___
___ 06:05AM BLOOD ___ PTT-33.9 ___
___ 06:05AM BLOOD Glucose-97 UreaN-16 Creat-0.7 Na-137
K-4.2 Cl-96 HCO3-27 AnGap-18
___ 06:05AM BLOOD Calcium-9.0 Phos-3.4 Mg-1.8
Brief Hospital Course:
SUMMARY:
___ with > 120 py smoking history, oropharyngeal squamous cell
carcinoma s/p chemo-radiation ___ ___ and placement of PEG tube (___), recently diagnosed
lung mass presenting with dyspnea. He was treated with
levofloxacin and clindamycin for post-obstructive pneumonia. He
was clinically stable throughout hospitalization without oxygen
requirement. He was maintained on his home pain medications only
and was discharged on lower dose due to sedation. He underwent
bronchoscopy with fine needle biopsy.
# R bronchus obstruction: Pt presented with dyspnea to OSH and
found to have R bronchus obstruction from mass. Pt actually
currently comfortable with no SOB, satting in upper ___, and no
significant cough. No fever, significant cough, leukocytosis to
warrant abx currently for presumed PNA. S/P bronch on ___ w/
dilation, pus visualized, multiple biopsies. Will complete a 10
day course of levofloxacin/flagyl. Outpatient oncology follow-up
arranged.
# oropharyngeal squamous cell carcinoma s/p chemo-radiation
___ ___ and placement of PEG tube:
Unclear if new lung nodules are pimary lung cancer vs
recurrence/metastasis of oropharyngeal SCC. Patient unclear of
plan fo further management. Pt has not been using PEG tube for 2
months. Patient has outpatient f/u with ENT, oncology previously
arranged and now sooner.
# Afib: amiodarone and warfarin and diagnosis of afib in
outpatient cardiology notes. NSR on ECG, rhythm control with
amio. Continued home beta ___, amiodarone. Held
coumadin prior to bronch with biopsy. Conservatively restarted
prior to discharge with patient to f/u with PCP ___ ___.
# CAD: continued home atorvastatin, ___, metoprolol
TRANSITIONAL ISSUES:
- Last day of antibiotics = ___ for two weeks course following
bronchoscopy
- Patient underwent fine needle aspiration of endobronchial
lesion. Oncologist, Dr. ___ will need records regarding biopsy
results.
- patient on oxycodone 60 mq Q6 hrs at home, discharged on
decreased dose. Consider continued down titration given high
dose.
- CODE STATUS: FULL
- CONTACT: Wife, ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 3 mg PO DAILY16
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
3. Amiodarone 200 mg PO DAILY
4. carisoprodol 350 mg oral TID
5. Pantoprazole 40 mg PO Q24H
6. OxycoDONE (Immediate Release) 60 mg PO Q6H:PRN pain
7. pilocarpine HCl 5 mg oral TID
8. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
2. Amiodarone 200 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. carisoprodol 350 mg oral TID
5. Pantoprazole 40 mg PO Q24H
6. pilocarpine HCl 5 mg oral TID
7. Atorvastatin 10 mg PO QPM
RX *atorvastatin 10 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
8. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
9. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*9
Tablet Refills:*0
10. Outpatient Lab Work
Atrial fibrillation ICD 10 148.91
Labs drawn for INR on ___ faxed to:
Name: ___.
Phone: ___
Fax: ___
11. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every 8 hours Disp
#*30 Tablet Refills:*0
12. Warfarin 2.5 mg PO DAILY16
RX *warfarin 2.5 mg 1 tablet(s) by mouth daily Disp #*15 Tablet
Refills:*0
13. OxycoDONE (Immediate Release) 30 mg PO Q4H:PRN pain
RX *oxycodone 30 mg 1 tablet(s) by mouth every four hours Disp
#*36 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Post-obstructive pneumonia
SECONDARY:
Oropharyngeal squamous cell carcinoma
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 caring for you at the ___
___. You were recently admitted for shortness of
breath and productive cough, likely caused by a pneumonia due to
a lung mass. You were treated with medications prior to
undergoing biopsy of this lesion with via bronchoscopy. You were
treated with antibiotics and improved and will continue to take
these medications at home. In order to expedite your follow-up,
you will see Dr. ___ of Dr. ___ your oncology
follow-up. This appointment has been arranged for you already.
Please continue to take all of your medications as prescribed
and keep all of your follow-up appointments. OF note, you will
be on two antibiotics with the last day being ___. See Dr.
___ new oncologist on ___ at 9am. See Dr. ___,
___ primary care doctor at 2:30pm on ___. See Dr. ___,
___ ear/nose/throat specialist on ___ at 2:15pm.
It was a pleasure taking part in your care.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10686831-DS-18
| 10,686,831 | 22,779,623 |
DS
| 18 |
2126-09-11 00:00:00
|
2126-09-11 12:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
amoxicillin / Imitrex / Sulfa (Sulfonamide Antibiotics) /
venlafaxine
Attending: ___
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
PEG tube placement ___
History of Present Illness:
This is a ___ year old woman with a history of ___
disease (spinocerebellar ataxia type III), ESRD on HD T/Th/S0,
seizure disorder, and liver disease of unclear etiology
(possibly
DILI), who presents as a transfer from an outside hospital with
altered mental status and jaundice.
Notably, pt was recently admitted from ___ for
worsening jaundice and elevated bilirubin for which a CT torso
and MRCP were obtained and unremarkable. A liver biopsy showed
worsening cirrhosis with biliary duct involvement without a
clear
etiology for liver disease, though there was some thought that
this was due to DILI.
Pt is currently residing at a ___. She has felt generally
lethargic and weak since her most recent HD session on ___. She endorses worsening pruritus along her back as well
as subjective fevers and chills (SNF reported Tm 100.3). She
denied coughing, dysuria, headaches or neck stiffness.
___ course:
- Noted to be lethargic, slurring speech
- Labs: WBC 7.4, Hb/Hct ___, Na 136, BUN/Cr 59/5.1, NH3 34,
Tb
8.8, INR 1.2, procalcitonin 0.82, normal UA, CXR and NCHCT.
- Patient was given vancomycin and cefepime due to concern for
sepsis
She was transferred to ___ given that she is followed closely
by our hepatology service.
In the ___ ED:
- Initial vitals: 97.8 70 107/58 16 100% RA
- Exam notable for a lethargic, cachectic and jaundiced woman
with slurred speech and symmetrically/diffusely weak strength
effort without focal neuro changes.
- Labs notable for:
-- CBC: 7.0>7.0/22.7<286 MCV 97
-- Chem7: hemolyzed - Whole blood K 4.5, HCO3 21, BUN/Cr 71/5.4,
Glucose 121, AG 17
-- LFTs: ALT/AST ___, AP 709, Tb 8.5, alb 2.9
-- Coags: not obtained in our ED
-- Tox: negative serum tox screen, Utox not obtained
- Imaging notable for a RUQ duplex U/S with gallbladder sludge
and increased echogenicity of the bilateral kidneys likely
reflecting CKD.
- Consults: hepatology was consulted who recommended treating
with lactulose and admitting to ET. They also noted that her
LFTs
are actually improved from prior admission.
- Patient was given: Keppra 500 mg PO, Lacosamide 200 mg PO and
Lactulose 30 mL x2. Pt refused an NGT and was able to take these
medications by mouth.
Vitals prior to transfer: AF 89 141/78 12 99% RA
Upon arrival to the floor, pt states that she has never felt
like
this before. She is intermittently falling asleep during the
discussion and is having word finding difficulties. She states
that she is not eating well at the facility she is at and has
lost some weight. She cannot answer which medications she's on
at
the moment and recognizes that she's confused. She does feel
like
she's having difficulty focusing her eyes but cannot elaborate.
She feels diffusely weak but denies isolated weakness. Despite
report of low grade temp 100.3 at facility, she denies any
fevers.
REVIEW OF SYSTEMS: per HPI
Past Medical History:
Chronic liver disease of unclear etiology (?DILI)
___ (spinocerebellar ataxia type III)
ESRD on HD ___ (unclear etiology) for ___ years
Hypertension
Seizures (secondary to TBI, ___
Anemia
PAST SURGICAL HISTORY:
Liver biopsy
Left AV fistula placement in ___
Abdominal surgery for endometriosis
Left ACL repair
Tonsillectomy
Social History:
___
Family History:
Mother with ___
Father with prostate cancer, later got leukemia
Mother with lung cancer (no tobacco exposure)
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 98.8 155 / 80 85 20 99 Ra
GEN: cachectic and frail appearing woman, jaundiced, lying in
bed
in no acute distress
HEENT: jaundiced, dry mouth, sclera icteric, slight L.
exotropia,
right eye ? strabismus
CV: RRR, no murmurs
PULM: clear anteriorly
ABD: soft, NT, ND
EXT: cachectic, right leg w/ muscle wasting > left leg, no
edema;
+left forearm AV fistula + thrill.
NEURO: AOx2 (name, deaconess, ___, able to count backwards
from 10 to 1 but intermittently falling asleep during exam with
word finding difficulties, speech is dysarthric, EOMI: slightly
limited end gaze bilaterally, leftward beating nystagmus on left
gaze + rightward beating nystagmus on right gaze; limited upward
gaze but ? mild upward beating nystagmus as well
DISCHARGE PHYSICAL EXAM
==========================
VS: 24 HR Data (last updated ___ @ 1135)
Temp: 98.4 (Tm 99.2), BP: 125/66 (119-136/53-82), HR: 78
(78-86), RR: 18, O2 sat: 98% (95-99), O2 delivery: RA
Fluid Balance (last updated ___ @ 1136)
Last 8 hours Total cumulative 459ml
IN: Total 534ml, PO Amt 120ml, TF/Flush Amt 302ml, IV Amt
Infused 112ml
OUT: Total 75ml, Urine Amt 75ml
Last 24 hours Total cumulative 1524ml
IN: Total 1599ml, PO Amt 660ml, TF/Flush Amt 827ml, IV Amt
Infused 112ml
OUT: Total 75ml, Urine Amt 75ml
GEN: cachectic and frail appearing woman, jaundiced, lying in
bed
in no acute distress
HEENT: jaundiced, MMM, sclera icteric,
CV: RRR, no murmurs/rubs/gallops
PULM: CTAB anteriorly; Crackles in LLL posteriorly
ABD: soft, NT, ND, BS+, G-tube site c/d/i without surrounding
erythema or tenderness
EXT: cachectic, ___ muscle wasting, no edema
NEURO: AOx3, no asterixis, speech is slow however improved,
slightly dysarthric,
leftward beating nystagmus on left gaze, rightward beating
nystagmus on right gaze; limited upward gaze.
Pertinent Results:
ADMISSION LABS
================
___ 04:05PM BLOOD WBC-7.0 RBC-2.33* Hgb-7.0* Hct-22.7*
MCV-97 MCH-30.0 MCHC-30.8* RDW-20.8* RDWSD-73.2* Plt ___
___ 04:05PM BLOOD Neuts-81.1* Lymphs-7.1* Monos-7.6 Eos-1.9
Baso-0.9 Im ___ AbsNeut-5.68 AbsLymp-0.50* AbsMono-0.53
AbsEos-0.13 AbsBaso-0.06
___ 04:05PM BLOOD Glucose-121* UreaN-71* Creat-5.4* Na-138
K-6.3* Cl-100 HCO3-21* AnGap-17
___ 06:55AM BLOOD ___ PTT-26.2 ___
___ 06:55AM BLOOD Ret Aut-0.9 Abs Ret-0.02
___ 04:05PM BLOOD ALT-28 AST-52* AlkPhos-709* TotBili-8.5*
DirBili-5.0* IndBili-3.5
___ 04:05PM BLOOD Lipase-30
___ 04:05PM BLOOD Albumin-2.9* Calcium-9.5 Phos-4.4 Mg-2.6
___ 04:05PM BLOOD VitB12-612
___ 04:05PM BLOOD AFP-2.4
___ 04:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
Other Pertinent Labs/Micro
===========================
___ 04:50AM BLOOD LACOSAMIDE (VIMPAT)-9.3
___ 04:50AM BLOOD CLOBAZAM-PND
___ 06:10AM BLOOD CERULOPLASMIN-34 (reference range:
___ 06:55AM BLOOD Hapto-227* LD(___)-269* TotBili-9.4*
DirBili-7.1* IndBili-2.3
___ 06:55AM BLOOD Hypochr-1+* Anisocy-2+* Poiklo-3+*
Macrocy-1+* Microcy-1+* Ovalocy-1+* Target-2+* Acantho-1+* RBC
Mor-SLIDE REVI
___ 04:43PM BLOOD Hypochr-1+* Anisocy-1+* Poiklo-1+*
Polychr-1+* Target-1+* RBC Mor-SLIDE REVI
___ 1:00 pm BLOOD CULTURE #1 SOURVCE: VENIPUNCTURE.
Blood Culture, Routine (Final ___: NO GROWTH.
___ 02:30PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 02:30PM URINE Blood-NEG Nitrite-NEG Protein-100*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.5* Leuks-NEG
___ 02:30PM URINE RBC-1 WBC-2 Bacteri-FEW* Yeast-NONE
Epi-17
___ 2:30 pm URINE Source: ___.
SPECIMEN NOT PROCESSED DUE TO: Urinalysis had insufficient
pyuria
(<=10 WBCs/hpf). Please see ___ UA w/reflex Culture
protocol
for more information. If there is a reason why this
patients urine
culture should be run despite the urinalysis findings, and
it is
within 72 hours from when the specimen was received by the
lab, order
an Add-on urine culture. You will be required to
document the
reason for overriding the reflex protocol.
**NOT PROCESSED**
___ 5:20 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 6:50 pm BLOOD CULTURE 2 OF 2.
Blood Culture, Routine (Pending): No growth to date.
___ 03:39AM URINE Color-Yellow Appear-Hazy* Sp ___
___ 03:39AM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-TR*
___ 03:39AM URINE RBC-1 WBC-7* Bacteri-FEW* Yeast-NONE
Epi-10
___ 03:39AM URINE Mucous-RARE*
___ 3:39 am URINE Source: ___.
SPECIMEN NOT PROCESSED DUE TO: Urinalysis had insufficient
pyuria
(<=10 WBCs/hpf). Please see ___ UA w/reflex Culture
protocol
for more information. If there is a reason why this
patients urine
culture should be run despite the urinalysis findings, and
it is
within 72 hours from when the specimen was received by the
lab, order
an Add-on urine culture. You will be required to
document the
reason for overriding the reflex protocol.
**NOT PROCESSED**
___ 4:43 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 3:39 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final ___:
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
___ 2:31 pm MRSA SCREEN Source: Nasal swab.
MRSA SCREEN (Pending):
PERTINENT IMAGING/STUDIES
===========================
RUQUS (___)
1. Normal hepatic parenchymal echotexture.
2. Gallbladder sludge ball without acute cholecystitis.
3. Increased echogenicity of the bilateral kidneys may reflect
underlying chronic renal disease.
EKG (___)
Sinus rhythm
Probable left ventricular hypertrophy
Nonspecific ST-T wave abnormalities
No significant change
EEG (___)
1. Generalized periodic discharges at 0.5 to 1.0Hz indicative of
cortical hyperexcitability with increased risk for seizures.
2. Diffuse slowing and disorganization of the background with
generalized rhythmic delta activity, indicative of moderate
encephalopathy, nonspecific to cause.
There were no electrographic seizures.
EEG (___) - ...Mild to moderate encephalopathy. Compared to
the previous day, the discharges occur less frequently.
CT Head wo contrast (___)
1. No acute intracranial abnormality.
2. Grossly stable severe atrophy of the brainstem and cerebellum
consistent with ___ disease.
3. Mild sinus disease.
EGD (___)
-Normal mucosa in the whole esophagus
-Normal mucosa in the whole stomach
-Normal mucosa in the whole examined duodenum
-Gastrostomy in the Stomach body.
CXR (___)
Finding suggests minor pulmonary edema and left basilar
atelectasis.
Developing pneumonia at the left lung base seems less likely
although hard to entirely exclude; it may be helpful to obtain
short-term follow-up radiographs if needed clinically
CXR (___)
Mild improvement in left basilar opacity. Persistent evidence
for mild pulmonary edema.
Brief Hospital Course:
SUMMARY:
====================
This is a ___ year old woman with a history of ___
disease (spinocerebellar ataxia type III), ESRD on HD T/Th/S0,
seizure disorder, and liver disease of unclear etiology
(possibly DILI), who presents as a transfer from an outside
hospital with altered mental status and jaundice. Followed by
neurology, with EEG and neuro workup showing likely toxic
metabolic encephalopathy. Of note, she underwent PEG placement
this admission for chronic severe malnutrition. Course was
further complicated by fevers and HAP - treated with IV
antibiotics.
TRANSITIONAL ISSUES:
=====================
[ ] Large 8.3 cm x 7.6 cm x 6.8 cm solid mass arising from the
left adnexa noted on CT Imaging, recommend follow up with OBGYN
as outpatient
[] fibroscan elastrography or MRI elasto on outpatient followup
[] Please recheck TSH level at outpatient
[] Hydroxizine and meclizine were held due to concern for
contribution to
[] Started lactulose given asterixis, however it is unclear if
hepatic encephalopathy is the cause or if it is contributing -
would continue to assess need
[] Discharged on IV Cefepime with PICC in place to complete 7
day course to end ___.
[] Given need for intermittent PRBC transfusion inpatient
without e/o active bleeding, would consider increasing EPO.
[] PICC line in right arm should be removed following abx course
completion ___.
ACTIVE ISSUES
=============
# Altered mental status:
# Lethargy:
# Generalized weakness:
Pt p/w 2 days of lethargy, subjective weakness and slurred
speech, though per prior notes she has dysarthria at baseline.
Infectious work up unremarkable. ___ at ___ also
unremarkable. Neuro exam is notable for abnormal extraocular
movements (see above) though this seems to match prior neurology
note. She had bilateral asterixis, possibly ___ uremic
encephalopathy, and mental status improved after HD, however not
consistently. It was felt to be less likely ___ HE given she
does not have cirrhosis or portal hypertension. Also considered
over-sedation from medications, and AEDs were decreased to
reflect hepatic/renal dosing, and medications such as meclizine
and hydroxyzine were held. Given seizure disorder and hx of
nonconvulsive status, neurology was consulted and patient
underwent several days of EEG monitoring, with workup revealing
likely toxic metabolic encephalopathy. She was started on
rifaximin and lactulose given asterixis and continued given
improvement in mental status. Of note, her mental status
sometimes fluctuates surrounding dialysis sessions, and this is
expected to continue in the future.
# Cachexia
# Malnutrition
Profoundly cachectic though weight is stable from last
admission. Most likely related to swallowing dysfunction and
poor PO intake related to spinocerebellar ataxia. Alternatively
may be related to underlying liver disease or possible
malignancy given pelvic mass. Pt with known aspiration risk,
however is accepting that risk per patient and prior notes.
Started folic acid/thiamine and followed by nutrition.
Eventually she underwent PEG tube placement ___ and was started
on TFs, which she tolerated well.
# Fever
Had low-grade temperatures to 100.3 intermittently during
admission without localizing symptoms and with all initial
infectious workup negative. ON ___ spiked T 102 and CXR
revealing possible opacity next to right heart border and
possibly in left lower lobe, which would not be unexpected given
her high risk of aspiration. Also at risk for HAP given
prolonged hospitalization. UA negative for infection. Started on
vanc/cefepime for empiric treatment of HAP. Repeat CXR with mild
improvement left basilar opacity. IV Vanc/Cefepime Abx
eventually narrowed to just Cefepime to complete ___s
outpatient. Abx to end ___
# Liver disease of unclear etiology:
# Jaundice/elevated Tbili:
Dx with liver disease of unknown etiology, possibly DILI
(phenytoin). Presents with jaundice and altered mental status
though notably LFTs near or slightly better than on previous
admission. Her AMS is unlikely ___ liver disease as she does not
have cirrhosis. Liver biopsy with fibrosis, bile duct damage and
bile duct loss. Otherwise, showed iron deposition in Kupffer
cells, which is consistent with chronic disease or underlying
renal disease. Less consistent with hemochromatosis given
deposition is not in hepatocytes. RUQUS with gallbladder sludge
ball without acute cholecystitis. No further work-up indicated
at this time. Otherwise, patient was treated with lactulose and
rifaximin for AMS per above. MCRP ___ without focal lesion,
AFP 2.4. Pt was continued on home Ursodiol 500 mg PO BID.
Nutrition per above.
**OF NOTE: Recent discharge summary with MRI Liver that was
added INCORRECTLY - this patient DOES NOT have history of HCC or
liver lesions suspicious of HCC**
# ESRD on HD (___):
Recieved dialysis as inpatient. Continued Nephrocaps, sevelamer,
epo.
# Normocytic anemia:
Hb 7.0, slightly below baseline of 7.5. Attributed to renal
failure. Ferritin > 5,000, Iron 62. SPEP ___ wnl. B12 wnl.
Haptoglobin elevated. Abs retic 0.02. Required several units
pRBCs during amdmission, however there was not suspicion for
active bleeding.
CHRONIC/STABLE ISSUES
=========================
# Acute on chronic pruritus:
Likely related to cirrhosis and/or ESRD. Continued ursodiol 500
mg PO BID, dc'd hydroxyzine on admission given AMS.
# Pelvic mass:
Pelvic U/S ___ showed a large 8.3 cm x 7.6 cm x 6.8 cm
heterogeneous predominantly solid mass arising from the left
adnexa concerning for neoplasm. CEA normal at 3.0, CA 125 mildly
elevated at 46 and CA ___ also mildly elevated at 42. Will
follow-up with OBGyn as outpatient for further management.
# Seizure disorder:
AEDs were decreased on admission per above. Followed by
neurology; EEG monitoring showed generalized epileptic
discharges. 1mg IV Ativan was trialed and it was noted that it
did not cause any change in the background activity, and it was
therefore less likely to represent seizure activity.
# ___ disease:
Holding Meclizine 12.5 mg PO Q12H:PRN dizziness given concern
for contribution to AMS. Pt is at risk for aspiration as a
result of swallowing dysfunction and weakness, however is
accepting that risk and continues to take in PO.
# Hypertension: Continued on home CARVedilol 25 mg PO BID
# GERD: Continued on home Famotidine 20 mg PO DAILY
# Depression: Continued on home Citalopram 15 mg PO DAILY
# CODE: DNR/DNI (confirmed with patient ___
# CONTACT: ___ (sister): ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Famotidine 20 mg PO DAILY
2. HydrOXYzine 25 mg PO TID:PRN itching
3. Artificial Tear Ointment 1 Appl BOTH EYES BID
4. CARVedilol 25 mg PO BID
5. Citalopram 15 mg PO DAILY
6. Clobazam 10 mg PO BID
7. LACOSamide 200 mg PO BID
8. Lactulose 30 mL PO TID
9. LevETIRAcetam 500 mg PO 3X/WEEK (___)
10. LevETIRAcetam 1000 mg PO DAILY
11. Meclizine 12.5 mg PO Q12H:PRN dizziness
12. Nephrocaps 1 CAP PO DAILY
13. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
14. sevelamer CARBONATE 800 mg PO TID W/MEALS
15. Thiamine 200 mg PO DAILY
16. Ursodiol 500 mg PO BID
17. Vitamin D 800 UNIT PO DAILY
Discharge Medications:
1. CefePIME 1 g IV Q24H HAP PNA Duration: 2 Doses
last dose ___ for 7 day HAP tx course
2. LACOSamide 150 mg PO BID
3. Artificial Tear Ointment 1 Appl BOTH EYES BID
4. CARVedilol 25 mg PO BID
5. Citalopram 15 mg PO DAILY
6. Clobazam 10 mg PO BID
7. Famotidine 20 mg PO DAILY
8. Lactulose 30 mL PO TID
9. LevETIRAcetam 1000 mg PO DAILY
10. LevETIRAcetam 500 mg PO 3X/WEEK (___)
after dialysis sessions ___
11. Nephrocaps 1 CAP PO DAILY
12. sevelamer CARBONATE 800 mg PO TID W/MEALS
13. Thiamine 200 mg PO DAILY
14. Ursodiol 500 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
Toxic Metabolic ___ Acquired Pneumonia
Severe protein calorie malnutrition requiring PEG tube placement
SECONDARY:
Seizure disorder
Spinal Cerebellar Ataxia type III
End-Stage Renal Disease on Dialysis
Liver disease of unclear etiology
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. ___,
You were admitted to the hospital because you were more confused
than normal and low-grade fevers.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You liver function tests remained elevated, but stable
- You were seen by the neurology team who monitored you for
seizures and reduced some of your seizure medications
- You required several blood transfusions for your chronic
anemia
- You underwent a PEG tube placement - which is a tube that goes
into your stomach and provides you with extra nutrition.
- You developed a pneumonia and were treated with antibiotics
- 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
- 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:
___
|
10686844-DS-15
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DS
| 15 |
2118-09-01 00:00:00
|
2118-09-01 17:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
opioids
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
Mr. ___ is a ___ male with a PMH notable for
chronic
pancreatitis and pancreatic insufficiency who presents with
acute
on chronic abdominal pain.
Reports that he has had a long standing history of abdominal
pain
with frequent flares, which usually resolves on its own.
Typically flares involve epigastric abdominal pain, nausea,
vomiting, inability to eat. Has baseline watery, fatty diarrhea.
More recently for the past month, having significantly more
frequent flares, requiring ED visits about twice a week. Looking
through his records at ___, I see ED visits on ___, and ___ and a hospitalization on ___ for GI
complaints. On ___ went to see his PCP, and given report of
severe abdominal pain, he was referred to the ___ ED for
admission.
In the ED, vitals were stable. Received 2L LR IVF.
hydromorphone,
diphenhydramine, and ondansetron IV.
On the floor, reports ongoing significant abdominal pain and
severe nausea. Has been having subjective chills and sweating
along with flares. No significant change in diet from last year
to now. Having weight loss with difficulty tolerating PO intake.
Looking through his outpatient records, there is a documented
~10
lbs weight loss from ___ (152 lbs) to ___ (143 lbs).
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- idiopathic chronic pancreatitis
- PSTD
Social History:
___
Family History:
No family history of chronic GI problems that he can recall.
Physical Exam:
ADMISSION PHYSICAL:
===================
VITALS: ___ 1832 Temp: 98.8 PO BP: 146/96 L Lying HR: 77
RR:
18 O2 sat: 100% O2 delivery: RA
GENERAL: Alert and in no apparent distress.
EYES: Anicteric, pupils equally round.
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate.
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored.
GI: Abdomen soft, non-distended, epigastric tenderness 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. Has scattered tattoos.
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout.
DISCHARGE PHYSICAL
==================
T98.2, BP 144/97, HR 75, RR 18, O2 99% RA
Gen - NAD, sitting up in bed, comfortable appearing
HEENT - nc/at, moist oral mucosa
Eyes - perrl, anicteric
Neck - supple, no LAD, no JVD
___ - RRR, s1/2, no murmurs
Pulm - CTA b/l, no w/r/r
GI - soft, slightly tender in epigastric area but improved, non
distended, +bowel sounds
Ext - no peripheral edema or cyanosis
Skin - warm, dry, no rashes or lesions
Psych - calm, appropriate
Neuro - motor ___ all ext, non focal
Pertinent Results:
ADMISSION LABS:
===============
___ 01:40AM BLOOD WBC-6.7 RBC-5.35 Hgb-14.9 Hct-46.9 MCV-88
MCH-27.9 MCHC-31.8* RDW-13.9 RDWSD-43.9 Plt ___
___ 01:40AM BLOOD Neuts-59.7 ___ Monos-7.0 Eos-0.1*
Baso-0.4 Im ___ AbsNeut-3.99 AbsLymp-2.17 AbsMono-0.47
AbsEos-0.01* AbsBaso-0.03
___ 01:40AM BLOOD Glucose-89 UreaN-8 Creat-1.2 Na-147
K-6.1* Cl-107 HCO3-23 AnGap-17
___ 01:40AM BLOOD ALT-20 AST-49* AlkPhos-48 TotBili-0.3
___ 01:40AM BLOOD Lipase-26
___ 01:40AM BLOOD Albumin-4.7 Calcium-10.1 Phos-2.7 Mg-2.1
___ 01:53PM BLOOD Lactate-3.1* K-4.4
___ 04:49PM BLOOD Lactate-2.6*
IMAGING:
========
MRCP ___
IMPRESSION:
1. Findings suggestive of acute or subacute on chronic
pancreatitis given
normal enzymes involving the pancreatic head and uncinate
process. Additional
considerations include segmental autoimmune pancreatitis.
2. Background chronic pancreatitis.
3. No pancreatic necrosis. No fluid collection. Normal
pancreatic anatomy.
No gallstones or pancreaticoliths.
RECOMMENDATION(S): Recommend correlating with prior imaging to
assess for
interval change and chronicity of findings. Additionally a
follow-up MRCP
with contrast in 3 months is recommended to assess for interval
change.
EGD ___
Impression: Abnormal mucosa in the stomach
Normal mucosa in the duodenum (biopsy, endoclip)
Otherwise normal EGD to third part of the duodenum
DISCHARGE LABS ___:
===============
Wbc 5.0, Hg 11.7, Hct 37.7, Plt 207
Na 143, K 3.7, Cl 101, Co2 27, BUN/Cr ___, Glucose 104
ALT 16, AST 23, ALP 52, T bili 0.2
Gastric mucosa biopsy - pending
Blood culture - pending
Brief Hospital Course:
Mr. ___ is a ___ male with a PMH notable for
chronic pancreatitis and pancreatic insufficiency who presents
with acute on chronic abdominal pain.
# Abdominal pain
# Chronic Pancreatitis
# Weight Loss
-Etio of abdominal pain likely related to pancreatitis thought
to be exacerbated by EtOH intake. He had an MRCP consistent with
pancreatitis and an EGD with biopsies taken, pending at the time
of discharge. Had required IV pain meds but transitioned to PO
oxycodone. Tolerated a PO diet well with minimal pain. Counseled
on alcohol and tobacco cessation.
-Continue creon at home dose
-Increased omeprazole to 40mg BID
-F/u gastric biopsies as outpatient
-Encouraged to follow low fat low residue diet
-stool H pylori antigen was not sent ___ patient did not have a
bowel movement after it was ordered, can be done as outpatient
if needed
-Pain control: patient asked for narcotic Rx which was denied
based on him still having oxycodone at home from filling #50
tabs of Percocet ___. Additionally he has filled oxycodone
from 7 different providers within ___ year. Patient reports he has
enough medication at home so none was provided. It was added to
his discharge meds but it is not a new home medication.
-Resume home gabapentin for pain as prescribed by outpatient
provider
-___ bowel regimen while on narcotics, patient reports he
has at home
# Anemia - Hg dipped slightly, likely dilutional, has no signs
of acute blood loss, needs repeated as outpatient.
# PTSD:
- Not currently taking amitriptyline as prescribed
- outpatient follow up
# Dispo: d/c home today, f/u with GI within 1 week (appointment
set), PCP ___ ___ weeks.
Time spent: 45 minutes
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Ondansetron ODT 4 mg PO Q8H:PRN nausea, vomiting
2. Omeprazole 20 mg PO DAILY
3. Gabapentin 400 mg PO TID
4. Amitriptyline 25 mg PO QHS
5. DiphenhydrAMINE 25 mg PO Q8H:PRN itching
6. HydrOXYzine 50 mg PO Q8H:PRN itching
7. lipase-protease-amylase 20,880-78,300- 78,300 unit oral ASDIR
Discharge Medications:
1. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
Reason for PRN duplicate override: Alternating agents for
similar severity
2. Omeprazole 40 mg PO BID
3. Amitriptyline 25 mg PO QHS
4. DiphenhydrAMINE 25 mg PO Q8H:PRN itching
5. Gabapentin 400 mg PO TID
6. HydrOXYzine 50 mg PO Q8H:PRN itching
7. lipase-protease-amylase 20,880-78,300- 78,300 unit oral
ASDIR
8. Ondansetron ODT 4 mg PO Q8H:PRN nausea, vomiting
RX *ondansetron 4 mg 1 tablet(s) by mouth q8hrs prn Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: Chronic pancreatitis
SECONDARY: current smoking, current alcohol use, Post-traumatic
stress disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was our pleasure caring for you at ___
___. You were admitted to the hospital with
abdominal pain, which we determined was due to a flare of your
chronic pancreatitis. Our gastroenterologists evaluated you,
and we performed a scan called an MRCP, which was consistent
with pancreatitis. You also had an upper endoscopy that showed
some inflammation in the stomach and biopsies were taken, which
are pending at the time of discharge. We treated you with IV
fluids and pain medication, and when you were feeling better,
you were discharged home. Your home dose of Omeprazole was
increased.
It is critically important that you do everything you can to
stop smoking. Smoking hurts the pancreas and makes it more
likely that your attacks of pancreatitis will recur. Your
primary care physician can help by prescribing nicotine
replacement therapy if you so choose. You should also abstain
from alcohol, as this will also make chronic pancreatitis recur.
You should talk to your primary care physician about medication
options to assist with stopping drinking and smoking.
Thank you for allowing us to participate in your care.
Followup Instructions:
___
|
10686970-DS-20
| 10,686,970 | 25,363,627 |
DS
| 20 |
2195-07-06 00:00:00
|
2195-07-06 16:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / Peanut
Attending: ___.
Chief Complaint:
Left Sided Chest/Rib Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with past medical history of atrial
fibrillation on coumadin, bilateral blindness (legally blind),
hypertension, BPH s/p TURP who presents with left sided chest
pain that developed acutely at home while he was listening to
the radio (___ game). The patient states it is mildly
pleuritic and not associated with SOB, dyspnea on exertion,
diaphoresis, nausea/vomiting, fevers/chills, cough,
lightheadedness, syncope, sick contacts. It lasted only 30
minutes approximately, was ___. He has not had any recent falls
or injuries either, or lower extremity swelling.
In the ED, initial VS: T98.5, HR86, BP125/69, RR18, 95% on RA.
The patient's labs showed leukocytosis to 13.8, DDimer 997,
adequate anticoagulation with INR 2.9, troponin <0.01, lactate
1.1. CXR initially was read as LLL atelectasis and increased
vascularity, EKG showed atrial fibrillation with peaked T waves
and poor R wave progression. The patient initially received
aspirin 325mg with plans for Stress MIBI but CTA for elevated
DDimer revealed multifocal pneumonia, no pulmonary embolism. The
patient was given Ceftriaxone 1 gram X1, Azithromycin 500mg IV
X1 and admitted. Upon transfer, VS: T97.8, HR62, RR16, BP129/64,
96% on RA. Because patient was very stable and he has no hx of
hospital exposure, his abx were switched to Levofloxacin for
treatment of CAP.
Currently lying comfortably in bed drinking cranberry juice,
chest pain free. Eager to tell jokes X2 and wants to go home
today. Finds nothing good on television and thus, time in
hospital more boring; can ambulate around home without issues
and listen to music/radio.
.
ROS:
+ Per above
- Fever, chills, headache, rhinorrhea, congestion, sore throat,
cough, shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria.
Past Medical History:
MEDICAL & SURGICAL HISTORY:
* Atrial fibrillation - rate controlled and on coumadin
* Neuropathy
* Benign prostatic hyperplasis previously with chronic
indwelling ___ now s/p TURP
* Legally blind bilaterally
* Esophageal diverticulum
* Gait disorder
* Hypertension
* Kyphoscoliosis
* Left inguinal hernia s/p repair in ___
Social History:
___
Family History:
Father with history of MI
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 97.7F, BP 108/52, HR 76, R 20, O2-sat 97% RA
GENERAL - Well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, right sided ptsosis, sclerae anicteric, dry mucus
membranes, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, irregularly irregular, no MRG, nl
S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, strength and
sensation intact
DISCHARGE PE:
Vitals: 97.7 temp, BP 110/65, 76, 20, 97% on RA
GENERAL - Well-appearing man in NAD, comfortable, appropriate
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no wheezing, rales, rhonchi, good air
movement, no accessory muscle use
HEART - PMI non-displaced, irregularly irregular, no MRG, nl
S1-S2
ABDOMEN - Soft, non-tender, non-distended, BS +ve, no masses or
HSM, no rebound/guarding
EXTREMITIES - well-perfused, no clubbing or erythema, 2+
peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, strength and
sensation intact
Pertinent Results:
ADMISSION LABS:
___ 11:50PM WBC-13.8* RBC-4.45* HGB-13.1* HCT-40.7
MCV-92# MCH-29.4 MCHC-32.2 RDW-14.0
___ 11:50PM ___ PTT-41.1* ___
___ 09:20AM ___ PTT-42.5* ___
___ 09:20AM WBC-12.0* RBC-4.21* HGB-12.5* HCT-39.1*
MCV-93 MCH-29.6 MCHC-31.9 RDW-14.3
___ 11:50PM cTropnT-<0.01
___ 09:20AM CK-MB-1 cTropnT-<0.01
___ 09:20AM GLUCOSE-96 UREA N-21* CREAT-0.8 SODIUM-139
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-33* ANION GAP-8
MICRO:
___ 4:10 am BLOOD CULTURE X2
Blood Culture, Routine (Pending):
IMAGES:
CTA OF CHEST ON ___ (Preliminary Report):
Opacification of the pulmonary vasculature demonstrates no
filling defects to suggest a pulmonary embolism. The aorta and
great vessels are normal in caliber. The heart is moderately
enlarged, but stable and without a pericardial effusion. There
is no hilar, mediastinal or axillary lymphadenopathy by CT size
criteria. An aberrant right subclavian artery is incidentally
noted.
The airways are patent to the subsegmental levels. There are
multiple bilateral nodular opacities with more confluent
opacities at the bases, particularly at the left base (3:46, 35,
23, 7).
This study is not tailored for evaluation of subdiaphragmatic
structures, but the left adrenal gland appears prominent at 13 x
10 mm suggestive of a stable adenoma. A right renal cyst is
stable. A small hiatal hernia is noted. The remainder of the
visualized portions of the upper abdomen are normal.
OSSEOUS STRUCTURES: Moderate-to-severe degenerative changes of
the thoracolumbar spine are identified with bridging anterior
osteophytes and kyphosis of the spine. No acute fractures are
identified.
IMPRESSION:
1. Multiple bilateral nodular opacities, with the most
confluence at the left base, consistent with multifocal
pneumonia. A dedicated chest CT after resolution of symptoms can
be considered to evaluate for nodules. 2. Stable left adrenal
nodule, likely an adenoma.
3. No evidence of a pulmonary embolism or acute aortic injury.
CXRAY ON ___:
There are bilateral basal opacities with the most confluent at
the
left base suggestive of multifocal pneumonia. Otherwise,
cardiomediastinal silhouette appears moderately enlarged. There
is no pneumothorax or pleural effusion. Small lung nodules in
the upper lobes seen in concurrent CT are below the resolution
of this CXR.
IMPRESSION: Findings suggestive of multifocal pneumonia, worst
in the left lower lobe, and better delineated on the dedicated
chest CTA. Follow up in six weeks is recommended to ensure
resolution.
Brief Hospital Course:
___ year old male with past medical history of atrial
fibrillation on coumadin, bilateral blindness (legally blind),
hypertension, BPH s/p TURP who presents with left sided chest
pain that developed acutely at home, found to have WBC 13.8,
ddimer 997, suggestive on CTA of multifocal pneumonia currently
on Levofloxacin and clinically well.
1. Multifocal PNA: Consistent with elevated WBC and DDimer in
conjunction with CTA findings. Patient had atypical chest pain
on left lateral chest wall which was consistent with pneumonia
and resolved while he was here. He remained afebrile and with
decrease in leukocytosis. Discharged with 5 days of Levofloxacin
PO 750mg.
2. Atrial Fibrillation: On coumadin. His Coumadin dose was
decreased from 4mg daily to 2.5mg daily while on Levofloxacin.
INR was 3.1 today. He was instructed to have INR level repeated
on ___ and results sent to his PCP who monitors
his INR. He was continued on Atenolol for rate control.
3. Legal blindness: Stable. Continued betegan eye drops.
4. HTN: BP slightly lower this AM at 108/52 as per his baseline
was in the 120s-130s. Repeat after receiving Atenolol was 110.
Pt has been asymptomatic and afebrile. Currently clinically
stable, so d/ced home with close follow-up.
5. BPH s/p TURP: Stable
# CODE: Full Code, confirmed with patient
# CONTACT: Daughter ___: ___
TRANSITIONAL PROBLEMS:
- He will need to have repeat image of chest for evaluation of
resolution of pneumonia
- ___ draw on ___ since INR at 3.1 today and pt
on levofloxacin
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. Atenolol 25 mg PO DAILY Hypertension
2. Warfarin 4 mg PO DAILY16 Atrial Fibrillation
3. Levobunolol 0.25% 1 DROP LEFT EYE DAILY
4. traZODONE 25 mg PO HS:PRN Insomnia
Discharge Medications:
1. Atenolol 25 mg PO DAILY
Hold for SBP<100, HR<55
2. Levobunolol 0.25% 1 DROP LEFT EYE DAILY
3. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 (One) Tablet(s) by mouth Daily Disp
#*4 Tablet Refills:*0
4. Warfarin 2.5 mg PO DAILY16 Pneumonia Duration: 4 Days
RX *Coumadin 2.5 mg 1 (One) Tablet(s) by mouth Daily Disp #*5
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Pneumonia
Secondary Diagnosis: Atrial Fibrillation and High blood pressure
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. ___ you were treated here at ___
___ for your Pneumonia. Initially we gave you
antibiotics through your IV, but we will be sending you home on
oral medications. Because you take Coumadin for your irregular
heart beat (atrial fibrillation) your coumadin dose must be
lowered to 2.5mg daily while you are taking the antibiotics
(Levofloxacin). Your dose will be adjusted based on your primary
doctors ___. You will take antibiotics for five days
(until ___.
We have made the following changes to your medications:
- START of levofloxin 750mg once daily for a total of 5 days
(until ___.
- Decrease dose of coumadin from 4mg to 2.5mg given that your
coumadin level was elevated and your antibiotic may affect this
- You can take Tylenol up to 1000mg by mouth three times daily
for pain.
You will need to follow-up with your primary care doctor as
listed below.
Followup Instructions:
___
|
10686970-DS-21
| 10,686,970 | 29,211,441 |
DS
| 21 |
2196-01-06 00:00:00
|
2196-01-06 16:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / Peanut
Attending: ___
Chief Complaint:
Cough
Major Surgical or Invasive Procedure:
Right thoracentesis with drainage of 5 cc purulent fluid
___
History of Present Illness:
Mr. ___ is an ___ year old male with history of atrial
fibrillation on warfarin, esophageal diverticulum/dysphagia, and
blindness here with chronic non-productive cough and new
right-sided pleuritic chest pain developing ___ the last 48
hours. His pain is characterized by a ___ stabbing sensation at
worst (now ___ relived with analgesic medications but worsened
with inspiration or movement. His pain radiates to his
back/shouders. He has had similar pain ___ the past, most
recently ___ ___, and has received diagnoses of pneumonia. He
denies subjective fevers at home, fatigue, hoarseness, malaise,
lymphadenopathy, diaphoresis, left-sided chest pain,
lightheadedness, nausea, vomiting, or other somatic complaints.
Per OMR, he was admitted on ___ (and discharged same day)
with a diagnosis of mutifocal pneumonia after presenting with
left-sided pleuritic chest pain; discharged with prescription
for 5 days of levofloxacin and recommendations to have repeat
CXR to evaluate for resolution of pneumonia. Presented later to
PCP ___ ___ with non-productive cough but without other
symptoms/signs of pneumonia - diagnosed with latent pleural
irritation secondary to bronchitis. He has not had imaging ___
the interval from ___ until now.
___ the ED, initial VS were 99.0, 83, 156/81, 16, 100%. Initial
labs demonstrated leukocytosis with 14,600 WBCs, of which 88%
were PMNs. A CXR revealed bibasilar airspace opacities and
possible left pleural effusion. His d-dimer was 882. A
subsequent CTA chest demonstrated possible right-sided empyema
and LLL, RML multifocal pneumonia. He received 1g ceftriaxone
and 500mg azithromycin initially at 2330 on ___. He required
an extended stay ___ the ED due to bed availability and was then
managed by ___, who added 150mg clindamcyin at 0140 on ___
due to empyema presence. He was started on some of his home
medications, including warfarin 5mg daily, atenolol, and
mirtazapine. He required acetaminophen, tramadol, and oxycodone
for control of pleuritic pain. IP was consulted, who recommended
discontinuing warfarin (INR was 2.0) and considering FFP for
reversal of anticoagulation pending possible thoracentesis
and/or chest tube placement. He remained afebrile during his
time ___ the ED.
ROS:
(+) Per HPI
(-) Denies fatigue, subjective fever, fatigue, weight change,
headache, tinnitus, dysphagia, odynophagia, hoarseness,
palpitations, dyspnea, paroxysmal nocturnal dyspnea, orthopnea,
abdominal pain, nausea, vomiting, diarrhea, melena,
hematochezia, lymphadenopathy, dysuria, new bruising, new
bleeding, rash, or other somatic complaints.
Past Medical History:
- atrial fibrillation on warfarin
- benign prostatic hypertrophy previously with chronic
indwelling Foley now s/p TURP
- esophageal diverticulum leading to dysphagia
- HTN
- blindness secondary to macular degeneration on left, retinal
detachment on right
- gait disorder
- kyphoscoliosis
- left inguinal herniorrhaphy ___
- neuropathy
Social History:
___
Family History:
Father with history of MI
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS on arrival to floor: 97.8, 146/62, 89, 18, 0.99 on 3L NC
Gen: NAD, AAOx3, comfortably lying ___ bed and conversant
HEENT: NC/AT, right pupil clouded, yellowed and orbit sunken ___
socket, left pupil cloudy; sclera anicteric; oropharynx clear
without exudate or erythema, mucosa moist but slightly dry; no
LAD
CV: irregularly irregular, no m/r/g
Pulm: difficult to assess as patient moving small volumes of
air, but lung sounds decreased at left posterior bases
associated with left-sided dullness to percussion and egophany
Abd: BS+, soft, NT, ND, no HSM, no palpable masses, ___
negative
MSK: dorsalis pedis and radial pulses 2+ bilaterally, no c/c/e
Neuro: oriented x3, CNII-XII intact, moving all extremities,
sensation grossly intact
DISCHARGE PHYSICAL EXAM:
Unchanged.
Pertinent Results:
ADMISSION LABS:
___ 04:45PM BLOOD WBC-14.6* RBC-4.38* Hgb-13.7* Hct-41.7
MCV-95 MCH-31.2 MCHC-32.7 RDW-13.7 Plt ___
___ 04:45PM BLOOD Neuts-88.0* Lymphs-5.5* Monos-5.4 Eos-0.9
Baso-0.2
___ 03:09AM BLOOD ___
___ 04:45PM BLOOD Glucose-122* UreaN-15 Creat-0.8 Na-141
K-5.0 Cl-103 HCO3-29 AnGap-14
___ 04:45PM BLOOD ALT-11 AST-16 AlkPhos-120 TotBili-0.7
___ 04:45PM BLOOD Lipase-17
___ 04:45PM BLOOD Albumin-3.3*
___ 08:55AM BLOOD Calcium-8.5 Phos-2.6* Mg-2.1
___ 04:58PM BLOOD Lactate-1.7
DISCHARGE LABS:
___ 05:22AM BLOOD WBC-14.3* RBC-4.17* Hgb-12.7* Hct-40.1
MCV-96 MCH-30.5 MCHC-31.7 RDW-13.6 Plt ___
___ 05:22AM BLOOD Neuts-87.7* Lymphs-5.5* Monos-6.1 Eos-0.7
Baso-0.1
___ 05:22AM BLOOD ___
MICROBIOLOGY:
___ 10:15 am FLUID,OTHER RT LUNG EMPYEMA.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS, CHAINS, AND
CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
Reported to and read back by ___ ___ ___ 240PM.
FLUID CULTURE (Preliminary):
STREPTOCOCCUS ANGINOSUS (___) GROUP. MODERATE
GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Blood culture ___ x 2: no growth
STUDIES:
- Video swallow study ___: IMPRESSION: Penetration with
nectar thick liquid and aspiration with thin consistency barium.
- CT guided thoracentesis ___: IMPRESSION: CT-guided
empyema aspiration yielding 6 cc of purulent tan pus.
Microbiology and cytology are pending.
- CTA CHEST W AND W/O CONTRAST ___:
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic pathology.
2. Multifocal pulmonary opacities, most confluent ___ the left
lower lobe and ___ the right middle lobe, compatible with
multifocal pneumonia. Enhancing small fluid collection ___ the
right mid lung pleural space concerning for empyema.
3. Moderate sized right pleural effusion.
- CTA CHEST W AND W/O CONTRAST ___:
IMPRESSION:
1. Multiple bilateral nodular opacities, with the most
confluence at the left base, consistent with multifocal
pneumonia. A dedicated chest CT after resolution of symptoms
can be considered to evaluate for nodules.
2. Stable left adrenal nodule, likely an adenoma.
3. No evidence of a pulmonary embolism or acute aortic injury.
Brief Hospital Course:
Mr. ___ was admitted to ___ on ___ for workup and
treatment of multifocal pneumonia. His hospital course is as
follows:
1) Multifocal right middle lobe and left lower lobe pneumonia
with right parapneumonic effusion: suspicion of empyema ___
setting of esophageal diverticulum and dysphagia. History of
multifocal pneumonia ___ ___, similar clinically. Patient
remained afebrile, with stable vital signs throughout admission.
Initially the patient was started on ceftriaxone, azithromycin,
and clindamycin. Given likely aspiration pneumonia, he underwent
video swallow study as above. Per speech pathology
recommendations, diet should be nectar thickened liquids, soft
solids; POs while upright w/ oral care before meals. He
underwent CT-guided thoracentesis and drainage of 5 cc purulent
fluid at ___ location on ___. Initial gram stain of pleural
fluid growing 3+ GPCs and 1+ GPRs. Patient treated with
clindamycin and levofloxacin per ID recs, which will continue
for four weeks. He will require follow-up ___ ___ clinic to
determine resolution of pneumonia and determination of
antibiotic duration. Patient's white blood cell count was
rising on day of discharge, but with no change ___ clinical
status. Patient should have a CBC checked on ___ to follow up
this finding.
2) Atrial fibrillation/anticoagulation - CHADS2 score equal to
2. Taking 4 mg daily of warfarin at home. Rate controlled with
atenolol. INR was mildly prolonged on arrival, suggestive of
inhibition of metabolism by antibiotics. Temporarily
discontinued warfarin ___, then restarted 4mg
daily on ___ after thoracentesis completed. Continued atenolol
daily. INR on discharge equal to 1.7.
3) Hypertension - Well-controlled. Continued home atenolol.
4) Benign prostatic hypertrophy previously with chronic
indwelling Foley now s/p TURP - No issues throughout admission.
Voiding regularly.
5) Blindness secondary to macular degeneration on left, retinal
detachment on right - Chronic, stable. Redirected as necessary.
Continued home levobunolol.
TRANSITIONAL ISSUES:
- Please check kidney function and CBC on ___
- Small 5-mm nodule ___ the right lobe of the thyroid may need
dedicated imaging, such as ultrasound.
- ___ recs: okay for rehab or home w 24hr assistance and home ___
- Will require follow-up with PCP ___ ___
- Will require follow-up ___ ___ clinic to determine resolution of
pneumonia and determination of antibiotic duration.
- Will need CT scan ___ weeks after discharge to follow-up
resolution of pneumonia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
Hold for HR<60 or sBP<100.
2. Levobunolol 0.25% 1 DROP LEFT EYE DAILY
3. Mirtazapine 30 mg PO HS
4. Warfarin 4 mg PO DAILY16
5. Docusate Sodium 100 mg PO BID
6. DiphenhydrAMINE 25 mg PO HS:PRN insomnia
7. Acetaminophen 500 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Atenolol 25 mg PO DAILY
Hold for HR<60 or sBP<100.
3. Docusate Sodium 100 mg PO BID
4. Levobunolol 0.25% 1 DROP LEFT EYE DAILY
5. Mirtazapine 30 mg PO HS
6. DiphenhydrAMINE 25 mg PO HS:PRN insomnia
7. Warfarin 4 mg PO DAILY16
8. Clindamycin 300 mg PO Q6H
RX *clindamycin HCl [Cleocin] 300 mg 1 capsule(s) by mouth every
six (6) hours Disp #*120 Capsule Refills:*0
9. Levofloxacin 500 mg PO DAILY
RX *levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
- multifocal pneumonia with complicated parapneumonic effusion,
empyema
SECONDARY:
- dysphagia secondary to esophageal diverticulum
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
Thank you for choosing ___ for your medical care. You were
admitted with pain ___ your chest caused by a pneumonia. Your
pneumonia is probably caused by swallowing dysfunction.
You are now ready for discharge. Please take all your
medications as instructed by your doctors. Please keep all of
your appointments with your doctors, and bring a copy of your
medications to these visits. Upon discharge, please call your
PCP, ___, at ___ or return to the ED if you
experience any of the following: loss of conciousness, fever,
chest pain, trouble breathing, coughing up blood or pus,
palpitations, lightheadedness, or any other symptoms that
concern you.
It is important that you take precautions while eating to
minimize the risk of choking or inhaling small bits of food. You
must sit fully upright while eating and take only small sips of
liquids. Swallow twice for each bite and sip and clear your
throat after each swallow. Clean and rinse your mouth before
each meal to decrease the amount of bacteria ___ your throat. You
should remain seated upright for one hour after meals.
Followup Instructions:
___
|
10686970-DS-23
| 10,686,970 | 25,122,924 |
DS
| 23 |
2196-09-23 00:00:00
|
2196-10-02 12:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / Peanut
Attending: ___.
Chief Complaint:
Confusion, productive cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old male with PMH significant for atrial
fibrillation on warfarin, HTN, and prior RLL PNA ___ who
presented with anxiety and confusion. Pt states that he had an
episode of anxiety earlier in the day during which he couldn't
remember the name of ___ baseball pitcher. He states that once he
remembered the name of the player he felt better. He also
reports that he has had a productive cough and per his daughter,
he generally gets confused like this when he has an infection.
She confirms that he has been coughing phlegm for a few weeks.
Pt denies CP, SOB, dizziness, fever, chills, or nightsweats.
In the ED, initial vs were:98.2 64 118/81 24 99% RA Labs were
remarkable for WBC 8.7 with 78% PMN, normal chem-7, proBNP:
1325. Lactate:1.2, and INR 1.9. CXR showed pulmonary edema and a
persistent lateral right lung base opacity which may relate to
scarring at site of prior infection but underlying acute
infection is not excluded. Patient was given Ceftriaxone and
Azithromycin. Vitals on Transfer: 97.3 59 174/88 16 99% RA
On the floor patient reports that he was never confused and that
he feels fine other than being extremely anxious. He denies ever
being confused and reports that he called ___ because he was
extremely anxious. He reports that he has anxiety at baseline
but this episode was acutely worse. Pt is unable to describe it
any further.
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 dysuria. Denies arthralgias
or myalgias. Ten point review of systems is otherwise negative.
Past Medical History:
- atrial fibrillation on warfarin
- benign prostatic hypertrophy previously with chronic
indwelling Foley now s/p TURP
- esophageal diverticulum leading to dysphagia
- HTN
- blindness secondary to macular degeneration on left, retinal
detachment on right
- gait disorder
- kyphoscoliosis
- left inguinal herniorrhaphy ___
- neuropathy
Social History:
___
Family History:
Father with history of MI
Physical Exam:
*Admission Physical*
Vitals-98.2 L 160/80 R 180/80, 64 18 99%RA
General- Alert, orientedx3, in no acute distress
HEENT- MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- decreased beath sounds in right lung base, otherwise
clear to auscultation bilaterally, no wheezes, rales, rhonchi
CV- irregularly irregular, normal S1, S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, hard of hearing, motor function grossly
normal
*Discharge Physical*
Vitals: Tm 98.1 Tc 97.6 BP 154/78 (118-157/59-78) P 66 RR 18 02
98%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, blind in both eyes, MMM, oropharynx
clear
Neck: supple, JVP not elevated, no LAD
Lungs: Crackles at bases bilaterally but otherwise clear to
auscultation
CV: Irregularly irregular, no murmurs appreciated, no JVD
Abdomen: soft, non-tender, non-distended, bowel sounds
normoactive.
Ext: Warm, well perfused, 2+ pulses at DP, no edema
Skin: Venous stasis changes from ankle to knee bilaterally
without ulceration
Neuro: A&Ox3, able to do days of week backwards without
difficulty
Pertinent Results:
*Admission Labs*
___ 06:20PM BLOOD WBC-8.7 RBC-4.56* Hgb-13.9* Hct-42.3
MCV-93 MCH-30.5 MCHC-32.8 RDW-14.3 Plt ___
___ 06:20PM BLOOD Neuts-78.3* Lymphs-11.3* Monos-6.2
Eos-3.7 Baso-0.4
___ 06:36PM BLOOD ___ PTT-38.1* ___
___ 06:20PM BLOOD Glucose-110* UreaN-21* Creat-0.8 Na-142
K-4.4 Cl-104 HCO3-32 AnGap-10
___ 06:40AM BLOOD Mg-2.3
___ 06:27PM BLOOD Lactate-1.2
___ 06:20PM BLOOD proBNP-1325*
*Discharge Labs*
___ 06:45AM BLOOD WBC-8.3 RBC-4.50* Hgb-13.8* Hct-40.2
MCV-90 MCH-30.6 MCHC-34.3 RDW-14.4 Plt ___
___ 06:45AM BLOOD ___
___ 06:45AM BLOOD Glucose-93 UreaN-17 Creat-0.9 Na-138
K-4.1 Cl-103 HCO3-31 AnGap-8
___ 06:45AM BLOOD Calcium-8.9 Phos-2.5* Mg-2.3
*Microbiology*
Blood Culture ___: Negative
*Imaging*
EKG ___: Atrial fibrillation. Left axis deviation. Compared to
the previous tracing of ___ the atrial fibrillation is new.
Rate PR QRS QT/QTc P QRS T
65 0 94 434/442 0 -65 43
CXR ___: The cardiac silhouette remains severely enlarged.
Prominence of the interstitial markings bilaterally suggests a
component of pulmonary edema. There is persistent lateral right
lung base opacity which may relate to scarring at site of prior
infection. Underlying acute infection is not excluded, but less
likely. Additional mild bibasilar atelectasis is seen. No
large pleural effusion is seen. A trace right pleural effusion
is difficult to exclude. The mediastinal contours are stable.
Echo ___: The left atrium is moderately dilated. The right
atrium is moderately dilated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is ___
mmHg. There is mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global systolic function
(LVEF>55%). There is no ventricular septal defect. The right
ventricular cavity is mildly dilated with normal free wall
contractility. The aortic arch is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
CXR ___:
1. Interval clearing of pulmonary edema with partial
improvement of right lower lobe atelectasis and likely
pneumonia.
2. Mild stable left base atelectasis.
Brief Hospital Course:
___ w/ history of afib on coumadin, hypertension presenting
following acute anxious episode with question of confusion now
found to have pulmonary edema on CXR with elevated BNP
suggestive of mild CHF.
# Pulmonary edema: Patient presented with mild cough, found to
have evidence of pulmonary edema on CXR and physical exam and
elevated BNP. Initial concern for pneumonia in ED treated with
antibiotics in ED however, on further review of symptoms, no
evidence of pneumonia symptomatically, on imaging or on labs and
antibiotics were stopped. Patient was diuresed with IV lasix
with improvement of crackles on exam and interval improvement in
pulmonary edema on CXR. Echo was performed without evidence of
CHF and patient was not discharged on standing lasix. Patient
had stable oxygen saturation throughout his hospitalization.
Thought that pulmonary edema may have been caused by worsening
atrial fibrillation.
# Confusion/Anxiety: Patient with acute confusion ___ concerning
to his daughter given that he has had confusion in past with
infections. On further review of event, symptoms more consistent
with anxiety related to acute forgetfulness. No evidence of
confusion or delirium throughout admission. No other concerns
for infection during hospitalization.
# Atrial fibrillation: Patient with low INR (1.7) on admission.
In atrial fibrillation on EKG. CHADS-2 of 2 given lack of CHF on
echocardiogram and no evidence of valvular abnormality so
patient was not bridged. Patient's warfarin dose increased on
admission with plan to follow-up with primary care for
management of subtherapeutic INR. Continued on home atenolol
throughout admission.
# Hypertension: Hypertensive on admission to 180/80s. Improved
following atenolol on HD2 and thought to be most likely
secondary to acute anxiety around forgetfulness. Blood pressure
stable throughout admission. Continued on home atenolol and
buspirone for anxiety throughout admission.
# FEN: Patient seen by speech and swallow due to concerns from
daughter about patient drooling at home. Patient passed speech
and swallow exam prior to discharge.
# CODE: Full
# CONTACT: ___ (daughter) ___
--
Transitional Issues:
-Needs follow-up of INR (subtherapeutic on admission)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Levobunolol 0.25% 1 DROP LEFT EYE DAILY
3. Mirtazapine 30 mg PO QHS:PRN insomnia
4. TraZODone 50 mg PO Q4H:PRN agitation
5. Warfarin 4 mg PO 6X/WEEK (___)
6. Guaifenesin ___ mL PO Q6H:PRN cough
7. BusPIRone 5 mg PO BID
8. Warfarin 5 mg PO 1X/WEEK (TH)
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. BusPIRone 5 mg PO BID
3. Guaifenesin ___ mL PO Q6H:PRN cough
4. Levobunolol 0.25% 1 DROP LEFT EYE DAILY
5. Mirtazapine 30 mg PO QHS:PRN insomnia
6. Warfarin 5 mg PO DAILY16
7. TraZODone 50 mg PO Q4H:PRN agitation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
1. Pulmonary Edema
Secondary:
1. Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ with
some confusion and found to have fluid in your lungs. You were
treated with a diuretic with improvement in the amount of fluid
in your lungs. You had an echocardiogram that did NOT show any
evidence of congestive heart failure. You should eat a low
sodium diet to prevent yourself from holding onto water.
You were initially thought to have a pneumonia but you had no
symptoms of pneumonia and your antibiotics were stopped. If you
develop a worsening cough, fever, chills or difficulty
breathing, please call your doctor to discuss the possibility of
pneumonia.
While you were admitted, your INR (measured while you are on
coumadin) was below the target level of ___. We increased your
coumadin dose while you were here to 5mg daily. You should take
this dose tonight and then adjust your dose based on your
doctor's advice. A Visiting Nurse should check your INR tomorrow
and send it to your primary doctor to discuss the need to
further adjust your coumadin dosing.
It was a pleasure taking care of you!
Your ___ Team
Followup Instructions:
___
|
10686970-DS-24
| 10,686,970 | 21,491,579 |
DS
| 24 |
2196-10-21 00:00:00
|
2196-11-02 01:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / Peanut
Attending: ___.
Chief Complaint:
Cardboard Taste in Mouth
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Per ED report, ___ blind, poor hearing, dementia,
depression/anxiety with recent ED visit for SI/panic attack,
afib on coumadin, recent admissions for ___ and PNA presents
with dry mouth. Patient unable to provide additional history, he
says "just do something about my dry mouth and let me go home".
Currently unable to reach daughter for collateral information.
He denies all other complaints. h/o RLL PNA ___ with previous
multifocal PNA and empyema, also admitted ___ treated
for dCHF not dc'd on lasix.
In the ED, initial VS were 98.0 70 171/70 98.8%. Crackles were
heard on lung exam. ED resident noted new RLL & RML infiltrates
on CXR. Received Vanc/Cef for HCAP. Caphasol for dry mouth.
Admission VS were 98.6 76 134/56 95%RA.
On arrival to the floor, VS 97.7 155/91 60 100%RA. Patient is
conversant, oriented x3, but unable to give too many details as
to his medical history, just subjective statements as to his
current health status. Patient's daughter is later able to
confirm medications and PMH before leaving for the night.
Patient denies feeling unwell, n/v/d, cp/sob, abdominal pain. He
states he came to the ED because he was having a panic attack,
but thinks it subsided once he was here, and does not remember
what triggered it. He has occasional bowel and bladder sx. He is
blind in both eyes, and needs assistance for most of his daily
activities. He has a ___ caretaker at home. His mouth is dry
here.
REVIEW OF SYSTEMS: Per HPI.
Past Medical History:
- atrial fibrillation on warfarin
- benign prostatic hypertrophy previously with chronic
indwelling Foley now s/p TURP
- esophageal diverticulum leading to dysphagia
- HTN
- blindness secondary to macular degeneration on left, retinal
detachment on right
- gait disorder
- kyphoscoliosis
- left inguinal herniorrhaphy ___
- neuropathy
Social History:
___
Family History:
Father with history of MI
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS - 97.7 155/91 60 100%RA
General: Elder male, curled in bed, but alert, pleasant,
conversant, NAD
HEENT: NCAT, PERRLA, does not track movement with eyes, no sinus
tenderness, clear OP, moist MM, no LAD
Neck: no thyromegaly or thyroid nodules, no LAD
CV: Irregularly irregular, no r/g
Lungs: Bilateral coarse breath sounds and some rhonchi at the
lung bases, crackles at the lung base on the dependent side
(lying on R)
Abdomen: Soft, NT, ND, +BS
GU: No Foley
Ext: WWP, no edema
Neuro: CN V and VII - XII grossly intact, compromised CN II &
unable to participate in CN III, IV, VI exam, upper and lower
motor function grossly intact
Skin: Stage 1 sacral decubitus ulcer, dressed & covered
Note: Substantial R inguinal hernia noted on subsequent physical
exam night of admission
DISCHARGE PHYSICAL EXAM:
========================
VS - 98.4 144/86 82 990%RA
General: Elderly male, curled in bed, NAD,
HEENT: Does not track movement with eyes, clear OP, poor
dentition, moist MM, no LAD
CV: Irregularly irregular, no r/g
Lungs: Bilateral coarse breath sounds and some rhonchi at the
lung bases, crackles at the lung bases b/l R > L
Abdomen: Soft, NT, ND, +BS
GU: Deferred. R inguinal hernia, not incarcerated
Ext: WWP, no edema
Skin: Stage 1 sacral decubitus ulcer, dressed & covered
Pertinent Results:
ADMISSION LABS:
===============
___ 05:00PM BLOOD WBC-8.3 RBC-4.53* Hgb-13.6* Hct-42.4
MCV-94 MCH-30.1 MCHC-32.1 RDW-14.2 Plt ___
___ 05:00PM BLOOD Neuts-78.9* Lymphs-11.2* Monos-5.6
Eos-3.8 Baso-0.5
___ 05:00PM BLOOD ___ PTT-52.5* ___
___ 05:00PM BLOOD Glucose-110* UreaN-18 Creat-0.8 Na-141
K-5.1 Cl-104 HCO3-31 AnGap-11
___ 05:00PM BLOOD proBNP-1171*
___ 05:00PM BLOOD Calcium-9.1 Phos-2.6* Mg-2.4
___ 05:39PM BLOOD Lactate-1.6
PERTINENT LABS:
===============
___ 05:00PM BLOOD WBC-8.3 RBC-4.53* Hgb-13.6* Hct-42.4
MCV-94 MCH-30.1 MCHC-32.1 RDW-14.2 Plt ___
___ 05:00PM BLOOD Neuts-78.9* Lymphs-11.2* Monos-5.6
Eos-3.8 Baso-0.5
___ 05:00PM BLOOD ___ PTT-52.5* ___
___ 08:00AM BLOOD ___ PTT-40.1* ___
___ 05:00PM BLOOD proBNP-1171*
___ 05:39PM BLOOD Lactate-1.6
PERTINENT IMAGING:
==================
___ CXR - IMPRESSION:
New mild interstitial pulmonary edema and worsening bibasilar
opacities concerning for worsening infection or aspiration.
PERTINENT MICRO:
================
None
DISCHARGE LABS:
===============
___ 08:00AM BLOOD WBC-7.9 RBC-4.52* Hgb-13.6* Hct-42.5
MCV-94 MCH-30.1 MCHC-32.0 RDW-14.3 Plt ___
___ 08:00AM BLOOD Plt ___
___ 08:00AM BLOOD Glucose-134* UreaN-15 Creat-0.9 Na-138
K-4.1 Cl-100 HCO3-33* AnGap-9
___ 08:00AM BLOOD Calcium-8.9 Phos-2.4* Mg-2.3
Brief Hospital Course:
Mr. ___ is a ___ y/o M w/ PMH of blindness, dementia requiring
psych hospitalization for SI in the past, A-fib on coumadin,
presents initially for panic attack vs. bad taste in mouth, but
found to have findings consistent with pneumonia, concerning for
CAP vs. HCAP given recent hospitalization, also with
supratherapeutic INR.
ACTIVE ISSUES:
==============
# Pneumonia: Clinical exam findings with multifocal infiltrates
and recent hospitalizations prompted initiation of treatment for
hospital-acquired pneumonia. Started broadly on vancomycin,
cefepime and azithromycin on ___ however, he was narrowed to
Levofloxacin on ___ given no respiratory symptoms, no fever,
and no leukocytosis (the risk of resistant organisms was felt to
be low) for a total treatment duration of 8 days. On the day
prior to discharge, 1 of 2 blood cultures turned positive for
GPCs. Given the patient's history of empyema growing strep
anginosis, he was kept in-house for observation. The following
morning, testing confirmed that the GPCs were Coagulase-negative
staph (likely contaminant) and he was discharged home. Repeat
cultures drawn on ___ and ___ were both negative.
# Pulmonary Edema / Diastolic Congestive Heart Failure: Had a
recent hospitalization for pulmonary edema requiring diuresis.
ECHO on ___ showed LVEF > 55% but E/E' ratio borderline for
diastolic heart failure; moderate dilation of the atria
bilaterally was also noted. This admission, pulmonary edema is
suggested on chest X-ray with mildly elevated proBNP; diuresis
was initiated and the patient's lung exam improved. He was
discharged home on Lasix 20 mg PO QD for maintenance diuresis.
# Atrial Fibrillation with Supratherapeutic INR: INR on
admission was 5.3, etiology unclear, possible undernutrition
though he has ___ care at home. Coumadin (home dose = 5 mg PO
QD) was held on admission until INR came down to < 3 on ___, at
which point it was restarted at 3 mg PO QD. PCP ___ was
arranged for 2 days post-discharge for an INR check and
titratrion of coumadin as necessary
# Depression/Anxiety: The patient was stable at admission, but
occasionally demonstrated increasing agitation, particularly
when his daughter is away from the bedside. His home medications
(buspirone, mirtazapine and trazodone) were restarted, and his
mental status remained stable throughout the rest of his
hospitalization. Of note, the patient is very hard of hearing
and completely blind, so deliberate and careful re-orientation
and providing sensory aides was critical in preserving this
patient's mental status.
CHRONIC ISSUES:
===============
# BPH previously with chronic indwelling Foley now s/p TURP
A foley catheter was placed initially for urine output
monitoring. After it was removed, the patient had no difficulty
voiding, so this problem was felt to be stable during this
hospitalization.
# Esophageal diverticulum leading to dysphagia
The patient has had a speech and swallow evaluation in the past
and eats a modified thickened diet. It is possible that silent
aspiration may be occurring and contributing to his repeated
episodes of pneumonia.
# HTN
Stable, not an active issue on this hospitalization
# blindness secondary to macular degeneration on left, retinal
detachment on right
Stable, not an active issue on this hospitalization
TRANSITIONAL ISSUES:
====================
- Patient will need to have coumadin re-titrated to therapeutic
INR (2.5-3.5), may also benefit from nutritional work-up, as it
is unclear why he was supratherapeutic on this admission. INR
to be checked at PCP visit on ___.
- Monitor BP and electrolytes on new regimen of furosemide 20
mg daily
- Ensure completion of 8-day course of levofloxacin
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. BusPIRone 5 mg PO BID
3. Mirtazapine 45 mg PO HS
4. Warfarin 5 mg PO DAILY16
5. TraZODone 25 mg PO HS
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. BusPIRone 5 mg PO TID
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Mirtazapine 45 mg PO HS
5. TraZODone 25 mg PO HS
6. Warfarin 4 mg PO DAILY16
7. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 30 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
8. Guaifenesin ___ mL PO Q6H:PRN cough
RX *guaifenesin [Adult Tussin Chest Congestion] 100 mg/5 mL 5 mL
by mouth four times a day Disp #*1 Bottle Refills:*3
9. Levofloxacin 750 mg PO DAILY Duration: 3 Doses
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*3
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Pneumonia
Secondary: Blindess, Hard of Hearing, Dementia/Depression,
Diastolic Congestive Heart Failure
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was our pleasure caring for you at ___
___. You were admitted for pneumonia. You were
treated with IV antibiotics here, and successfully transitioned
to oral antibiotics. We also gave you a medication (Lasix) to
remove excess fluid from your lungs, and our physical therapists
worked with you during your stay. Finally, we stopped your
coumadin (a blood thinner) on admission because your blood
levels were too high. The level came back down to normal, and
this medication was restarted at discharge. You are being
discharged home with a course of oral antibiotics - please
continue to take them as prescribed.
The day before you left, one of your blood cultures grew
bacteria. We think this is most likely a contaminant and not a
sign of a blood stream infection. If you develop fevers, chills,
confusion, or any other symptoms that concern you, please call
your doctor right away.
We are also sending you home with a new medication to prevent
fluid build up in your lungs. You will take this new medicine,
called furosemide (or Lasix), every day.
Thank you for allowing us to participate in your care.
Followup Instructions:
___
|
10687144-DS-11
| 10,687,144 | 23,847,053 |
DS
| 11 |
2177-09-27 00:00:00
|
2177-10-07 19:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
venous sinus thrombosis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ former smoker (22 pack years, quit ___ years ago) with no
other PMHx was transferred from OSH with a HA and findings on
CT+
contrast concerning for venous sinus thrombosis. He states that
he was in his usual state of health up until the day prior to
presentation when he developed frontal throbbing ___ headache.
His pain was not relieved with Tylenol. By the next evening, his
headache increased in severity to ___ and he became nauseated.
He called a cab and went to ___ where CT showed evidence of
thrombosis. He does not complain of any other symptoms, no
weakness/numbness, no changes in vision, double vision, or eye
pain. He does not have any history of bleeding or clotting
problems. He remembers have some nose bleeds as a kid but no
other bleeding issues. He denies any family history of
miscarriages or blood clotting issues. He drinks 12 beers every
___ but denies any additional drinking. At ___, he was
started on a heparin gtt and received Benadryl, Reglan, and IVFs
at the OSH and was transferred to ___ for further management.
He reports that his symptoms have improved to a ___ with
increased pain with turning his head.
On neuro ROS, (+) frontal headache. The pt denies loss of
vision,
blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, (+) nausea associated with the
pain. 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:
tobacco abuse
Social History:
___
Family History:
no family history of clotting disorders, miscarriages or other
hematological disorders. No history of migraines
Physical Exam:
Vitals: 98.2 94 116/63 14 98%
- General: Awake, cooperative, NAD.
- HEENT: NC/AT, scleral injection
- Neck: Supple. No nuchal rigidity
- Pulmonary: CTABL
- Cardiac: RRR, no murmurs
- Abdomen: soft, nontender, nondistended
- Extremities: no edema, pulses palpated
- Skin: no rashes or lesions noted.
NEURO EXAM:
- Mental Status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive, able to name ___ backward
without difficulty. Language is fluent with intact repetition
and
comprehension. Normal prosody. There were no paraphasic errors.
Able to name both high and low frequency objects ___
speaking, missed hammock). Able to read without difficulty.
Speech was not dysarthric. Able to follow both midline and
appendicular commands. Able to register 3 objects and recall ___
at 5 minutes. There was no evidence of apraxia or neglect.
- Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, crisp disk margins, no exudates,
or
hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
- Motor: Normal bulk and tone throughout. No pronator drift
bilaterally. No adventitious movements such as tremor or
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
- Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
- DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was flexor bilaterally.
- Coordination: No intention tremor or dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
- Gait: Deferred
Discharge Exam:
Unchanged from above
Pertinent Results:
___ 05:50AM BLOOD WBC-12.1* RBC-5.57 Hgb-15.8 Hct-45.3
MCV-81* MCH-28.4 MCHC-34.9 RDW-14.5 Plt ___
___ 04:36AM BLOOD WBC-10.3 RBC-5.73 Hgb-16.3 Hct-45.7
MCV-80* MCH-28.5 MCHC-35.8* RDW-13.8 Plt ___
___ 04:45AM BLOOD WBC-11.3* RBC-5.58 Hgb-16.0 Hct-44.9
MCV-81* MCH-28.7 MCHC-35.6* RDW-14.0 Plt ___
___ 05:50AM BLOOD cTropnT-<0.01
___ 04:36AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 05:50AM BLOOD TSH-2.6
___ 04:36AM BLOOD ___
___ 04:35PM BLOOD ___
___ 05:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:50PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 01:50PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-RARE Epi-0
___ 01:50PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
URINE CULTURE (Final ___: <10,000 organisms/ml.
___ CT HEAD
Dural venous sinus thrombosis involving the distal portion of
the superior sagittal sinus and right transverse sinus. No
intracranial hemorrhage hydrocephalus or or infarct seen.
___ MRI/MRA BRAIN
No acute infarct mass effect or hydrocephalus. Thrombosis of
the posterior superior sagittal sinus and right transverse sinus
extending to the right proximal jugular vein.
___ CT CHEST
No incidental thyroid findings. No supraclavicular,
infraclavicular or
axillary lymphadenopathy. Minimum thymic remnant. No enlarged
lymph nodes in the mediastinum or the hilar structures. Normal
appearance of the heart. No pericardial effusion. No
abnormalities in the posterior mediastinum. The upper abdomen
is reported in detail in the abdominal CT report. No osteolytic
lesions at the level of the ribs, the sternum or the vertebral
bodies. Normal attenuation values of the lung parenchyma. No
pleural thickening, no pleural effusions. The airways are
patent. Bilateral dependent atelectasis at the level of the
lower lobes. No suspicious lung nodules or masses. No evidence
of diffuse lung disease.
___ CT ABD/PELVIS
No evidence of malignancy in the abdomen or pelvis.
Brief Hospital Course:
Transitional Issues:
# Will need outpatient hypercoagulability labs: factor 5,
prothrombin 202-10a, factor 8 levels, lupus anticoagulant
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Mr ___ is a ___ man with PMHx significant only for tobacco
abuse who was transferred to ___ on a heparin gtt for venous
sinus thrombosis, etiology unknown. The patient had a normal
neurologic exam on presentation and was admitted to the neuro
ICU for close monitoring given the very large sinus thrombus.
His exam remained stable throughout the rest of his hospital
course. He was started on warfarin 5mg and continued on the
heparin gtt until his INR became therapeutic. The plan is to
continue anti-coagulation for at least six months. CT Torso was
negative for malignancy. Inpatient hypercoagulability workup
showed negative ___, anti-cardiolipin ABs = wnl (<14, <12),
beta-2-glycoprotein Abs IgG = wnl (<9); protein c/s functional =
wnl (134, 132). He was discharged in stable condition with a
therapeutic INR, very close PCP follow up to manage his
outpatient Coumadin therapy, and neurology follow up.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO PRN pain
Discharge Medications:
1. Acetaminophen-Caff-Butalbital 1 TAB PO Q8H:PRN headache
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg 1
capsule(s) by mouth twice daily Disp #*10 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:*5
3. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*5
4. Warfarin 5 mg PO DAILY16
RX *warfarin 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*5
5. Acetaminophen 650 mg PO PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Venous Sinus Thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
You were hospitalized due to symptoms of severe headache
resulting from a VENOUS SINUS THROMBOSIS, a condition in which a
blood vessel carrying blood away from the brain develops a clot
disrupting the normal 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 abnormal blood supply can result in a
variety of symptoms.
As you have had a blood clot in your brain, we recommend
anticoagulation or blood thinners for the next six months. You
will require routine monitoring of you blood by test known as
INR. This test will provide information about your warfarin
level and whether we need to increase or decrease the
medication. You will need to follow these levels with your PCP.
While you were admitted, some labs were sent to determine your
risk for making blood clots in the future. So far, these tests
have come back negative. We will need to send additional tests
once you out of the hospital and off warfarin.
MEDICATION CHANGES:
START
-Coumadin (warfarin) 7.5mg daily; the dose will be adjusted
based on the levels
-Thiamine and folic acid daily (vitamins)
-Acetaminophen-Caff-Butalbital (fiorocet) for severe headaches
as needed; do not take more than ___ times per week to avoid
getting a new type of headache from taking too much pain
medicine
ON DISCHARGE:
- You will need to go to the emergency room at ___
___ to have a blood draw to check your
coumadin level on ___
- When you see your primary care doctor, please have them check
blood work for coumadin level and things that can make your
blood clot; a prescription is included
We recommend a heart healthy diet (low fat, low salt), daily
exercise, and stress reduction techniques. Please follow up with
your primary care physician in the next week. We would also like
you to follow up in our clinic in ___ months. These appointments
have been scheduled for you.
Followup Instructions:
___
|
10687144-DS-12
| 10,687,144 | 25,864,657 |
DS
| 12 |
2177-10-03 00:00:00
|
2177-10-07 19:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
right sided numbness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ yo man recently diagnosed with dural venous
sinus thrombosis (posterior superior sagittal sinus and right
transverse sinus extending to the right proximal jugular vein)
with initial symptoms of headache and nausea, now therapeutic on
warfarin, who presents with right sided numbness and weakness.
The patient noticed numbness starting in his right leg,
spreading
up his torso and to his arm and face, over 30 sec to 1 minute.
This occured around 2 pm. It was numb for 3 minutes, then
sensation returned to normal. He thinks the right arm and leg
become weak when they are numb, and the weakness resolves when
the numbness resolves. When he feels weak he is still able to
walk and stand. This same episode occured again at 5 pm, 6 pm,
and 7 pm. It has happened an additional 3 times since the
patient
went to the ED.
He initially presented to OSH, where he had a CT Head that was
per report stable.
He denies loss of consciousness, problems with speech, facial
droop, visual disturbance. He denies funny tastes or smells,
visual or auditory hallucinations.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. No bowel or bladder
incontinence or retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
Dural venous sinus thrombosis, on warfarin
Social History:
___
Family History:
- no family history of clotting disorders, miscarriages or other
hematological disorders. No history of migraines.
Physical Exam:
T= 98.2F, BP= 114/79, HR= 89, RR= 18, SaO2= 99% on RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM, oropharynx clear
Neck: Supple, no nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Pt. was able to name high frequency objects. Speech
was
not dysarthric. Able to follow both midline and appendicular
commands. Attentive, able to name ___ backward without
difficulty. Pt. was able to register 3 objects and recall ___
at
5 minutes. The pt. had good knowledge of current events. There
was no evidence of neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm, both directly and consentually; brisk
bilaterally. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch, pinprick in all
distributions
VII: No facial droop, facial musculature symmetric
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No adventitious movements,
such as tremor, noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ ___ ___ 5 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
- Plantar response was flexor bilaterally.
- Pectoralis Jerk was absent, and Crossed Adductors are absent.
-Sensory: No deficits to light touch, pinprick, proprioception
throughout.
-Coordination: No intention tremor noted. No dysmetria or ataxia
on FNF or HKS bilaterally.
-Gait: Not tested.
Discharge Exam:
Unchanged from above
Pertinent Results:
___ 07:10AM BLOOD WBC-8.7 RBC-5.82 Hgb-16.9 Hct-47.7 MCV-82
MCH-29.1 MCHC-35.4* RDW-14.7 Plt ___
___ 06:57AM BLOOD WBC-10.2 RBC-5.61 Hgb-15.9 Hct-46.0
MCV-82 MCH-28.3 MCHC-34.5 RDW-14.8 Plt ___
___ 07:10AM BLOOD Neuts-62.7 ___ Monos-5.0 Eos-2.4
Baso-0.6
___ 09:30AM BLOOD ___ PTT-36.6* ___
___ 06:57AM BLOOD ___ PTT-34.5 ___
___ 06:57AM BLOOD Plt ___
___ 07:05AM BLOOD ___ PTT-38.2* ___
___ 07:10AM BLOOD ___ PTT-38.1* ___
___ 06:42AM BLOOD ___ PTT-39.4* ___
___ 06:57AM BLOOD Glucose-88 UreaN-18 Creat-1.0 Na-138
K-4.2 Cl-101 HCO3-23 AnGap-18
___ 07:10AM BLOOD Glucose-79 UreaN-16 Creat-0.9 Na-137
K-4.3 Cl-103 HCO3-23 AnGap-15
___ 06:42AM BLOOD Glucose-82 UreaN-16 Creat-0.9 Na-139
K-4.2 Cl-102 HCO3-26 AnGap-15
___ 04:52PM BLOOD CK-MB-<1 cTropnT-<0.01
___ 06:57AM BLOOD Calcium-10.2 Phos-3.8 Mg-2.1
___ 07:10AM BLOOD Calcium-9.7 Phos-3.7 Mg-2.0
___ 06:42AM BLOOD Calcium-9.9 Phos-4.1 Mg-2.0
___ 04:35PM URINE bnzodzp-NEG barbitr-POS opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ EEG
This is an abnormal awake and asleep EEG because of frequent
bursts of generalized, centrally predominant, irregular theta
and delta
slowing superimposed on otherwise normal background patterns.
These findings are suggestive of deep midline dysfunction which
may be related to his known dural venous sinus thrombosis. There
are no prominent areas of focal slowing, definite epileptiform
discharges, or electrographic seizures.
___ MRI and MRA
1. New thrombosis of the left vein of Trolard with minimal
adjacent edema
suggestive of venous ischemia in a location which may explain
the patient's right-sided symptoms.
2. Partial recanalization of the previously completely
thrombosed right
internal jugular vein and right sigmoid sinus.
3. Unchanged thrombotic occlusion of the superior sagittal sinus
and right transverse sinus.
4. Normal MRA of the brain.
___ EEG
This telemetry captured five pushbutton activations, all without
electrographic correlate. Otherwise, it showed frequent bursts
of generalized high voltage slowing indicative of deep midline
dysfunction. The background was of normal frequency during
wakefulness and sleep. There were areas of prominent focal
slowing. There were no definite epileptiform discharges or
electrographic seizures.
___ CTA Chest w/wo
No evidence of pulmonary embolism or acute aortic pathology.
___ EEG
This telemetry captured a single pushbutton activation,
apparently accidental. Otherwise, the recording showed a normal
background in wakefulness and in sleep. There were no areas of
prominent focal slowing. There were no epileptiform features or
electrographic seizures.
___ ECG
Sinus rhythm. Left axis deviation. Minor non-specific ST-T wave
changes
___ MRI w/wo
1. Compared to the previous examination, there appears to be
establishment of some flow surrounding the thrombus in the
superior sagittal sinus indicating of recanalization with
decrease in size of the thrombus within the right
transverse and sigmoid sinuses.
2. There is persistent thrombosis of the cortical vein in the
left frontal region with collateral venous structures visualized
in the region.
3. No acute infarct or significant brain edema identified. No
hydrocephalus.
Brief Hospital Course:
# Will need outpatient hypercoagulability labs: factor 5,
prothrombin 202-10a, factor 8 levels, lupus anticoagulant
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Mr. ___ is a ___ yo man recently diagnosed with dural venous
sinus thrombosis, therapeutic on warfarin with negative
hypercoagulable workup, who presents with stereotyped transient
episodes of right sided numbness and weakness. The pattern and
timing of spread were suggestive of simple partial seizures.
MRI/MRV showed new hyperintensity along the left parietal lobe.
cvEEG showed no evidence of seizure activity. He did not develop
any additional weakness or sensory symptoms. MRI w/wo on the day
of discharge some flow surrounding the thrombus in the superior
sagittal sinus indicating of recanalization with decrease in
size of the thrombus within the right transverse and sigmoid
sinuses.
His stereotyped spreading paresthesias were thought to be due to
phenomena akin to complex migraine vs cortical depolarization
without any electrographic correlate. He was prescribed with
Topiramate 25mg BID for symptomatic control. This can be
increased as needed for symptom control. His INR increased to >
3 so his warfarin was decreased to 5mg daily. Incidentally, he
had several episodes of asymptomatic sinus tachycardia on
telemetry associated with activity. EKG showed sinus rhythm. CTA
chest was negative for PE.
He was discharged with close PCP follow up for management of
warfarin as well as neurology follow up.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Warfarin 7.5 mg PO DAILY16
3. Thiamine 100 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Acetaminophen-Caff-Butalbital 1 TAB PO DAILY:PRN headache
Discharge Medications:
1. Acetaminophen-Caff-Butalbital 1 TAB PO DAILY:PRN headache
2. FoLIC Acid 1 mg PO DAILY
3. Thiamine 100 mg PO DAILY
4. Warfarin 5 mg PO DAILY16
RX *warfarin 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
5. Topiramate (Topamax) 25 mg PO BID
RX *topiramate [Topamax] 25 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*5
6. Acetaminophen 325-650 mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Venous Sinus Thrombosis
Headaches
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
You were hospitalized due to symptoms of sensory changes as a
result of your VENOUS SINUS THROMBOSIS, a condition in which a
blood vessel carrying blood away from the brain develops a clot
disrupting the normal 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 abnormal blood supply can result in a
variety of symptoms. We evaluated you with an continuous EEG
and these events are not seizures. They are more consistent with
headaches. You can expect them to continue for some time as your
body repairs itself. We have started you on a medication called
Toperimate. This medication can be increased by your primary
care doctor as needed for headache control. You were evaluated
with repeat imaging prior to your discharge. Your thrombosis was
unchanged so you will be discharged home. If you develop a
severe headache or any new symptoms including sudden weakness,
problems talking, problems with walking, or any other acute
change, please go to the nearest Emergency Room for evaluation.
As you have had a blood clot in your brain, we recommend
anticoagulation or blood thinners for the next six months. You
will require routine monitoring of you blood by test known as
INR. This test will provide information about your warfarin
level and whether we need to increase or decrease the
medication. Right now, we recommend that you take Warfarin 5mg
daily. You will need to follow these levels with your PCP. While
you were admitted, some labs were sent to determine your risk
for making blood clots in the future. So far, these tests have
come back negative. We will need to send additional tests once
you out of the hospital and off warfarin. We recommend a heart
healthy diet (low fat, low salt), daily exercise, and stress
reduction techniques. Please follow up with your primary care
physician in the next week. We would also like you to follow up
in our clinic in ___ months. These appointments have been
scheduled for you.
Followup Instructions:
___
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2151-05-30 12:52:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
HA and falls
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F hx prior stroke, chronic dizziness who fell out of bed
early morning on ___ with persistent HA since that time. Pt
reports when she fell out of bed she couldn't get herself up for
a couple of hours but did not call for help because she didn't
want to disturb her husband who sleeps in another room.
Eventually she was able to get herself up. She reporst baseline
peripheral neuropathy, right side weakness and difficulty
walking since her stroke as well as hoarse voice. Pt is not
fully reliable historian. Phone interview with her husband
reveals that she has been having increasing unsteadiness walking
since ___ for which he has been in touch with her PCP
and her neurologist. He notes that she frequently falls and
does not tell anyone that she has fallen. He attributes the
falls to chronic dizziness since her stroke for which she takes
Diazepam 30mg Q6 hours PRN and Meclezine 25mg Q8 hrs PRN. CT
head at osh showed bilat SDH. INR at OSH was found to be 4.5
and so the patient was given Vit K 10mg and PCC for reversal and
transferred to ___ for further evaluation.
Past Medical History:
? afib or irregular heart beat (sees cardiologist Dr. ___ at
___),chiari decompression ___ (suboccipital
craniectomy, C1 lami with Dr. ___ at ___, TIAs, Left
basal ganglia infarct ___ with mild residual right weakness and
paralyzed vocal cords (hoarse voice), HTN, HLD, Depression,
GERD, chronic dizziness since stroke, G6PD deficiency
Social History:
Nonsmoker, No ETOH
Physical Exam:
O: T: 97.7 HR:68 BP:136/64 RR:12 Sat:98% RA
Gen: WD/WN, comfortable, NAD. lehtargic
HEENT: Normocephalic, atraumatic
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Hoarse voice, Speech fluent with good comprehension
and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 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 not fully assessed due to pt
cooperation
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 bilaterally, decreased in ___
Coordination: dysmetric normal on finger-nose-finger on left
Upon Discharge:
Patient noted to be awake, alert in bed when staff passes by
(including ___ staff) but when approached- patient becomes
somnolent. Oriented x3, voice hoarse at baseline, very soft
spoken, follows commands, MAE to command with good strength but
does not always follow full motor exam. PERRL, face symmetric.
Pertinent Results:
___ CT Cspine:
IMPRESSION:
1. No fracture or traumatic malalignment.
2. Please note that MRI is more sensitive for the evaluation of
ligamentous injury.
3. Multilevel degenerative changes as described.
4. Postsurgical changes related to patient's prior suboccipital
decompression surgery and C1 laminectomy.
___ CT Head:
IMPRESSION:
1. Grossly stable right sided subdural hemorrhage.
2. Stable left acute on chronic subdural hematoma.
3. Findings suggestive of blood products layering along
bilateral cerebellar tentorium, as described.
4. No new hemorrhage.
5. Postsurgical changes related to prior suboccipital
decompression surgery and C1 hemilaminectomy.
6. Paranasal sinus disease as described.
___ CT Head:
Stable head CT compared to previous CT.
Brief Hospital Course:
Mrs. ___ was admitted under neurosurgery for observation
after sustaining a fall resulting in a SDH with mixed density.
The patient was monitored overnight and a repeat Head CT was
done ___ which remained stable. Her husband reported
unsteadiness and a ___ consult was placed. The team spoke to
her PCP as well. ___ recommended Rehab at this time. On ___,
patient was seen wide awake in bed by nursing and neurosurgery
but when approached by staff patient becomes somnolent. Slow to
initiate exam and ADLs. Her neuro exam remains stable. She was
discharged to rehab.
Plan:
SDH: The SDH is not acute but subacute. Stable in appearance
over 2 scans. SDH could be contributing to worsening gait
imbalance but per family this has been an issue since her
stroke. Family reports padding the home to help reduce injury.
Hold COumadin for 4 weeks. Patient will be seen in 4 ___ for
follow-up with a repeat CT. Patient exhibits an odd affect.
Spoke with PCP who also confirmed an odd affect/ dynamic.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amitriptyline 10 mg PO QHS
2. Myrbetriq (mirabegron) 25 mg oral DAILY
3. Alendronate Sodium 70 mg PO QSUN
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Simvastatin 40 mg PO QPM
6. Duloxetine 60 mg PO DAILY
7. Lisinopril 5 mg PO DAILY
8. Warfarin 5 mg PO DAILY16
9. Ondansetron 4 mg PO Q8H:PRN nausea
10. Dexilant (dexlansoprazole) 60 mg oral DAILY
11. Diazepam 30 mg PO Q6H:PRN dizziness
12. Meclizine 25 mg PO Q8H:PRN dizziness
13. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
Discharge Medications:
1. Alendronate Sodium 70 mg PO QSUN
2. Duloxetine 60 mg PO DAILY
3. Lisinopril 5 mg PO DAILY
4. Meclizine 25 mg PO Q8H:PRN dizziness
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Myrbetriq (mirabegron) 25 mg oral DAILY
7. Simvastatin 40 mg PO QPM
8. Acetaminophen 650 mg PO Q6H:PRN pain
9. Docusate Sodium 100 mg PO BID
10. TraMADOL (Ultram) 50-100 mg PO Q4H:PRN pain
11. Ondansetron 4 mg PO Q8H:PRN nausea
12. Omeprazole 40 mg PO DAILY
Replaced home med dexlansoprazole
13. Dexilant (dexlansoprazole) 60 mg oral DAILY
___ restart when able. Given Omeprazole inpatient as this med
was nonformulary
14. Amitriptyline 10 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Mixed density SDH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Discharge Instructions
Brain Hemorrhage without Surgery
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) for 4 weeks.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___ cath
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
___ female with locally advanced pancreatic cancer
initiated on FOLFIRINOX ___, GERD, depression presented from
___ clinic for urgent evaluation of chest pressure.
She reports that she woke up early am of ___ with sudden onset
substernal chest pressure. Of note, she was started her first
infusion of FOLFIRINOX finishing FOLFOX infusion started ___
The pain was constant, not exertional, not positional, not
pleuritic. Severity waxed and waned. She took Ativan, which
helped somewhat. It was not associated with shortness of breath,
nausea, diaphoresis, palpitations, lightheadedness.
She called into her oncologist's office and was advised to
present. There, her infusion was stopped. Her chest pain
recurred
and progressed. She was given aspirin, sublingual nitro and sent
to the emergency room.
There, initial ekg was unremarkable. Chest pain progressed and
serial ekgs during chest pain ~1800 showed dynamic changes
including STE in 1 avl concerning for inferior ischemia. Trops
were negative x2, labs were otherwise unremarkable. She was
taken
to the cath lab.
Cath was significant for clean coronaries and mid LAD myocardial
bridging without evidence of vasospasm.
On the floor she reports full resolution of her symptoms. She
denies chest pain, shortness of breath, nausea, diaphoresis. She
is relieved her cath is complete and that she needed no
intervention.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS
- Diabetes: none
- Hypertension: none
- Dyslipidemia: none
2. CARDIAC HISTORY
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
Social History:
___
Family History:
She has family history of MI in mother and sister in early ___
Brother: s/p ICD, ?h/o arrhythmia, patient is not sure of
details
Father: HTN, CAD
No history of sudden cardiac death
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 98.0 PO 130 / 63 R Lying 61 18 96 RA
GENERAL: well appearing female in NAD. Oriented x3. Mood, affect
appropriate. Husband at the bedside.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa.
NECK: Supple with no JVD
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. soft systolic ejection murmur
appreciated at ___. No thrills, lifts.
LUNGS: No chest wall deformities. Resp were unlabored, no
accessory muscle use. CTAB.
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
ACCESS: port-a-cath clean without erythema
DISCHARGE PHYSICAL EXAMINATION:
VS: 98.1 PO 152 / 60 69 18 98 RA
GENERAL: well appearing female in NAD. Oriented x3. Mood, affect
appropriate.
NECK: Supple with no JVD
CARDIAC: RRR, normal S1, S2. soft systolic ejection murmur
appreciated at ___. No thrills, lifts.
LUNGS: No chest wall deformities. Resp were unlabored, no
accessory muscle use. CTAB.
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
ACCESS: port-a-cath (R upper chest) clean without erythema
Pertinent Results:
CXR ___
FINDINGS:
The lungs are clear without consolidation, effusion, or edema.
Opacity at the
posterior costophrenic angles compatible with left fat
containing Bochdalek's
hernia seen on CT. The cardiomediastinal silhouette is within
normal limits.
Right chest wall port is noted. No acute osseous abnormalities.
Deformity of
the proximal left humerus is only partially visualized,
potentially old healed
trauma but to be correlated clinically.
IMPRESSION:
No acute cardiopulmonary process.
Known lung nodule seen on recent prior chest CT are not clearly
delineated on
this film.
Partially visualized deformity of the proximal left humerus,
potentially old
healed fracture, to be correlated clinically.
___, MD electronically signed on WED ___ 6:07
___
CARDIAC CATH ___
Coronary Anatomy
Dominance: Right
* Left Main Coronary Artery
The LMCA is without significant disease.
* Left Anterior Descending
The LAD is with mid systolic myocardial bridging (no diastolic
compression). The ___ Diagonal is without significant disease.
The ___ Diagonal is with mild origin disease
* Circumflex
The Circumflex is without significant disease.
* Right Coronary Artery
The RCA is without significant disease.
The Right PDA is without significant disease.
___ ___ DOB: ___ Procedure Date:
___ Cath Number: ___
Intra-procedural Complications: None
Impressions:
No significant obstructive coronary artery disease or current
evidence of coronary vasospasm Mid LAD with systolic myocardial
bridging (no diastolic compression)
___ ECHO
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). The gradient increased with the Valsalva
manuever. Right ventricular chamber size and free wall motion
are normal. The diameters of aorta at the sinus, ascending and
arch levels are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Preserved biventricular systolic function. Mildlly
increased LVOT gradient with Valsalva. No clinically significant
valvular regurgitation or stenosis. Indeterminate pulmonary
artery systolic pressure.
Compared with the prior study (images reviewed) of ___, an
inducible LVOT gradient is now appreciated; its presence was not
assessed previously .
Brief Hospital Course:
SUMMARY: ___ female with locally advanced pancreatic
cancer initiated on FOLFIRINOX ___, GERD, depression (no cardiac
hx; echo in ___ showed EF 55%) presented from ___ clinic
for urgent evaluation of chest pressure during first infusion of
___, with dynamic ST elevations on EKG. On cath, found to have
myocardial bridging but no significant disease (had mid
LAD-myocardial bridging), and no evidence of vasospasm.
#CORONARIES: without significant disease
#PUMP: LVEF>55% (___) trivial mitral regurg
#RHYTHM: sinus
=================================
ACTIVE ISSUES:
=================================
#Chest pain I/s/o ___
#Myocardial bridging
#ST Elevations in I and aVL
She experienced chest pain I/s/o first ___ administration and
was found to have ST elevations in 1 and aVL. Coronary
catheterization revealed significant myocardial bridging (with
significant reduction in caliber during systole) in LAD. This
was in the setting of active chest pain during cardiac
catheterization. There was no observed vasospasm on cath,
despite ___ being known to cause vasospasm. It is possible that
she had underlying myocardial bridging that was made severe by
vasospasm caused by ___. She had no other lesions on cardiac
catheterization. She was started on diltiazem, discharged with
dose of 120mg XL daily, for the myocardial bridging. Her
echocardiogram revealed asymmetric LVH with septal wall
hypertrophy and inducible LVOT. This is possibly consistent
HCOM, and one could consider cardiac MRI in future (pending
status of pancreatic cancer). She will follow up with
cardiology-oncology shortly after discharge to discuss further
workup, such as cardiac MRI. She will also require re-evaluation
regarding appropriateness of ___ and whether other agents could
be used instead.
#Pancreatic cancer
#Risk of neutropenia
Followed by Dr. ___ as an outpatient. Continued
symptomatic management, diazepam, zofran, reglan, immodium prn.
CHRONIC/STABLE ISSUES:
#Duodenitis/GERD -continued omeprazole, ranitidine
#Depression/Grief - continue sertraline
=========================
TRANSITIONAL ISSUES:
=========================
[ ] She will require re-evaluation regarding appropriateness of
___ and whether other agents could be used instead.
[ ] TTE ___ showed asymmetric LVH with septal wall
hypertrophy and inducible LVOT. Possibly c/w HCOM, could
consider cardiac MRI in future.
#NEW MEDS
-diltiazem 120 XR PO daily
-loperimide prn for diarrhea (chemotherapy side effect)
#CHANGED MEDS: none
#DICONTINUED MEDS: none
#CODE STATUS: full, presumed
#CONTACT: Husband, ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 8 mg PO Q8H:PRN nausea
2. Prochlorperazine 10 mg PO Q12H:PRN nausea
3. LORazepam 0.5-1 mg PO QHS:PRN anxiety, insomnia
4. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
5. Omeprazole 40 mg PO BID
6. Sertraline 75 mg PO DAILY
Discharge Medications:
1. Diltiazem Extended-Release 120 mg PO DAILY
RX *diltiazem HCl 120 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
2. LOPERamide 2 mg PO QID:PRN diarrhea
RX *loperamide 2 mg 1 tab by mouth four times a day Disp #*30
Capsule Refills:*0
3. LORazepam 0.5-1 mg PO QHS:PRN anxiety, insomnia
4. Omeprazole 40 mg PO BID
5. Ondansetron 8 mg PO Q8H:PRN nausea
6. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
7. Prochlorperazine 10 mg PO Q12H:PRN nausea
8. Sertraline 75 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary artery vasospasm associated with ___
Myocardial bridging of coronary vessels
Pancreatic cancer (locally advanced)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
You came to the hospital because of chest pain.
WHAT HAPPENED IN THE HOSPITAL?
==============================
In the hospital, your EKG showed that parts of your heart were
getting insufficient bloodflow. You had a procedure ("cardiac
catheterization") that looked at the vessels that supply your
heart. It showed that some of the vessels were squeezing down
because they were buried in the heart muscle("myocardial
bridging"). We have put you on a new medication called diltiazem
to help prevent this condition from causing you any problems
down the road. You also probably had some squeezing of the blood
vessels ("vasospasm") that can occur with the chemotherapy that
you received starting on ___.
WHAT SHOULD I DO WHEN I GO HOME?
================================
When you go home, you should continue to take all of your
medications as prescribed and follow up with all of your doctors
as listed.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
diagnostic laparoscopy and evacuation of hemoperitoneum
Physical Exam:
Pre-Admission Physical Exam:
VS: HR ___, BP 120s/50s, AF, RR low ___, 99% ___
PE: Acute distress ___ pain, RRR, CTAB, abdomen diffusely TTP
with peritoneal signs, trace ___
Discharge physical exam
Vitals: VSS
Gen: NAD, A&O x 3
CV: RRR
Resp: no acute respiratory distress
Abd: soft, appropriately tender, no rebound/guarding, incision
c/d/i
Ext: no TTP
Pertinent Results:
___ 07:41PM BLOOD WBC-20.3*# RBC-4.00 Hgb-11.8 Hct-36.0
MCV-90 MCH-29.5 MCHC-32.8 RDW-12.9 RDWSD-42.2 Plt ___
___ 06:44AM BLOOD WBC-16.1* RBC-3.33* Hgb-10.0* Hct-30.1*
MCV-90 MCH-30.0 MCHC-33.2 RDW-13.2 RDWSD-43.0 Plt ___
___ 07:41PM BLOOD Neuts-86.0* Lymphs-9.8* Monos-3.3*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-17.45* AbsLymp-1.98
AbsMono-0.66 AbsEos-0.00* AbsBaso-0.05
___ 07:41PM BLOOD ___ PTT-22.8* ___
___ 07:41PM BLOOD Plt ___
___ 06:44AM BLOOD Plt ___
___ 07:41PM BLOOD Glucose-151* UreaN-10 Creat-0.6 Na-137
K-4.0 Cl-105 HCO3-19* AnGap-17
___ 07:41PM BLOOD ALT-25 AST-23 AlkPhos-50 TotBili-<0.2
___ 07:41PM BLOOD Albumin-4.0 Calcium-9.3 Phos-2.4* Mg-1.8
Brief Hospital Course:
On ___, Ms. ___ was admitted to the gynecology
service after undergoing a diagnostic laparoscopy and evacuation
of hemoperitoneum.
In brief, she is a ___ G0 presenting to the ___
emergency department (ED) the day of admission for abdominal
pain following an uncomplicated vaginal oocyte retrieval earlier
in the day. In the ED, a transvaginal ultrasound showed a small
amount of free fluid and asymmetric enlargement of the left
ovary with a rind of non-vascularized material (left adnexal
structure measuring 8.2 x 6.2 x 7.9 cm) possibly representing
hematoma with arterial and venous waveforms present but
inability to exclude intermittent torsion. The decision was made
to proceed with urgent laparoscopy given the concerning findings
on ultrasound and the persistent severe abdominal pain.
The procedure was notable for evacuation of 500cc of
hemoperitoneum with no evidence of active bleeding identified
and enlarged cystic ovaries bilaterally consistent with recent
stimulation with no ovarian or tubal torsion seen. Please see
the operative report for full details.
Her post-operative course was uncomplicated. Immediately
post-op, her pain was controlled with IV dilaudid/Tylenol.
Immediately following the procedure, her foley was removed.
However, she failed to void and the foley was re-inserted with
600cc of urine drained. On post-operative day 1, her urine
output was adequate and her Foley was removed and she voided
spontaneously with a PVR of 0. Her diet was advanced without
difficulty and she was transitioned to oxycodone/Tylenol.
By post-operative day 1, she was tolerating a regular diet,
ambulating independently, and pain was controlled with oral
medications. She was then discharged home in stable condition
with outpatient follow-up scheduled.
Medications on Admission:
hormones for ovarian stimulation, daily Imodium for IBS
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
Do not exceed more than 4g in 24 hours
RX *acetaminophen 500 mg 1 tablet(s) by mouth every four (4)
hours Disp #*40 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*1
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Do not drive or operate machinery while on this medication
RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth every four (4)
hours Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
hemoperitoneum following ovarian stimulation and vaginal oocyte
retrieval
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the gynecology service after your
diagnostic laparoscopy. You have recovered well and the team
believes you are ready to be discharged home. Please call Dr.
___ office with any questions or concerns. Please follow
the instructions below.
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Take a stool softener such as colace while taking narcotics to
prevent constipation.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* No strenuous activity until your post-op appointment.
* Nothing in the vagina (no tampons, no douching, no sex) for 6
weeks.
* No heavy lifting of objects >10 lbs for 6 weeks.
* You may eat a regular diet.
* You may walk up and down stairs.
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No tub baths for 6 weeks.
* If you have steri-strips, leave them on. They will fall off on
their own or be removed during your followup visit.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
10687982-DS-6
| 10,687,982 | 29,848,990 |
DS
| 6 |
2190-01-20 00:00:00
|
2190-01-20 17:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Antihistamines - Alkylamine
Attending: ___.
Chief Complaint:
abd pain, difficulty urinating
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with T-LGL on daraprim (pyrimethamine, off
study use of clinical trial drug at ___) admitted with
abdominal pain and difficulty urinating. Seen most recently in
___ by Dr. ___ at ___, discussed MTX off protocol or
pyrimethamine protocol and she was interested in the latter. Had
previously followed with Dr. ___. THree days ago she
developed dysuria
(h/o UTI, this feels similar). Also has h/o kidney stones in
remote past. Endorses nausea and no solid PO intake since ___
(keeping up with fluids however, and no vomiting, but nausea
keeping her from desiring to eat). Drinking liquids does not
cause worsening abd pain. Abd pain is constant in the lower
quadrants especially however present diffusely throughout; no
diarrhea or constipation or fevers, and the pain is particularly
severe when she attempts to urinate at which point it feels like
a burning esp at the end of void stream. No hematuria. SHe let
her ___ Drs ___ this three days ago and they told her to
hold her pyrimethamine.
Note she has chronic back pain for years and takes vicodin for
this at home. SHe states back pain remains severe but not worse
than prior. No urinary incontinence, bowel/bladder incontinence,
no leg weakness. Pain is located bilaterally in the mid thoracic
spine and per pt is stable, exacerbated as usual with
movement/walking. Denies constipation.
ED course:
98.2 100 126/77 18 100% RA. lactate 1.4. Chem reassuring
along w/ LFTs WBC was 5.2, hct 27, plts 82
R CVAT and diffuse abd tenderness. ultrasound w/ 300-400cc in
bladder with mild-mod hydro but this was not confirmed on the CT
a/p which showed moderate hiatal hernia and no acute intra-abd
process no e/o nephrolithiasis or hydronephrosis. UA suggestive
of infection. . Given CTX, fluids, and total of 4mg IV dilaudid
on arrival to the floor, she endorses ongoing abd pain and
significant back pain, consistent with known chronic back pain
for which she uses vicodin at home. She denies headache,
bleeding, does endorse mild sore throat and nasal congestion "I
have a cold" which she states is very mild and improving. All
other 10 point ROS neg.
Past Medical History:
# T-LGL
- dx' elevated lymphocytosis (___)
- Flow cytometry showed 98% lymphoid gated: T-cell. 87% CD8+,
CD56+, CD16+ with a loss of CD7 suspicious of a T-cell
lymphoproliferative disorder.
- T-cell gene rearrangement studies at ___: clonal pattern
(___)
- BM Biopsy- T- LGL with a B Lymphoid nodule of unclear
significance (___)
- started on Pyrimethamine mid ___
# HTN
# GERD
# Eczema
# Post-herpetic neuralgia
# Fe def anemia
# B12 def
# h/o hysterectomy
# colonic adenoma
# TOB dependence
Social History:
___
Family History:
strong history of asthma and allergies. Father with bladder
cancer, was a smoker.
Physical Exam:
VITAL SIGNS: 98.3 119/73 98 20 95% RA
General: NAD except when moving back pain seems to make her
uncomfortable
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
GI: no masses, diffusely tender throughout but no
rebound/guarding
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
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; no tremor/asterixis
Pertinent Results:
LABORATORY ANALYSIS:
(___) WBC: 5.2. H/H 9.2/27.3 Plt 82 Na 139, K 3.3, Cl 99, CO2
27, BUN 11, Creat 0.9, AP 129, TBili 0.6, Tbili 0.6
U/A: Nit+, ___ mod, WBC 41
Urine cx>100,000 GNR (sensitivities pending)
IMAGING:
# Abd CT (___): 1. Moderate size hiatal hernia. Normal appendix.
No acute intra-abdominal process identified. 2. No evidence of
nephrolithiasis or hydronephrosis.
Brief Hospital Course:
___ h/o HTN, chronic back pain, T-LGL on pyrimethamine (off
trial use, followed by DFCI) admitted with abdominal pain and
difficulty urinating found to have UTI.
# Abd pain, Difficulty urinating: Ms. ___ was admitted with
diffuse abd tenderness. Labs were notable for WBC 5.2, U/A ___id not show any nephrolithiasis or acute abdominal
pathology. There was also no signs of flank tenderness.
She was initially placed on PO cipro. Urine cultures
ultimately grew >100,000 gram negative rods - sensitivities and
ID pending on the day of discharge. The cultures results will
be follow up to ensure adequate coverage. Due to significant
bladder spasm, she was also given Pyridium, with good effect.
Given her theoretical immunosuppression (neutropenia ~ ANC 500),
the UTI will be treated as complicated - and she will receive a
total 7 day course. PVR checked twice revealed good emptying
with post-void volume of ___ cc.
The abd pain/cramping and nausea may also be a side effect
from the pyrimethamine. By her report, she noted steadily
progressive nausea, vomiting while on pyrimethamine during the 3
weeks ago she was on that medications. Abdominal cramping - is
also a reported complication. This medication was stopped 3
days prior to admission. For symptom control, she was given
dilaudid, Zofran IV initially - and then transitioned to PO
Zofran and PO oxycodone PRN.
ON the day of discharge, she was able to tolerate regular
diet and was dependent on only oral medications.
Of note, there was no evidence of rash to suggest the
presence of Zoster.
# Heme: Neutropenia, Anemia, thrombocytopenia in setting of
T-LGL. Due to significant hydration, there was overall decrease
in all cell lines. This was likely augmented by the folate
inhibiting effects of the Pyrimethamine. There were no clinical
e/o bleeding or hypotension. No heparin SQ was given. She was
discharged on neutropenic diet.
# LGL - followed by Dr. ___ but now getting care
at ___ on pyrimethamine protocol. Pyrimethamine was
discontinued as an outpt.
# OTHER ISSUES AS OUTLINED.
#FEN: [X] IVF [X] Oral [] NPO [] Tube Feeds []
Parenteral
#DVT PROPHYLAXIS: d/c heparin due to thrombocytopenia
#LINES/DRAINS: [X] Peripheral [] PICC [] CVL [] Foley
#PRECAUTIONS: None
#COMMUNICATION: Pt
#CODE STATUS: [X]full code []DNR/DNI
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Daraprim unknonw Other DAILY
2. DULoxetine 10 mg PO DAILY
3. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain -
Mild
4. Potassium Chloride 40 mEq PO DAILY
5. Losartan Potassium Dose is Unknown PO DAILY
6. Ondansetron 8 mg PO Q8H:PRN nausea
Discharge Medications:
1. DULoxetine 10 mg PO DAILY
2. Ondansetron 8 mg PO Q8H:PRN nausea
RX *ondansetron 8 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
3. Ciprofloxacin HCl 500 mg PO Q12H Duration: 4 Days
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*10 Tablet Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*32 Tablet Refills:*0
5. Phenazopyridine 100 mg PO TID Duration: 3 Days
RX *phenazopyridine [Pyridium] 100 mg 1 tablet(s) by mouth three
times a day Disp #*6 Tablet Refills:*0
6. Potassium Chloride 40 mEq PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
UTI
Pancytopenia
Nausea/vomiting - possibly secondary to Pyrimethamine
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure looking after you. As you know, you were
admitted with abdominal pain, nausea and vomiting. Multiple
tests were done including blood tests, urine tests, and
abdominal CT scan. The CT scan did not show any acute
abnormalities. Urine test showed that you had a urinary tract
infection.
For this infection, you were placed on antibiotics
(ciprofloxacin) which can be continued for a total of 5 days.
In addition, Pyridium was added for treatment of the pain you
experience during urination.
To address the abdominal pain, I am prescribing additional
doses of oxycodone - which can be taken INSTEAD of the vicodin.
You will also be given antinausea medications to take as needed.
We expect the need for these medications to decrease as your
infection is treated and as the effects of the Pyrimethamine
decrease over the next few days.
We wish you the best of luck!
___ Team
Followup Instructions:
___
|
10688297-DS-12
| 10,688,297 | 21,525,631 |
DS
| 12 |
2192-02-01 00:00:00
|
2192-02-02 15:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Chronic Hip Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with a history of bilateral
chronic hip pain, HTN and CAD who presents for evaluation of
acute-on-chronic hip and back pain following a taper of his
narcotics in the outpatient setting.
Mr. ___ has had a long history of bilateral hip pain s/p
multiple surgeries and hip replacement many years ago at ___
that was managed with high doses of methadone and oxycodone ___
in the outpatient setting over ___ years. Per recent records,
the patient violated his narcotics contract on several occasions
in the ___ by taking unprescribed benzodiazepines. As a
result of these violations and concerns about the safety of his
outpatient regimen, his outpatient providers initiated ___
narcotics taper in ___.
He presented to the ED today reporting worsening pain in the
setting of having run out of pain medications two days ago. In
the ED, he complained of bilateral hip pain radiating to his
lumbar spine. He denied fever, chills, urinary or fecal
incontinence. In the ED, initial vital signs were ___ 80 145/76
20 95% RA. His labs were remarkable for Cr 1.3, WBC of 10.6 and
Hemoglobin of 13.7. He received Oxycodone-Acetaminophen X 1, IM
Ketorolac, IV Morphine Sulfate 5 mg X 2 and Oxycodone SR
(OxyconTIN) 10mg. Vitals on transfer were as follows: 98.0 75
128/72 16 99% RA.
Upon arrival to the floor, the patient details the history above
and continued pain in his lower back and hips bilaterally. He
was initially able to manage on the lesser doses of narcotics
but over the past ___ months his mobility has been limited by
pain. He reports that he has had a loss of appetite for 3 days
due to the pain. He also had two headaches over the past three
days, self-limited and several months of tingling in his hands
and feet. He denies headache, fever, chills, chest pain,
shortness of breath, loss of vision or floaters, urinary or
fecal incontinence, dysuria, nausea, vomiting or diarrhea. He
denies any falls or recent trauma to his back or hips.
Past Medical History:
Hypothyroidism
Obesity
Bilateral Chronic Hip Pain
Anxiety
Hypertension
Coronary Artery Disease s/p MI
Hx of Anemia
Social History:
___
Family History:
None reported.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.4F 170/68 63 16 95%RA
General: obese older man in NAD, lying in bed with cane
HEENT: NC/AT, EOMI, PERRLA, sclerae anicteric
Neck: supple
CV: regular rate and rhythm, no murmurs, rubs or gallops
Lungs: clear to auscultation bilaterally, no wheezes
Abdomen: obese, non-tender, non-distended, bowel sounds present
GU: no Foley
Ext: ___ cool bilaterally, 2+ DP pulses bilaterally, no ___ edema
Neuro: CN II-XII intact, strength ___ in the UE and ___
bilaterally, no focal point tenderness over the spine, gait
deferred
Skin: several scabs on the anterior shins bilaterally, no ulcers
DISCHARGE PHYSICAL EXAM:
Vitals: 98.1 116/57 74 18 99%RA
General: obese older man in NAD, lying in bed with cane
HEENT: NC/AT, EOMI, PERRLA, sclerae anicteric
CV: regular rate and rhythm, no murmurs, rubs or gallops
Lungs: clear to auscultation bilaterally, no wheezes
Abdomen: obese, non-tender, non-distended, bowel sounds present
Ext: ___ cool bilaterally, 2+ DP pulses bilaterally, no ___ edema
Neuro: CN II-XII intact, strength ___ in the UE and ___
bilaterally, no focal point tenderness over the spine, gait
deferred
Skin: several scabs on the anterior shins bilaterally, no ulcers
Pertinent Results:
ADMISSION LABS
___ 03:08PM WBC-10.6 RBC-4.60 HGB-13.7* HCT-38.4* MCV-84
MCH-29.8 MCHC-35.6* RDW-13.9
___ 03:08PM NEUTS-73.3* LYMPHS-16.9* MONOS-6.0 EOS-3.5
BASOS-0.3
___ 03:08PM PLT COUNT-229
___ 03:08PM GLUCOSE-89 UREA N-17 CREAT-1.3* SODIUM-135
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-23 ANION GAP-15
IMAGING:
PLAIN FILM OF THE HIP
IMPRESSION:
1. Broken cerclage wire on the right.
2. No acute fracture.
PLAIN FILM OF LUMBAR SPINE
Moderate multilevel degenerative change of the lumbar spine.
Brief Hospital Course:
___ w/ CAD, HTN and chronic hip pain presents for pain
management after narcotics taper was initiated in the outpatient
setting.
#CHRONIC BILATERAL HIP PAIN: Mr. ___ was admitted for
management of chronic pain in his hips and lumbar spine
secondary to multiple surgeries. He reported ___ pain without
clear inciting event other than of running out of pain
medication at home. Of note, patient had been on a 6-month
narcotics taper in the outpatient setting. This was initiated
because he had multiple urine toxicology screens that were
positive for unprescribed benzodiazepines in the ___ and ___
___. During this admission, plain films did not demonstrate
any new lytic lesions or fractures. His labs were within normal
limits. Patient was seen by the Chronic Pain Service who
recommended concomitant treatment of anxiety with an SSRI. He
was continued on Methadone at 7.5mg q6AM/5mg q noon/5mg q
6pm/7.5mg q2AM and Oxycodone 5mg q4hr PRN as well as
acetaminophen for pain during his hospitalization He was
discharged on this dose of methadone as well as oxycodone 2.5mg
TID PRN for pain along with fluoxetine and discharged with a
plan to follow-up in clinic. Of note, multiple meetings were had
with the patient's primary care team from ___ in deciding on
this regimen.
#HTN: Continued home Lisinopril 10mg and home Metoprolol
fractionated to 12.5mg Tartrate BID. Discharged on home
Lisinopril and Metoprolol.
#CAD: Continued home aspirin 81mg and atorvastatin 80mg daily.
TRANSITIONAL ISSUES
- Mr. ___ was started on the following medications for
chronic pain management at home:
1. METHADONE: 7.5mg q6AM / 5mg q12PM / 5mg q6PM / 7.5mg q2AM
2. OXYCODONE: 2.5mg q8HRS PRN for pain
3. FLUOXETINE: 20mg daily
- Per discussion with the patient's Primary Care Physician, his
narcotics contract may continue at the current doses if the
patient adheres to a scheduled meeting with the Social Worker at
___. He will also be required to attend monthly clinic visits to
have serial ECG performed for QTc monitoring and complete urine
drug testing. If these stipulations are not met or if the
patient has a positive screen for an unprescribed controlled
substance, his primary outpatient team will no longer be able to
prescribe him opiate pain medications.
- The patient was enrolled in the PACT Program during this
admission. This team will continue to follow him in the
outpatient setting.
- PLEASE CHECK EKG AT NEXT ___ APPOINTMENT FOR QTc MONITORING.
- FYI Both medication refill overrides for the year were used up
on this admission to refill his opiates per insurance.
.
[X] Time spent on discharge activities: > 30 minutes.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lisinopril 10 mg PO DAILY
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Methadone 5 mg PO Q6AM
6. OxycoDONE (Immediate Release) 2.5 mg PO Q8H:PRN pain
7. Methadone 5 mg PO Q12PM
8. Methadone 5 mg PO Q6PM
9. Methadone 7.5 mg PO Q2AM
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*90
Tablet Refills:*0
3. Lisinopril 10 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. OxycoDONE (Immediate Release) 2.5 mg PO Q8H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) capsule(s) by mouth three
times per day Disp #*15 Capsule Refills:*0
6. Methadone 7.5 mg PO Q2AM
RX *methadone 5 mg 1.5 (One and a half) tablets by mouth twice
daily at 6AM and 2AM Disp #*18 Tablet Refills:*0
7. Methadone 5 mg PO Q6PM
8. Methadone 7.5 mg PO Q6AM
9. Methadone 5 mg PO Q12PM
RX *methadone 5 mg 1 tablet by mouth twice daily at 12PM and 6PM
Disp #*18 Tablet Refills:*0
10. Fluoxetine 20 mg PO DAILY
RX *fluoxetine 20 mg 1 capsule(s) by mouth daily Disp #*90
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Chronic Hip Pain
Secondary Diagnosis: Coronary Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the ___
with chronic hip pain. You were treated with pain medications
and this pain stabilized. You were also seen by the Chronic Pain
Service who recommended some changes to your home pain
medications. You are being discharged on the following
medications for pain:
- METHADONE: 7.5mg q6AM / 5mg q12PM / 5mg q6PM / 7.5mg q2AM
- OXYCODONE: 2.5mg q8HRS PRN for pain
- FLUOXETINE: 20mg daily
Per the discussion with your Primary Care Physician, you will
need to continue to attend clinic visits where you will undergo
monthly urine drug tests, and meet with the Social Worker.
Please call ___ to schedule an appointment with a
social worker.
Best Wishes,
Your ___ Team
Followup Instructions:
___
|
10688297-DS-13
| 10,688,297 | 25,586,019 |
DS
| 13 |
2194-08-23 00:00:00
|
2194-08-23 16:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Dyspnea, lower extremity swelling, palpitations
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old gentleman with history of HTN,
atrial fibrillation on eliquis, hx of R hip replacement, hx of
CVA, pulmonary nodules, R foot ulcer, visual loss, chronic R hip
pain, recently admitted to ___ for UTI ___ ___omplicated by toxic metabolic encephalopathy, presenting with
dyspnea, palpitations, and volume overload.
He was in usual state of health until 3 weeks ago when he had
progressive dyspnea on exertion. He previously could walk
without issue, but now has to stop after walking 10 feet. He
reports orthopnea and PND. Reports some phlegm, but no cough,
chest pain, fevers, chills, n/v/d/abdominal pain.
In the ED, HR was up to 160s. He was given IV diltiazem 15mg x2
and PO diltiazem 30mg with improvement in rates to 110s. The
patient had ___ edema, crackles, and elevated JVP with pleural
effusions on CXR. 20mg IV Lasix was given with no urine output.
Lactate was 2.7. Troponin was negative. He was also given home
methadone, gabapentin, IV fluids and PO metoprolol XL 25mg.
Of note, per ___ note with PCP, patient presented to clinic
with AFwRVR and refused to go to ED. Discussion with pt and wife
revealed lack of support for home and inability to take care of
self and each other. After prior visit, call was placed to Elder
protective services regarding this.
Past Medical History:
Hypothyroidism
Obesity
Bilateral Chronic Hip Pain
Anxiety
Hypertension
Coronary Artery Disease s/p MI
Hx of Anemia
Social History:
___
Family History:
No known history of coronary artery disease, diabetes, or colon
cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T: 98.3, BP: 133/78, HR: 86, RR: 21, 96% 2L
GENERAL: No apparent distress
HEENT: AT/NC, anicteric sclera, pink conjunctiva, MMM
NECK: JVP elevated to ear
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Bibasilar crackles
ABDOMEN: Nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: 2+ pitting edema from legs to sacrum, extremities
warm
NEURO: no gross motor/coordination abnormalities
SKIN: stasis dermatitis on lower extremities bilaterally
DISCHARGE PHYSICAL EXAM:
========================
Vitals: T: 98.2, BP: 128/52, HR: 85, RR: 20, 94% RA
WEIGHT: 298 (___) from 314.5 on admission
GENERAL: No apparent distress
HEENT: AT/NC, anicteric sclera, pink conjunctiva, MMM
NECK: JVP difficult to assess due to patient body habitus and
positioning
HEART: irregularly irregular rhythm, normal HR. S3. heart sounds
soft.
LUNGS: Lungs clear to auscultation anterior fields bilaterally
ABDOMEN: Nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: 2+ pitting edema in lower extremities bilaterally
to shin
NEURO: moving all extremities, speech clear, CN II-XII grossly
intact
SKIN: stasis dermatitis on lower extremities bilaterally
Pertinent Results:
===============
ADMISSION LABS:
___
___ 05:43PM BLOOD WBC-11.0* RBC-4.32* Hgb-11.9* Hct-39.2*
MCV-91 MCH-27.5 MCHC-30.4* RDW-17.3* RDWSD-56.1* Plt ___
___ 05:43PM BLOOD Neuts-76.0* Lymphs-13.0* Monos-8.3
Eos-1.9 Baso-0.4 Im ___ AbsNeut-8.38* AbsLymp-1.43
AbsMono-0.91* AbsEos-0.21 AbsBaso-0.04
___ 05:43PM BLOOD ___ PTT-31.8 ___
___ 05:43PM BLOOD Glucose-114* UreaN-16 Creat-1.2 Na-142
K-4.4 Cl-101 HCO3-27 AnGap-14
___ 05:43PM BLOOD ALT-9 AST-12 AlkPhos-109 TotBili-1.3
___ 05:43PM BLOOD Lipase-22
___ 05:43PM BLOOD proBNP-5601*
___ 05:43PM BLOOD cTropnT-<0.01
___ 07:25AM BLOOD Calcium-8.5 Phos-4.3 Mg-1.8
========================
PERTINENT INTERVAL LABS:
========================
___ 05:43PM BLOOD calTIBC-263 Ferritn-131 TRF-202
___ 05:43PM BLOOD TSH-5.0*
___ 07:35AM BLOOD CRP-36.5*
___ 07:35AM BLOOD ESR-9
===============
DISCHARGE LABS:
===============
___ 07:15AM BLOOD WBC-7.5 RBC-4.13* Hgb-11.4* Hct-37.8*
MCV-92 MCH-27.6 MCHC-30.2* RDW-17.0* RDWSD-56.4* Plt ___
___ 07:15AM BLOOD ___ PTT-32.1 ___
___ 07:15AM BLOOD Glucose-101* UreaN-22* Creat-1.1 Na-137
K-4.6 Cl-93* HCO3-30 AnGap-14
___ 07:15AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.4
___ 06:15AM BLOOD proBNP-___*
================
IMAGING STUDIES:
================
CXR (___):
1. Retrocardiac opacity may reflect atelectasis but infection is
not excluded in the correct clinical setting.
2. Probable small bilateral pleural effusions.
CT C SPINE (___):
No cervical spine fracture or definite traumatic malalignment.
Mild
anterolisthesis of C4 on C5 is likely degenerative.
CT T SPINE (___):
1. No evidence of acute fractures in the thoracic spine.
Partially imaged
lumbar spine demonstrates mildly displaced right L1 and L2
transverse process fractures with mild callus formation
compatible with subacute fractures.
2. Suggestion of moderate spinal canal narrowing at T8-T9.
3. Please refer to the same-day CTA chest report for
intrathoracic findings.
CT L SPINE (___):
Mildly displaced right L1, L2, and L3 transverse process
fractures demonstrate callus formation suggesting a subacute
time course. Otherwise no lumbar vertebral body height loss or
alignment abnormality to suggest acute fracture.
CT PELVIS (___):
1. The bones are osteopenic which limits evaluation for subtle
nondisplaced fractures. Within this limitation, there are no
gross pelvic fractures.
2. Additional findings as above including moderate-sized ventral
abdominal
hernia containing nonincarcerated small bowel loops.
CTA CHEST (___):
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Moderate bilateral pleural effusions.
3. Additional findings above.
TTE (___):
The left atrial volume index is moderately increased. No left
atrial mass/thrombus seen (best excluded by transesophageal
echocardiography). Left ventricular wall thicknesses and cavity
size are normal. There is moderate global left ventricular
hypokinesis (LVEF = 30 %). Systolic function of apical segments
is relatively preserved. The right ventricular cavity is
moderately dilated with moderate global free wall hypokinesis.
The aortic root is mildly dilated at the sinus level. The aortic
valve leaflets are mildly thickened (?#). No aortic
regurgitation is seen. The mitral leaflets are mildly thickened.
Moderate (2+) mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] Moderate [2+] tricuspid
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity size with moderate global hypokinesis in a pattern most
suggestive of a non-ischemic cardiomyopathy. Right ventricular
cavity dilation with free wall hypokinesis. At least moderate
mitral regurgitation. Moderate tricuspid regurgitation.
CLINICAL IMPLICATIONS:
The left ventricular ejection fraction is <40%, a threshold for
which the patient may benefit from a beta blocker and an ACE
inhibitor or ___. A right pleural effusion is present.
CT HEAD (___):
No acute intracranial process. Please note that MRI is more
sensitive for the detection of acute infarct.
=============
MICROBIOLOGY:
=============
__________________________________________________________
___ 9:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 6:33 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
Mr. ___ is a ___ year old gentleman with history of HTN,
atrial fibrillation on Eliquis, hx of R hip replacement, hx of
CVA, pulmonary nodules, R foot ulcer, visual loss, chronic R hip
pain, recently admitted to ___ for UTI ___ ___omplicated by toxic metabolic encephalopathy, presenting with
AF with RVR and acute heart failure exacerbation.
ACTIVE ISSUES:
==============
# ACUTE HFrEF (EF 30%)
Patient with history of heart failure, including TTE (___)
showing evidence of HFrEF with normal RV function, who presents
with dyspnea and volume overload in the setting of atrial
fibrillation with RVR. On arrival ___, repeat TTE showed
moderate global hypokinesis (EF 30%) in a pattern most
suggestive of a non-ischemic cardiomyopathy as well as RV cavity
dilation with free wall hypokinesis. Potential etiology includes
tachycardia-induced cardiomyopathy secondary to atrial
fibrillation with RVR as below vs. ischemic cardiomyopathy.
Ischemic workup with negative troponins and no evidence of EKG
changes or localized wall motion abnormalities on TTE. However,
he does have known history of CAD (MI s/p PCI in ___, so,
though less likely, could also be ischemic etiology. Plan to
follow up with cardiology for further ischemic workup, likely
including nuclear stress testing as an outpatient. Otherwise,
infectious workup has been negative, including CXR, UA, urine
cultures, and blood cultures. Patient was started on IV
diuresis, then converted to PO Lasix 20mg daily. Home Lisinopril
was continued. He will be discharged on metoprolol 100mg XL BID
rather than 200mg XL daily for more consistent heart rate
control throughout the day as below. And, home diltiazem was
discontinued given newly reduced EF.
# ATRIAL FIBRILLATION WITH RVR
Notably, at prior PCP ___ (___), patient was noted to be
in atrial fibrillation with RVR to 140s and declined to go to
the ED. On arrival to ED on this admission, HR in 160s, better
controlled now with increasing beta blockade to 80-100bpm and
volume status management as above. Likely ___ volume overload,
although also may have precipitated heart failure exacerbation.
Patient dig loaded on ___ but does not like taking it, as he
says it makes him "feel funny," so it was discontinued. Will be
discharged on metoprolol 100mg XL BID for more consistent heart
rate control throughout the day (previously on metoprolol 200mg
XL daily). Continue home apixaban BID for anticoagulation.
#BLURRY VISION
On ___ patient reported one episode of blurry vision. Code
stroke was called due to patient's history of cardio-embolic
disease and retinal artery occlusion. His visual symptoms
resolved within 15 minutes. ___ SS ___, no indication for TPA
and CT head negative for acute bleed. Was some concern for GCA
initially, as patient has history of jaw claudication, with past
workup for ___ at ___. Previously underwent biopsy at that time
which was negative on right but on left side was non-diagnostic
(not enough tissue). Determined to have a retinal artery
occlusion, most likely ___ embolic event ___ atrial fibrillaton.
Ophthalmology and rheumatology were consulted this admission
after episode of blurry vision, again with very low concern for
GCA. Inflammatory markers, only mildly elevated/normal (ESR 9,
CRP 36.5). Rheumatology recommending no biopsy or ultrasound at
this time, given low likelihood of GCA, alternative explanation
for previous symptoms (embolic retinal artery occlusion), and
inherent high risk for repeat biopsy given that he would need
likely need to be off anticoagulation for that procedure. He is
currently asymptomatic. Ophthalmology recommending outpatient
follow up with retina specialist.
#URINARY RETENTION
Patient struggling to urinate with post-void residual of 600cc
on bladder scan on arrival to floor. Due to need for close UOP
monitoring and high PVRs recommended Foley placement. Patient
denied red flag symptoms such as worsening back pain, saddle
anesthesia, incontinence of stool or bladder function; however
there is report of possible recent falls. Had CT C, T, and L
spine (___) with evidence of T8-T9 narrowing on ___ CT scan,
no other evidence of fractures. Foley catheter discontinued
___ prior to discharge with successful void trial. Continue
home tamsulosin.
#R FOOT ULCER
Documented history of right foot ulcer by PCP note on ___.
This was closely followed by ___ as an outpatient. Appears
clean/dry/intact.
CHRONIC ISSUES:
===============
# HTN: Continue home lisinopril, discontinue diltiazem given low
LVEF
# CAD: Continue home aspirin
# Chronic pain: Continue home Tylenol, gabapentin, methadone,
oxycodone at home dosing
# Constipation: Continue home lactulose, bisacodyl, docusate,
senna, and miralax
TRANSITIONAL ISSUES:
====================
DISCHARGE WEIGHT: 295.19
DISCHARGE CR: 1.1
[ ] Home diuretic: Lasix 20mg daily
[ ] Discontinued diltiazem due to low EF
[ ] Changed metoprolol dosing to 100mg XL BID
[ ] Follow up with cardiology for further cardiomyopathy workup
including nuclear stress test as an outpatient
[ ] Please check basic metabolic panel (including Cr) at
upcoming visit given multiple medication changes
[ ] Patient prescribed methadone from PCP ___ for chronic
pain, but inpatient and unable to get new scripts. Has no
methadone left at home. Contacted ___ via email during
this admission who recommended providing prescription to bridge
with methadone until PCP follow up ___.
[ ] Per ophthalmology consult, should follow-up with retina
specialist after discharge either at ___ or here (missed retina
follow-up at ___ in ___ for retinal artery occlusion
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Lisinopril 5 mg PO DAILY
4. Metoprolol Succinate XL 200 mg PO DAILY
5. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
6. Methadone 10 mg PO Q6H
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. Acetaminophen 650 mg PO Q8H
9. Apixaban 5 mg PO BID
10. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
11. Bisacodyl 10 mg PR QHS:PRN constipation
12. Docusate Sodium 100 mg PO DAILY
13. Senna 8.6 mg PO DAILY
14. Gabapentin 600 mg PO TID
15. Lactulose 30 mL PO BID:PRN constipation
16. melatonin 30 mg oral QHS:PRN
17. Nystatin Cream 1 Appl TP BID
18. Polyethylene Glycol 17 g PO BID:PRN constipation
19. Diltiazem Extended-Release 180 mg PO DAILY
20. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Metoprolol Succinate XL 100 mg PO BID
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
3. OxyCODONE (Immediate Release) 5 mg PO QID:PRN BREAKTHROUGH
PAIN
RX *oxycodone 5 mg 1 tablet(s) by mouth twice daily as needed
Disp #*6 Tablet Refills:*0
4. Acetaminophen 650 mg PO Q8H
5. Apixaban 5 mg PO BID
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
9. Bisacodyl 10 mg PR QHS:PRN constipation
10. Docusate Sodium 100 mg PO DAILY
11. Gabapentin 600 mg PO TID
12. Lactulose 30 mL PO BID:PRN constipation
13. Lidocaine 5% Patch 1 PTCH TD QAM
14. Lisinopril 5 mg PO DAILY
15. melatonin 30 mg oral QHS:PRN
16. Methadone 10 mg PO Q6H
RX *methadone 10 mg 1 tablet(s) by mouth four times a day Disp
#*20 Tablet Refills:*0
17. Nystatin Cream 1 Appl TP BID
18. Polyethylene Glycol 17 g PO BID:PRN constipation
19. Senna 8.6 mg PO DAILY
20. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Congestive Heart Failure
Atrial Fibrillation with RVR
Secondary Diagnosis:
Urinary Retention
Hypertension
Chronic Pain
Retinal artery occlusion
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 the ___
___!
Why was I admitted to the hospital?
-You were admitted because you had shortness of breath and
increased lower leg swelling.
What happened while I was in the hospital?
- You had an ultrasound of your heart which showed that your
heart was weak. This is called "congestive heart failure" and
can cause fluid to accumulate in your legs, stomach, and lungs
which can make you short of breath.
- We gave you medications to help you urinate out some of this
excess fluid. It is important that you continue to take Lasix
20mg once a day to prevent the fluid and your symptoms from
coming back.
- You were also found to have an abnormal heart rhythm on EKG
called atrial fibrillation with very fast heart rates. This can
also make you short of breath and weaken your heart. You will
need to take your metoprolol twice a day now, rather than once,
as prescribed.
What should I do after leaving the hospital?
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
- Please stop taking your home diltiazem
- Please start taking Lasix once a day
- Please start taking your new metoprolol pills twice a day
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team
Followup Instructions:
___
|
10688297-DS-15
| 10,688,297 | 21,249,411 |
DS
| 15 |
2195-10-08 00:00:00
|
2195-10-08 22:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
failure to thrive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with history of CVA, HFrEF (EF 30%), atrial
fibrillation on Eliquis, chronic pain on methadone/oxycodone,
total hip replacement bilaterally, presents with abdominal pain.
___ days ago, patient began having intermittent abdominal pain,
that was diffuse throughout his whole abdomen, which he rated a
7
out of 10. This is alleviated by moving his bowels, but has
been
associated with fecal incontinence over the last 3days, and this
morning he woke up incontinent to stool. This is in the setting
of his wife being placed on hospice 2 weeks ago, and she used to
take care of everything for him. He has been inability to get
out of bed, and has had difficulty ambulating with his walker.
Both his wife, and his friend ___ called his PCP over the last
few days due to concern over Mr. ___ well-being and safety.
Visiting nursing checked up on him and found that he had
abdominal pain with hypoactive bowel sounds last bowel movement
a
week ago. Visiting nurse ___ Mr. ___ to present to the
ED.
He denies fever chills, headache, visual changes cough, chest,
urinary symptoms. Patient notes he does have chronic leg pain
and has had difficulty last couple of weeks with this.
___ saw him in the ED and recommended rehab at this time. Case
management also evaluated and filed an application for mass
health. For this he will needed admission.
His last hospitalization here was ___ to ___ when he was
admitted for nausea and vomiting thought to be due to possible
gastroenteritis. He was initially admitted to the ICU for
hypotension with SBP is in the ___, which improved with IV fluid
resuscitation and did not require vasopressors. His hospital
course was complicated by A. fib with RVR in the setting of
holding metoprolol.
On the floor he affirms the above history, and adds that he has
had intermittent abdominal pain, but this improved when he had a
bowel movement in the ED. He also endorses headache.
In the ED, initial vitals were: T 96.3 HR93 BP 103/69 RR 17
O2sat 98% RA
However these decreased to blood pressures 80/52, which later
improved to 99/50s-60s.
Exam notable:
- patient covered in stool. Abdomen that is soft, nontender,
nondistended, but with an umbilical hernia without signs of
erythema.
- 1 cm right hallux ulcer on plantar aspect of foot, no signs of
erythema or discharge.
Labs:
-Leukocytosis to 10.6
-Anemia to 11.7
-Elevated INR 1.8
Studies:
-CT abdomen and pelvis with contrast ___ with
prior
from ___. Fat and bowel containing umbilical hernia
is unchanged. Colonic diverticulosis without diverticulitis.
Normal appendix. Mitral annular calcification. No findings to
account for
symptoms of abdominal pain.
-Foot AP lateral and oblique right XR ___ definite signs
of
osteomyelitis. Severe osteoarthritis at the first MTP joint.
Small soft tissue ulcer at the forefoot plantar surface on the
lateral view.
-CXR ___: No acute intrathoracic process.
-EKG with atrial fibrillation, rate 95. Abnormal R wave
progression, and prolonged QTC to 592.
They were given:
- 1 L LR
- Gabapentin 600 mg
- Methadone 10 mg
- Acetaminophen 1000 mg
- NS ( 500 mL ordered)
REVIEW OF SYSTEMS:
==================
Complete ROS obtained and is otherwise negative.
Past Medical History:
Hypothyroidism
Obesity
Bilateral Chronic Hip Pain
Anxiety
Hypertension
Coronary Artery Disease s/p MI
Hx of Anemia
Social History:
___
Family History:
No known history of coronary artery disease, diabetes, or colon
cancer.
Physical Exam:
========================
ADMISSION PHYSICAL EXAM:
========================
___ Temp: 98.1 PO BP: 104/64 HR: 83 RR: 18 O2
sat: 96% O2 delivery: Ra
GENERAL: Elderly gentleman sleeping in bed, but arousable to
voice. Pleasant and cooperative with exam..
HEENT: Cataract right eye. PERRL, EOMI. Sclera anicteric and
without injection. MMM. Dentures
NECK: No cervical lymphadenopathy. JVP at earlobe with patient
at 30 degrees.
CARDIAC: Irregular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing on room air.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: Right lower extremity with 1 cm ulcer with
granulation tissue, no purulent discharge on first metatarsal
plantar aspect. Dopplerable pulses DP and TP in bilateral lower
extremities. Palpable radial pulses in bilateral upper
extremities.
SKIN: Warm. Cap refill <2s. Chronic stasis changes in bilateral
lower extremities..
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. CN2-12
intact.
======================
DISCHARGE PHYSICAL EXAM
======================
24 HR Data (last updated ___ @ 631)
Temp: 97.7 (Tm 99.1), BP: 126/73 (97-126/60-73), HR: 106
(74-115), RR: 18 (___), O2 sat: 97% (85-97), O2 delivery: Ra,
Wt: 273.59 lb/124.1 kg
GENERAL: alert and interactive, in no acute distress
HEENT: NC/AT, sclera anicteric and without
injection.
CARDIAC: Quiet heart sounds but grossly normal rate, irregularly
irregular rhythm. Normal S1 and S2. No murmurs/rubs/gallops.
LUNGS: Breathing comfortably on room air, clear to auscultation
bilaterally
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: WWP. No lower extremity edema. Right foot wrapped
in bandage: Clean, dry, and intact.
NEUROLOGIC: AOx3.
Pertinent Results:
=============
ADMISSION LABS
=============
___ 10:50AM ___ PTT-33.1 ___
___ 10:50AM PLT COUNT-186
___ 10:50AM NEUTS-70.1 LYMPHS-18.1* MONOS-8.4 EOS-2.8
BASOS-0.3 IM ___ AbsNeut-7.43* AbsLymp-1.92 AbsMono-0.89*
AbsEos-0.30 AbsBaso-0.03
___ 10:50AM WBC-10.6* RBC-4.14* HGB-11.7* HCT-37.5*
MCV-91 MCH-28.3 MCHC-31.2* RDW-14.3 RDWSD-47.7*
___ 10:50AM CRP-6.4*
___ 10:50AM ALBUMIN-3.5 CALCIUM-8.5 PHOSPHATE-3.5
MAGNESIUM-1.6
___ 10:50AM LIPASE-36
___ 10:50AM ALT(SGPT)-9 AST(SGOT)-23 ALK PHOS-100 TOT
BILI-0.8
___ 10:50AM estGFR-Using this
___ 10:50AM GLUCOSE-90 UREA N-18 CREAT-1.2 SODIUM-139
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-26 ANION GAP-12
___ 10:55AM O2 SAT-62
___ 10:55AM LACTATE-1.7
___ 10:55AM ___ PO2-35* PCO2-40 PH-7.45 TOTAL CO2-29
BASE XS-3
================
PERTINENT STUDIES
================
CXR ___: No acute intrathoracic process.
R foot X ray ___:
No definite signs of osteomyelitis. Severe osteoarthritis at
the first MTP
joint. Small soft tissue ulcer at the forefoot plantar surface
on the lateral
view.
CT a/p w/o contrast ___: No findings to account for abdominal
pain.
============
MICROBIOLOGY
============
_________________________________________________________
___ 6:06 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
__________________________________________________________
___ 4:00 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 3:50 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 11:42 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 9:30 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
=============
DISCHARGE LABS
=============
___ 06:10AM BLOOD WBC-11.8* RBC-3.60* Hgb-10.4* Hct-33.6*
MCV-93 MCH-28.9 MCHC-31.0* RDW-14.6 RDWSD-50.4* Plt ___
___ 06:10AM BLOOD ___ PTT-26.8 ___
___ 06:10AM BLOOD Glucose-86 UreaN-16 Creat-1.2 Na-136
K-5.0 Cl-101 HCO3-24 AnGap-11
___ 06:10AM BLOOD Calcium-8.5 Phos-2.9 Mg-2.3
Brief Hospital Course:
Mr. ___ is a ___ man with coronary artery disease, A.
fib with RVR, HFrEF, and chronic pain who presents with failure
to thrive.
# Failure to thrive
Per outpatient notes, patient has had difficulty caring for self
as wife's health has deteriorated over the past few months. She
was recently placed on home hospice 2 weeks prior to admission
and he has been
having difficulty with PO intake and management of medications.
Social work is aware, saw him in the ED, admitted for placement.
Physical therapy also evaluated in the ED, and recommended
rehab.
# Leukocytosis: On the morning of discharge, the patient had a
mild leukocytosis of 11.8 (up from 6.4 the day prior). He felt
vaguely uncomfortable (though had just had a large, hard BM). He
was afebrile and was otherwise without localizing signs or
symptoms of infection. He felt comfortable being discharged from
the hospital but was encouraged to let his care team know should
other symptoms arise.
# Hypotension
Patient's baseline SBP ranges from ___. He occasionally
dips into the ___ systolic. His mentation remained normal
during
these episodes. No laboratory evidence of hypoperfusion during
these episodes (i.e. normal lactate).
- Held home furosemide
- Held Lasix 20mg. Could consider restarting these above
medications should BP remain stable
- Continued Metoprolol given afib
# Anemia, stable
Normocytic. No signs of bleeding. No laboratory evidence of
hemolysis. B12 low
end of normal. Iron studies showed mixed picture: Low serum
iron, low TIBC, and ferritin at high end of normal all suggest
anemia of chronic disease/inflammation; however, transferrin
saturation is low at 12%. Consider outpatient colonoscopy if
within goals of care. Consider IV Fe repletion. Would avoid PO
iron repletion for now given constipation.
# Constipation
Patient had significant issues with constipation during this
admission but was able to empty his bowels on the day of
discharge.
#Urinary retention, improved
#BPH
Patient has a history of BPH and is on tamsulosin at home. Was
retaining urine during this admission, possibly secondary to
opioid use, now improved after starting finasteride.
# Chronic pain
# QTc prolongation, resolved
Patient reportedly takes methadone 10 mg PO TID and oxycodone
___ mg PO TID. Holding home methadone in the setting of QTC
prolongation to 503. Substituted long-acting OxyContin dose
reduced at 50%. QTc improved to 466. Pain well controlled on
current regimen. Continued home oxycodone, acetaminophen, and
gabapentin.
# Right lower extremity ulcer
Foot x-ray in the ED without definite signs of osteomyelitis.
Does not appear infected on exam. CRP mildly elevated at 6.4.
Per outpatient note, patient has had problems with left lower
externally ulcers in the past, and is followed by podiatrist Dr.
___ as well as ___ once a week. He was
seen by wound care nursing who recommended podiatry consult.
Podiatry performed a bedside procedure; left plantar ulcer was
excisionally debrided to healthy granular subcutaneous tissue
using a #10 blade. Following debridement, the wound was
noted to have a healthy amount of bleeding. They recommended
continuing to wear surgical shoe when ambulatory and daily
betadine dressings.
# Chronic systolic heart failure
Most recent echo ___ with moderate global hypokinesis
suggestive of nonischemic cardiomyopathy, LVEF 30%, and RV
dilation with moderate MR and moderate TR. ___ on exam. He
held his home lisinopril and furosemide and fractionated his
home metoprolol in the setting of soft BPs.
#Fungal rash
Patient was noted to have erythematous fungal rash on
intertriginous region under
breast tissue on chest wall. He was continued on his home
nystatin cream.
___, resolved
Had creatinine bump to 1.3 on ___. Resolved with 500 cc IV
fluids.
# Atrial fibrillation with RVR
We continued his home apixaban. We fractionated his home
metoprolol in the setting of hypotension.
# Coronary artery disease status post stent
Patient denied any chest pressure, pain, or tightness on
admission. We continued his home aspirin and atorvastatin.
=================
TRANSITIONAL ISSUES
=================
#discharge weight: 124.1 kg
#discharge Hgb: 10.4
#discharge QTc: 466
[] Patient's baseline SBP ranges from ___. He occasionally
dips into the ___ systolic. His mentation remains normal during
these episodes. No laboratory evidence of hypoperfusion during
these episodes (i.e. normal lactate).
[] Consider outpatient colonoscopy if within goals of care for
workup of anemia of unclear etiology. Consider IV Fe repletion.
Would avoid PO iron repletion given constipation.
[] Please ensure patient has regular bowel movements. Uptitrate
bowel regimen as needed.
[] Please bladder scan patient q6H and straight cath if
retaining > 600 cc.
[] Please check QTc before starting any QTc prolonging meds. QTc
was > 500 on methadone. Would avoid methadone in the future.
[] Please wean opioids as tolerated.
[] For R foot ulcer, our podiatrists recommend:
-wear surgical shoe when ambulatory
-daily betadine dressings
[] Patient euvolemic at discharge weight. Please check and
assess volume status and adjust diuretic dose accordingly.
[] Patient's lisinopril and Lasix stopped in the setting of soft
BPs. He would benefit from this medication given his chronic
systolic heart failure. If blood pressures can tolerate,
consider re-starting.
[] We fractionated his home metoprolol in the setting of soft
BPs. If BPs remain stable, consider consolidating to metop
succinate for ease of administration.
[] Monitor for fevers or signs of infection with bump in
leukocytosis and day of discharge.
#CODE: Full code
#CONTACT:
___
Relationship: Nephew
Phone number: ___
>30 minutes were spent in discharge planning and coordination of
care on the day of discharge.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q8H
2. Apixaban 5 mg PO BID
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Bisacodyl 10 mg PR QHS:PRN constipation
6. Gabapentin 600 mg PO TID
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. Methadone 10 mg PO TID
9. Polyethylene Glycol 17 g PO BID:PRN constipation
10. Senna 8.6 mg PO DAILY
11. Tamsulosin 0.4 mg PO QHS
12. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
13. melatonin 3 mg oral QHS:PRN
14. Nystatin Cream 1 Appl TP BID
15. Furosemide 20 mg PO DAILY
16. Lisinopril 5 mg PO DAILY
17. Metoprolol Succinate XL 100 mg PO BID
18. OxyCODONE (Immediate Release) ___ mg PO BID PRN Pain -
Moderate
19. Lactulose 30 mL PO DAILY PRN CONSTIPATION
Discharge Medications:
1. Finasteride 5 mg PO DAILY
2. Metoprolol Tartrate 50 mg PO Q6H
3. Multivitamins W/minerals 1 TAB PO DAILY
4. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
5. Polyethylene Glycol 17 g PO BID
6. Senna 17.2 mg PO BID
7. Acetaminophen 650 mg PO Q8H
8. Apixaban 5 mg PO BID
9. Aspirin 81 mg PO DAILY
10. Atorvastatin 80 mg PO QPM
11. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
12. Bisacodyl 10 mg PR QHS:PRN constipation
13. Gabapentin 600 mg PO TID
14. Lactulose 30 mL PO DAILY PRN CONSTIPATION
15. Lidocaine 5% Patch 1 PTCH TD QAM
16. melatonin 3 mg oral QHS:PRN
17. Nystatin Cream 1 Appl TP BID
18. OxyCODONE (Immediate Release) ___ mg PO BID PRN Pain -
Moderate
19. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
================
PRIMARY DIAGNOSIS
================
Failure to thrive
===================
SECONDARY DIAGNOSIS
===================
Hypotension
Anemia
Constipation
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Mr. ___,
You came into the hospital because you were having belly pain
and difficulty managing your health at home. You will be
discharged to a rehabilitation facility where you can get help
managing your medications and have time to get stronger.
When you leave the hospital you should:
- Take all of your medications as prescribed.
- Attend all scheduled clinic appointments.
It was a pleasure taking care of you,
Your ___ Care Team
Followup Instructions:
___
|
10688297-DS-17
| 10,688,297 | 24,647,867 |
DS
| 17 |
2196-08-13 00:00:00
|
2196-08-12 12:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
periprosthetic joint infection
Major Surgical or Invasive Procedure:
Periprosthetic joint infection washout and antibiotic spacer
placement
History of Present Illness:
___ male past medical history of CAD, hypertension,
hyperlipidemia, status post hip replacement ___ years ago by Dr.
___, complicated by prosthetic joint infection status post
two-stage explant and replant approximately ___ years ago by Dr.
___. The patient has presented with 3 days of increasing
pain,
and noticed a bulge on his right hip replacement incision, the
patient denies any discharge, denies any fevers or chills,
denies
any night sweats.
Patient said he has increased pain, he does not ambulate much at
baseline however the patient does have pain with ambulation.,
Intolerance to weightbearing., Of note the patient has a
history
of MRSA infections in his right hip. Patient states that he
took
Eliquis this morning.
Past Medical History:
Hypothyroidism
Obesity
Bilateral Chronic Hip Pain
Anxiety
Hypertension
Coronary Artery Disease s/p MI
Hx of Anemia
Social History:
___
Family History:
No known history of coronary artery disease, diabetes, or colon
cancer.
Physical Exam:
General: Resting, breathing comfortably
MSK: Left hip: Preveena vac in place and holding suction,
serosang
output. dressing over drain site c/d/i.
Pertinent Results:
___ 10:30 am TISSUE Site: HIP RIGHT HIP CAPSULE.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
PSEUDOMONAS AERUGINOSA. GROWING IN BROTH ONLY.
Susceptibility testing performed on culture # ___-___
___.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopaedic surgery team. The patient was found
to have periprosthetic joint infection and was admitted to the
orthopaedic surgery service. The patient was taken to the
operating room on ___ for washout and antibiotic spacer
placement, which the patient tolerated well. For full details of
the procedure please see the separately dictated operative
report. Postoperatively the patient required ICU level care for
hypotension. He was on multiple pressors. He was weaned off
pressors on ___. He was deemed stable to transfer to the
floor. Given his multiple comorbidities he was transferred to
the medicine service. He was initially on vancomycin and
ceftriaxone. He was then switched to vancomycin and cefepime on
___. He continued on IV Cefepime for Pseudomonas based on
outside cultures, to be continued until ___. Final
antibiotics duration to be determined at outpatient ID follow
up. A Praveena VAC was placed on ___ to be in place for
7 days. The patient worked with ___ who determined that discharge
to rehab was appropriate. The ___ hospital course was
otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
non weight bearing in the right lower extremity, and will be
discharged on ___ 2.5 mg BID for DVT prophylaxis. The
patient will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
___ [ELIQUIS] - Eliquis 5 mg tablet. 1 tablet(s) by mouth
twice daily
ATORVASTATIN [LIPITOR] - Lipitor 80 mg tablet. 1 tablet(s) by
mouth daily
DIGOXIN - digoxin 125 mcg (0.125 mg) tablet. 1 tablet(s) by
mouth
once a day
FINASTERIDE - finasteride 5 mg tablet. 1 tablet(s) by mouth once
a day
GABAPENTIN - gabapentin 600 mg tablet. 1 tablet(s) by mouth
three
times a day
LACTULOSE - lactulose 20 gram/30 mL oral solution. 30 ml by
mouth
once a day as needed for constipation
LANOLIN-MINERAL OIL - lanolin-mineral oil lotion. Apply to feet
every other day
MELATONIN - melatonin 3 mg tablet. 1 tablet(s) by mouth daily 1
hr prior to bedtime as needed for insomnia
METH BLUE-GEN VIOLET-FOAM BAND [HYDROFERA BLUE READY] - Dosage
uncertain - (Prescribed by Other Provider: per med
reconciliation w/ ___ and rehb d/c med list; Apply to left heel
topically every evening every ___ and every ___. VN to
order.)
METHADONE - methadone 10 mg tablet. 1 tablet(s) by mouth twice a
day 28 day supply
METOPROLOL SUCCINATE - metoprolol succinate ER 100 mg
tablet,extended release 24 hr. 1 tablet(s) by mouth twice a day
MULTIVITAMIN - multivitamin tablet. 1 tablet by mouth once a day
for wound healing
NALOXONE - naloxone 1 mg/mL injection syringe. 1 mL each nostril
once for suspected opioid overdose Repeat after 3 min if
no/minimal response [disp intranasal mucosal atomizing devices]
NYSTATIN - nystatin 100,000 unit/gram topical cream. Apply one
application beneath breasts twice a day - (Not Taking as
Prescribed: per rehab d/c med list)
OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1
capsule(s) by mouth once a day
OXYCODONE - oxycodone 10 mg tablet. 1 tablet(s) by mouth twice a
day 28 day suply
POLYETHYLENE GLYCOL 3350 - polyethylene glycol 3350 17 gram/dose
oral powder. 1 dose by mouth once a day as needed for
constipation
ROLLATOR WITH SEAT - Rollator with Seat . Use as directed
Dx:Severe DJD, Chronic B/L hip buttock and hip pain, CAD,s/p
multiple hip surgeries. Lifetime need. Ht 71", Wt 274 lbs
SILVER SULFADIAZINE - silver sulfadiazine 1 % topical cream.
Apply topically to buttocks twice a day For wound care.
TAMSULOSIN [FLOMAX] - Flomax 0.4 mg capsule. one capsule(s) by
mouth hs
Medications - OTC
ACETAMINOPHEN - acetaminophen ER 650 mg tablet,extended release.
1 tablet(s) by mouth every six (6) hours as needed for pain in
lower extremities rated <5
ASPIRIN [ADULT LOW DOSE ASPIRIN] - Adult Low Dose Aspirin 81 mg
tablet,delayed release. 1 tablet,delayed release (___) by
mouth daily
BISACODYL - bisacodyl 10 mg rectal suppository. Insert one
suppository per rectum every 24 hours as needed for constipation
MAGNESIUM HYDROXIDE [MILK OF MAGNESIA] - Milk of Magnesia 400
mg/5 mL oral suspension. 30 ml by mouth once a day as needed for
constipation
MICONAZOLE NITRATE [ANTI-FUNGAL] - Anti-Fungal 2 % topical
powder. Use as directed every eight (8) hours as needed for
fungal rash. Apply to Groin/Axillary/Under Breast topically.
SENNOSIDES - sennosides 8.6 mg tablet. 2 tablets by mouth at
bedtime once a day as needed for constipation.
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. CefePIME 2 g IV Q8H
RX *cefepime [Maxipime] 2 gram 2 g every eight (8) hours Disp
#*63 Vial Refills:*0
3. Polyethylene Glycol 17 g PO DAILY
4. ___ 2.5 mg PO BID
5. Artificial Tears Preserv. Free ___ DROP LEFT EYE Q4H:PRN
corneal abrassion Duration: 6 Days
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Bisacodyl 10 mg PO DAILY
9. Digoxin 0.125 mg PO DAILY
10. Erythromycin 0.5% Ophth Oint 0.5 in LEFT EYE QID corneal
abrsion Duration: 5 Days
11. Finasteride 5 mg PO DAILY
12. Gabapentin 600 mg PO TID
13. Methadone 10 mg PO TID
Consider prescribing naloxone at discharge
14. Metoprolol Succinate XL 100 mg PO DAILY
15. Midodrine 10 mg PO Q8H
16. Omeprazole 20 mg PO DAILY
17. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
18. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right hip periprosthetic joint infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
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:
-50% weightbearing on right lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per ___ regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon
9) Methadone for chronic pain
ANTIBIOTICS
Patient was started on CefePIME 2 g IV Q8H for 28 days
Please obtain weekly CBC with differential, BUN, Cr, CRP.
Please sent all lab results to ___ clinic: FAX ___
ANTICOAGULATION:
- Please take home ___ 2.5 mg twice daily for 4 weeks
-Please follow-up with your primary care physician regarding
___ dose after the 4 weeks
WOUND CARE:
- Please do not shower or get Praveena VAC wet/dirty. Okay to
sponge bath
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
-Praveena VAC to be left on for 7 days
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___ at
___ in 2 weeks. Someone from Dr. ___
should be in touch with you regarding the follow up. If you do
not hear from them, please call the clinic. ___
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.
Please follow up with infectious disease service in outpatient
setting to determine final antibiotics plan. They will schedule
a follow up appointment and call you to confirm. If you do not
hear from them, please call ___ (ID clinic).
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
Physical Therapy:
50% weight bearing on right lower extremity
Treatments Frequency:
IV cefepime
methadone for chronic pain
Followup Instructions:
___
|
10688397-DS-15
| 10,688,397 | 21,827,393 |
DS
| 15 |
2155-05-24 00:00:00
|
2155-05-28 17:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Iodinated Contrast Media - IV Dye / cefazolin / donepezil /
benazepril / zolpidem / diphenhydramine
Attending: ___.
Chief Complaint:
Trauma: fall off scooter:
Left thigh laceration
left forearm laceration
left forehead lacerations
Major Surgical or Invasive Procedure:
___ debridement, VAC change
___ wash-out, VAC placement of left thigh wound, suture of
head laceration
___ forehead sutures removed
History of Present Illness:
Mr. ___ is an ___ man brought in by Medflight from
___, found found mostly up side down in a pond in his
motorized wheelchair, found by bystanders and supported above
water until EMTs came. Major injuries include a large left leg
laceration requiring surgery.
Past Medical History:
PMH:
renal failure (s/p txp ___, HTN, gout, afib on digoxin, anemia,
gout, diverticulitis, hernia,
Pshx:
kidney txp ___, collar bone removal ___, c1-c3 fusion ___, right
knee replacement, left hip replacement, left knee cap surgery
___, IVC filter
Social History:
___
Family History:
nc
Physical Exam:
Physical examination upon admission: ___:
VS: 98.0 70 156/89 18 94%RA
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI,
PERRL.
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: (+/-) BS x 4 quadrants, soft, non tender,
non-distended.
EXTREMITIES: b/l edema, large wound at his left thigh with VAC
on it.
Physical examination upon discharge: ___:
vital signs:t=98.7, hr=70, bp=156/89, rr= 18. 99% room air
CV: irregular
LUNGS: clear, diminished in bases
ABDOMEN: soft, non-tender
EXT: ecchymosis upper arms and lower ext, ace wrap to lower leg
and thigh, ace to abrasions upper ext., ecchymosis to shoulders
and abdomen, no calf tenderness bil.
NEURO: slow speech, asking appropriate questions, follows
commands
SKIN: Mepiplex dressing to coccyx
Pertinent Results:
___ 04:30PM ___ 04:30PM PLT COUNT-109*
___ 04:30PM ___ PTT-25.1 ___
___ 04:30PM WBC-6.1 RBC-2.46* HGB-8.6* HCT-28.2* MCV-115*
MCH-35.0* MCHC-30.5* RDW-16.6* RDWSD-69.0*
___ 04:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 04:30PM DIGOXIN-0.8*
___ 04:30PM LIPASE-47
___ 04:30PM estGFR-Using this
___ 04:30PM UREA N-60* CREAT-1.7*
___ 04:35PM GLUCOSE-130* LACTATE-4.1* NA+-142 K+-4.0
CL--109* TCO2-22
___ 08:00PM PLT SMR-LOW PLT COUNT-106*
___ 08:00PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+
SCHISTOCY-1+ TEARDROP-1+
___ 08:00PM NEUTS-64 BANDS-10* LYMPHS-15* MONOS-7 EOS-0
BASOS-0 ___ METAS-3* MYELOS-1* AbsNeut-6.44* AbsLymp-1.31
AbsMono-0.61 AbsEos-0.00* AbsBaso-0.00*
___ 08:00PM WBC-8.7 RBC-2.96* HGB-9.7* HCT-30.5*
MCV-103*# MCH-32.8* MCHC-31.8* RDW-19.7* RDWSD-73.0*
___ 08:00PM CALCIUM-8.3* PHOSPHATE-4.7* MAGNESIUM-2.0
___ 08:00PM ALT(SGPT)-22 AST(SGOT)-17 ALK PHOS-47 TOT
BILI-0.7
___ 08:00PM GLUCOSE-173* UREA N-61* CREAT-1.6* SODIUM-141
POTASSIUM-4.3 CHLORIDE-112* TOTAL CO2-21* ANION GAP-12
___ 08:33PM freeCa-1.22
___ 08:33PM GLUCOSE-154* LACTATE-1.3
___ 08:33PM TYPE-ART PO2-358* PCO2-44 PH-7.28* TOTAL
CO2-22 BASE XS--5
___ 11:38PM PLT COUNT-101*
___ 11:38PM WBC-8.4 RBC-2.63* HGB-8.8* HCT-27.7* MCV-103*
MCH-33.5* MCHC-32.5 RDW-20.3* RDWSD-75.5*
___ 11:51PM TYPE-ART PO2-209* PCO2-38 PH-7.35 TOTAL
CO2-22 BASE XS--3
___: cat scan of the head:
Mild limited exam due to motion despite repeat acquisitions.
Left
supraorbital and left parietal scalp swelling without underlying
fracture.
No acute intracranial process.
Right temporal and left frontal lobe encephalomalacia, some of
which may be posttraumatic in nature.
___: cat scan of the chest:
. No acute sequelae of trauma.
2. 1.2 cm chronic pseudoaneurysm of the aortic arch.
3. Anterior displacement of the left humeral head with abnormal
soft tissue density in the region of both glenohumeral joint
spaces. Please correlate clinically.
4. Right lower quadrant transplant kidney is noted.
___: x-ray of the wrist:
Severe collapse of the carpus with extensive chondrocalcinosis
and secondary degenerative change. The appearances are most
suggestive of
hyperparathyroidism or CPPD arthropathy.
___: x-ray of the elbow:
1. Fracture of the struts of the most proximal vascular stent in
a presumed AV fistula. This is unlikely to be of any clinical
significance but correlation
with clinical examination findings recommended.
2. Small joint effusion. In the absence of a visible bony
injury, this may reflect an undisplaced radial head fracture.
___: chest x-ray:
No relevant change as compared to ___. Constant
monitoring and support devices. Constant low lung volumes.
Moderate cardiomegaly.
Bilateral pleural effusions and pulmonary edema, basal right and
retrocardiac atelectasis
___: chest x-ray:
No comparison. Osteolysis of the right clavicle. Potential
dislocation of the left humerus. Low lung volumes. Moderate
cardiomegaly. Small bilateral pleural effusions and evidence of
mild pulmonary edema
Brief Hospital Course:
Mr. ___ is an ___ year old male with history of ESRD s/p
renal transplant (___) and a-fib not anticoagulated who
suffered a mechanical fall into a pond while driving his
scooter. He was helmeted with no LOC. On trauma survey, he
suffered a large deep left thigh laceration and was immediately
taken to the operating room for exploration due to brisk
bleeding. A vac was placed and he received 2u PRBCs intra-op.
Post-operatively, he was admitted to the trauma ICU intubated
and with ongoing pressor requirement. Left forearm and left
forehead lacerations were washed out and closed with simple
sutures. Once weaned off pressors and extubated, the patient was
transferred to the floor for further care.
Salient aspects of his hospital course are summarized by systems
below.
NEUROLOGIC: Patient was sedated while intubated. He received
sufficient pain control, IV then transitioned to PO once
extubated and tolerated POs. He suffered no neurologic injuries
from his trauma. There was question of a C-spine fracture though
was thought to be chronic. C collar was kept on until patient
was awake for an adequate exam, after which it was removed.
CV: Patient required pressors until HD3. He was resuscitated
with both crystalloids, colloids, and blood products. He has
resumed his antihypertensive agents and his digoxin. His vital
signs have been stable.
PULM: The patient remained stable from a pulmonary standpoint;
vital signs were routinely monitored. Good pulmonary toilet.
GI/GU/FEN: The patient was initially kept NPO in the ICU then
the diet was advanced sequentially to a Regular diet, which was
well tolerated. Patient's intake and output were closely
monitored. His appetite has been poor and he needs encouragement
and assistance with meals. The patient has a condom catheter.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none. On prednisone, daily BS
with sliding scale if needed. Tacrolimus levels daily. The
patient has been afebrile with WBC at 6.4
HEME: The patient's blood counts were closely watched for signs
of bleeding, initially he was bleeding form the left laceration
at the left thigh of which he required 2 units of prbcs. First
day after OR, he was putting out bloody secretion from the VAC
that required additional one unit of PRBCs, his hematocrit
become after stable and closely monitored.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay.
Over all, he has had wound exploration and washout soon after he
arrived to the ED. He required to stay in ICU until he became
hemodynamically stable, he has been transferred to the regular
floor and monitored closely. His VAC has been changed at bedside
twice during his stay and the wound has been watched for signs
of infection in which non has been seen. orthopedic team has
been consulted regarding his anterior chronic shoulder
dislocation by patient with no pain and reassuring exam. they
recommended no operative indication at this time and no need for
relocation. The patient has been seen by renal transplant team
that recommend no NSAIDs or additional nephrotoxic agents,
Monitor I/Os closely, no additional IVF, continue with renal
dosing of ___, Check daily dig levels until renal
function is established to be stable and Continue CellCept 250
mg BID and tacro 3mg in the morning & 2mg qhs, Daily tacro
troughs ___ acceptable) in which his last tacro level on
___ (tacroFK: 7.4) and continue home dose of Bactirm for ppx
purposes.
Then the patient has been evaluated by ___ service in which they
recommend sending him to rehabilitation program which the
patient agrees and is willing to participate.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
voiding, and pain was well controlled. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Please reapply vac dressing to left leg wound, black sponge,
machine at 125mm HG., change every 3 days.
Medications on Admission:
tacro 3'/2', cellcept 250'', prednsione 5', digoxin 0.125',
torsemide 20', metoprolol 12.5'', ASA 81', allopurinol ___,
pravastatin 40', tamsulosin 0.8', finasteride 5', travatan 1
drop each eye qdaily, rimlol 1 drop both eyes BID, multivitamin,
melatonin 5 qhs.
Discharge Medications:
1. Tacrolimus 2 mg PO Q12H
2. Mycophenolate Mofetil 250 mg PO BID
3. PredniSONE 5 mg PO DAILY
4. Digoxin 0.125 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Heparin 5000 UNIT SC TID
7. Metoprolol Tartrate 12.5 mg PO BID
8. Senna 8.6 mg PO BID
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
11. Finasteride 5 mg PO DAILY
12. Tamsulosin 0.8 mg PO DAILY
13. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
14. Travatan Z (travoprost) 0.004 % ophthalmic DAILY
15. Pravastatin 40 mg PO QPM
16. Torsemide 10 mg PO DAILY
follow-up with Cardiologit regarding dose change (patient in
past has been on 20 mg)
17. Acetaminophen 650 mg PO TID
may increase to 1 gm if needed
18. Insulin SC
Sliding Scale
Fingerstick q6
Insulin SC Sliding Scale using REG Insulin
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Trauma: fall off scooter:
Left thigh laceration
left forearm laceration
left forehead lacerations
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You sustained mechanical fall into a pond from your scooter,
helmeted with no LOC. You sustained a deep left thigh
laceration. You underwent an exploration and placement of a vac
dressing. During your stay, you were evaluated by the
Orthopedic, Geriatric, and Transplant service. You were
evaluated by physical therapy and because of your
deconditioning, it was advised that you be discharged to a
rehabilitation facility to regain your strength and mobility.
Followup Instructions:
___
|
10688510-DS-25
| 10,688,510 | 23,297,564 |
DS
| 25 |
2164-07-23 00:00:00
|
2164-07-23 18:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Statins-Hmg-Coa Reductase Inhibitors / rifampin
Attending: ___.
Chief Complaint:
shortness of breath, abdominal pain, weakness
Major Surgical or Invasive Procedure:
Right heart catheterization
History of Present Illness:
___ is a ___ y/o M with h/o CAD, ischemic
cardiomyopathy w/ LVEF ___ (on milrinone gtt, listed for
cardiac transplantation at ___), CKD (baseline Cr 1.6-1.8),
DM-2, hypothyroidism and Addison's on prednisone and
fludrocortisone, with recent S. epidermidis endocarditis s/p
explant of ICD on cefazolin, presenting with abdominal bloating
and dry heaving consistent with prior fluid overload symptoms.
Of note, the patient was recently discharged from ___
following endocarditis s/p explant of ICD with ongoing Keflex
treatment. Following discharge, he was seen in clinic with an
elevated WBC of 17.8 with plan to repeat labs today at ___
___. He then called in to report he is feeling "terrible,"
with worsening SOB, abdominal bloating and weakness, without
fevers or chills.
Past Medical History:
- CAD s/p LAD/CX stent (___), unrevasc RCA CTO
- HFrEF
- T2DM
- Hypertension (prior, not currently on meds)
- Hyperlipidemia
- Addison's disease
- Hypothyroidism
- Obesity
- OSA
Social History:
___
Family History:
No family history of early cardiomyopathy or sudden cardiac
death.
Physical Exam:
ADMISSION
=========
Weight: 115.9kg
VS: 97.3 116 / 67 89 20 97 RA
General: Well-appearing, sitting up comfortably eating dinner,
non-toxic appearing, NAD
Neck: JVP at 10cm
CV: RRR, no m/r/g
Pulm: Decreased sounds at the bases, crackles in the R middle
lobe, otherwise CTAB without wheezes
Abd: Significant abdominal distension without fluid wave,
non-tender to palpation, non-peritoneal
Ext: trace ___ edema, WWP
DISCHARGE
=========
- VITALS: afeb 117-124/53-69, 67-94, 18, 98% on RA
- I/Os:
- 24: 1273/1400
- 8: 302/625
- WEIGHT: 115.4 -> 115.3 -> 115.0 -> 114.3 -> 114 -> 112.2 -->
112.6 -> 112.9
- WEIGHT ON ADMISSION: 115.9
- TELEMETRY: NSR
GENERAL: Pleasant middle-aged male, NAD.
HEENT: JVP 8cm
LUNGS: Normal effort, CTAB
HEART: RRR, no m/r/g
ABDOMEN: Soft, mildly distended, NT
EXT: Trace ___ edema, distal pulses intact.
Pertinent Results:
ADMISSION
=========
___ 01:07PM BLOOD WBC-14.5* RBC-4.58* Hgb-12.4* Hct-38.6*
MCV-84 MCH-27.1 MCHC-32.1 RDW-14.9 RDWSD-44.9 Plt ___
___ 01:07PM BLOOD Neuts-82.6* Lymphs-7.2* Monos-7.2
Eos-0.8* Baso-0.6 Im ___ AbsNeut-11.99* AbsLymp-1.05*
AbsMono-1.05* AbsEos-0.12 AbsBaso-0.08
___ 01:07PM BLOOD ___ PTT-26.1 ___
___ 01:07PM BLOOD Glucose-186* UreaN-60* Creat-2.0* Na-128*
K-4.7 Cl-87* HCO3-28 AnGap-18
___ 08:45PM BLOOD CK(CPK)-26*
___ 01:07PM BLOOD Albumin-4.2 Calcium-9.4 Phos-3.6 Mg-2.1
PERTINENT
=========
___ 04:16AM BLOOD Glucose-77 UreaN-60* Creat-1.6* Na-130*
K-3.9 Cl-88* HCO3-30 AnGap-16
___ 01:07PM BLOOD CK-MB-4 proBNP-3053*
___ 01:07PM BLOOD cTropnT-0.06*
___ 08:45PM BLOOD cTropnT-0.05*
___ 03:40PM BLOOD Osmolal-303
___ 09:48AM BLOOD Type-MIX Temp-36.9
___ 08:14PM BLOOD Type-MIX pO2-35* pCO2-49* pH-7.43
calTCO2-34* Base XS-6
___ 04:11PM BLOOD Lactate-2.1*
___ 06:04AM BLOOD Lactate-1.1
___ 01:40PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 01:40PM URINE Color-Straw Appear-Clear Sp ___
MICRO
=====
___ BLOOD CULTURE Blood Culture, Routine-No
Growth
___ BLOOD CULTURE Blood Culture, Routine-No
Growth
___ URINE URINE CULTURE-No Growth
___ BLOOD CULTURE Blood Culture, Routine-No
Growth
DISCHARGE
=========
___ 05:33AM BLOOD WBC-8.4 RBC-4.14* Hgb-11.2* Hct-34.5*
MCV-83 MCH-27.1 MCHC-32.5 RDW-14.9 RDWSD-45.2 Plt ___
___ 05:33AM BLOOD Glucose-134* UreaN-64* Creat-2.2* Na-130*
K-3.9 Cl-88* HCO3-28 AnGap-18
___ 05:31AM BLOOD ALT-<5 AST-16 AlkPhos-161* TotBili-0.6
___ 05:33AM BLOOD Calcium-9.4 Phos-4.6* Mg-2.2
IMAGING AND STUDIES
===================
RHC ___:
SvO2 62
CVP 10
PAP 57/29 mean 36
wedge 30
CO 5.8
CI 2.5
SVR 870
RHC 1600 ___:
SVO2 sat 61
CVP 13
PAP 66/35 m45
PCWP 40
CO 5.1
CI 2.2
SVR 972
RHC ___
SVO2 61
CVP 16
PA 61/35 m43
Wedge 41
CO 5.07
CI 2.11
SVP 805
RHC ___:
SVO2 64 CVP 8 PA ___ (37) wedge 30 CO 5.55 CI 2.34 MVO2 64 SVR
908 PVR 101
RHC ___: 0930:
SVO2 63 CVP 6 PA ___ wedge 13 CO 5.12 CI 2.15 SVR 1056 PVR
156
CXR ___:
Cardiomegaly. Probable small right pleural effusion. Increased
interstitial markings as seen on prior, suggesting interstitial
edema. More conspicuous right basilar opacity potentially
atelectasis, infection not excluded.
Brief Hospital Course:
Mr. ___ is ___ y/o M with h/o CAD, ischemic cardiomyopathy w/
LVEF ___ (on
milrinone gtt, listed for cardiac transplantation at ___), CKD
(baseline Cr 1.6-1.8), DM2, hypothyroidism and Addison's on
prednisone
and fludrocortisone, with recent S. epidermidis endocarditis s/p
explant of ICD on cefazolin, presenting with abdominal bloating
and
dry heaving consistent with prior fluid overload symptoms, with
RHC numbers demonstrating stable cardiac function and volume
overload.
# CORONARIES: LAD mid total occlusion s/p DES, proximal cx
occlusion s/p DES. RCA occlusion.
# PUMP: EF ___
# RHYTHM: afib
ACTIVE ISSUES:
================
#HFrEF: LVEF ___, dry weight 254 lbs (115.45 kg)
BNP essentially at baseline, was transferred to ICU for c/f
inadequate inotropy, swan numbers showed CI of 2.5 (repeat 2.1)
with elevated wedge suggesting patient needed further diuresis
as well as some increased inotropic support. Patient had
milrinone uptitrated to 0.375 and was diuresed, with final swan
numbers demonstrating SVO2 63 CVP 6 PA ___ wedge 13 CO 5.12
CI 2.15 SVR 1056 PVR 156.
- Preload: torsemide 60mg BID
- Afterload: Has not tolerated afterload reduction in the past,
no plans for current therapy
- NHBK: Has not tolerated blockade in past, no plans for current
therapy
- Ionotrope: Continued home milrinone drip at 0.375
- On lifevest at home, no concerning events noted on telemetry
while admitted.
#Endocarditis: S/p ICD explant ___, completed course of IV
cefazolin ___. Will need to recheck cultures prior to LVAD
placement, planned for f/u appointment on ___.
___: Likely cardiorenal, diuresed, renally dosed medication and
avoided nephrotoxins. Cr slightly above baseline on discharge,
will recommend rechecking as an outpatient
#Hyponatremia: Trough 123, improved to 130 on discharge, likely
hypervolemic ___ chronic CHF. Will continue fluid restriction
1.5L moving forward.
#Leukocytosis: Peaked at 17, downtrended to normal 8.4,
infectious workup unremarkable.
CHRONIC ISSUES
==============
#CAD: Continued home ASA + ezetimibe; stopped clopidogrel in
anticipation of need for LVAD surgery in the near future
#Addison's disease: Continued home prednisone, fludricortisone
#Hypothyroidism: Continued home levothyroxine
#DMII: Standing insulin + HISS
TRANSITIONAL ISSUES:
===================
Discharge wt: 112.9kg/248.9lb
Discharge diuretic: Torsemide 60mg BID
- Will need two sets of blood cultures separated by at least 30
minutes drawn at follow-up appointment on ___
- Recheck chem 7 on ___, particular focus on creatinine and
K trend
- Patient had clopidogrel stopped in anticipation of upcoming
LVAD placement
CODE Status: Full (presumed)
Contact: ___, spouse, ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. CeFAZolin 2 g IV Q8H
2. Milrinone 0.25 mcg/kg/min IV DRIP INFUSION
3. Aspirin 81 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. DimenhyDRINATE 50 mg PO Q6H:PRN nausea
6. Ezetimibe 10 mg PO DAILY
7. Fludrocortisone Acetate 0.1 mg PO DAILY
8. Levothyroxine Sodium 250 mcg PO DAILY
9. PredniSONE 7.5 mg PO DAILY
10. Ranitidine (Liquid) 150 mg PO BID
11. Torsemide 40 mg PO DAILY
12. Glargine 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Milrinone 0.375 mcg/kg/min IV DRIP INFUSION
RX *milrinone 1 mg/mL 0.375 mcg/kg/min IV continuous Disp #*30
Vial Refills:*0
2. Torsemide 60 mg PO BID
RX *torsemide 20 mg 3 tablet(s) by mouth twice a day Disp #*180
Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. DimenhyDRINATE 50 mg PO Q6H:PRN nausea
5. Ezetimibe 10 mg PO DAILY
6. Fludrocortisone Acetate 0.1 mg PO DAILY
7. Glargine 50 Units Bedtime
Humalog 12 Units Breakfast
Humalog 12 Units Lunch
Humalog 12 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
8. Levothyroxine Sodium 250 mcg PO DAILY
9. PredniSONE 7.5 mg PO DAILY
10. Ranitidine (Liquid) 150 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Heart failure with reduced ejection fraction
Secondary diagnoses:
Endocarditis
Hyponatremia
Acute kidney injury
Elevated troponin
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 because you were having symptoms of heart
failure. Your heart was not pumping as good as it should. We
used medications called diuretics (water pills) to help you pee
off this fluid. We monitored your weight to make sure that you
were peeing enough fluid to make you feel better.
Your discharge weight is 249lbs on our scale. Please weigh
yourself tomorrow morning without clothes on after you pee but
BEFORE you eat breakfast to see what the equivalent weight is on
your scale. You should weigh yourself every morning without
clothes on, after you pee but BEFORE you eat breakfast. If your
weight is ever more than 3 pounds above or below the weight on
the scale that first morning, please call your doctor.
On discharge, we made sure that you are taking the right
medications at the right doses. Please see below for an updated
list of your medications. It is very important that you take
these medications.
Please see below for follow up appointments. It is very
important that you go to these appointments.
We wish you the best with your ongoing recovery.
Sincerely,
Your ___ care team
Followup Instructions:
___
|
10688753-DS-5
| 10,688,753 | 27,148,791 |
DS
| 5 |
2161-09-10 00:00:00
|
2161-09-10 16:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
fall w/ difficulty walking
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female with metastatic breast cancer currently
treated with gemcitabine (just started C3 last week) presenting
with left hip pain. ___ has chronic pain most prominent in L
hip. States that prior to starting gemcitabine she had pain in
entire lower pelvic region and upper legs L>R due to bony mets.
She noted improvement since C2, at baseline was taking up to
1800mg ibuprofen daily. She did not have any fall or clear
provoking events other than going down the stairs, lifting a
basket of laundry and bending. But while she was doing this last
night she developed new onset of burning type pain in L hip. Did
not radiate, no numbness or tingling. Notes some lower back pain
but only if she pushes in that area and this is not new. She
tried taking ibuprofen and Tylenol with no relief, then took
Ativan to help sleep and came to ED in am. She was able to get
into the car and took wheelchair to get into ED.
No change in bowel movements, no incontinence. No HA, nausea,
fever/chills. no lightheadedness or syncope.
In ED she underwent CT pelvis that showed multiple pathologic
fractures involving L iliac wing and R and L sacral ala frx
received total of 7.5mg oxycodone and 2g Tylenol. 5mg oxycodone
caused some sedation. 2.5mg dose only took edge off but did not
diminish the pain. She has taken tramadol in the past which she
did not tolerate well due to nausea.
She was able to get up and slowly shuffle to bathroom bearing
weight while in ED that she feels is an improvement.
REVIEW OF SYSTEMS:
GENERAL: get low grade temp elevation after gemcitabine which
happened last ___ as typical w/ her cycles, none since. No
fever, chills, night sweats, recent weight changes.
HEENT: No mouth sores, odynophagia, sinus tenderness,
rhinorrhea,
or congestion.
CARDS: No chest pain, chest pressure, exertional symptoms, or
palpitations.
PULM: No cough, shortness of breath, hemoptysis, or wheezing.
GI: No nausea, vomiting, diarrhea, constipation or abdominal
pain. No hematochezia, or melena.
GU: No dysuria, hematuruia or frequency.
MSK: as above
DERM: Denies rashes, itching, or skin breakdown.
NEURO: No headache, visual changes, numbness, paresthesias,
focal
weakness, wears eye patch due to chronic R diplopia
HEME: No bleeding or clotting
Past Medical History:
PAST ONCOLOGIC HISTORY:
___ diagnosed with left breast cancer with a 1.2 cm moderately
differentiated ER positive, PR positive, HER 2/neu negative
tumor
with ___ positive, LN. She was treated with FEC chemotherapy
followed by a left MRM and a prophylactic right simple
mastectomy
and tamoxifen.
___ she reported discomfort in the sternal region. Bone scan
showed uptake in the sternum. A chest CT confirmed a mixed lytic
and sclerotic lesion in the sternum. Several 2 mm nodules in the
lungs were noted and on abd/pelvic CT there was a very small
sclerotic lesion in the L4 vertebral body. She had a CT guided
biospy of the sternal lesion in ___ which was nondiagnostic.
However her CA ___ and CEA were elvated consistent with
metastatic disease.
___ she began zometa as well as zoladex as she was still
menstruating on the tamoxifen
___ began letrozole (continued on zoladex and zometa)for
progression of pleural nodules and mediastinal LN
___ added exemestane for increased pleural nodules
___ started taxol 80 mg/m2 day 1,___ and 15 on a 28 day cycle
for new pleural nodules and pleural effusion
___ s/p thoracentesis
___ initiated treatment with navelbine 20 mg/m2
___ pleurex placed for reaccumulation, removed ___ seen in ___ opinion by Dr ___, switched to ___
___ palliative XRT to the sternum and left
clavicular head
___ discontinue ___ and initiated eribulin due to
progression of pulmonary, pleural, nodal and bone metastases
with
increasing right pleural disease and new hepatic mets on MRI
___ fractions of SRS to the right base of the
skull for a total of 3000 cGy for osseous metastases inc right
anterior clinoid impinging on the right optic nerve and
extension
into the right cavernous sinus
___ received 3 cycles of liposomal doxorubicin for
progressive bony dz
___ hospitalized with PJP pneumonia dx on bronch.
Also dx w/ central DI
___ liver biopsy at ___ showed metastatic carcinoma
consistent with breast origin. The tumor cells are strong and
diffusely positive for GATA-3, ER, PR and are negative for CK7.
HER 2/neu is negative by FISH. Also had progressive osseous mets
___ initiated treatment with faslodex and palbociclib
___ had tooth extracted due to osteonecrosis
___ her old portocath was removed and replaced with a new
right anterior chest wall portocath at the ___ without
incident.
___ switched treatment to gemcitabine for progressive bony
and
hepatic mets
Social History:
___
Family History:
She has a CHEK2 VUS has been reclassified as probably benign.
She
has had BRCA1 and BRCA2 testing in ___. At that time a variant
of uncertain significance in BRCA2 was found. This variant is
termed S326R. This variant has since been reclassified as having
no clinical significance. She has had ___ testing which was
negative. She has three maternal aunts who had breast cancer in
their ___, a maternal uncle with prostate cancer. Another
maternal uncle died at ___ from a brain tumor. Two other uncles
had cancer, one had leukemia at ___ and another,a smoker, had
lung
cancer. Ms. ___ maternal grandfather had lunge cancer and a
maternal great grandmother had breast cancer at ___. On her
paternal side her father and all of his brothers had prostate
cancer in their ___. Her paternal grandmother had ovarian
cancer at ___ and she reports a first cousin once removed had
breast cancer and another had stomach cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
===========================
Temp: 98.4 PO BP: 120/80 HR: 83 RR: 18 O2 sat: 98% O2 delivery:
RA
___ 2232 Dyspnea: 0 RASS: 0 Pain Score: ___
General: NAD, thin
HEENT: MMM, no OP lesions
Neck: supple, no JVD
Lymph: no cervical, supraclavicular, axillary or inguinal
adenopathy
CV: RR, NL S1S2 no S3S4 or MRG
PULM: CTAB nonlabored
ABD: BS slow, soft, NTND, no palpable mass
EXT: warm well perfused, no edema. Able to lift both legs off
bed and int/ext rotate, uses hands for support on L due to pain
SKIN: No rashes or skin breakdown. nontender over palpation of
spine. Points to L iliac region that is most painful
NEURO: alert and oriented x 4, ___, EOMI, no nystagmus, face
symmetric, R gaze deviation, sensation intact to light touch,
gait not assessed
DISCHARGE PHYSICAL EXAM
===========================
Temp: 98.4 PO BP: 102/66 HR: 65 RR: 18 O2 sat: 98% O2 delivery:
RA
Gen: lying on bed, no acute distress
Cardiac: RRR, no R/M/G
HEENT: PERRL
Lungs: CTAB, no R/R/W
Abd: S/NT/ND
Ext: WWP, no edema. Left hip tender to palpation without
overlying skin changes or warmth
Neuro: AAOX3, no pronator drift. Able to lift both legs off bed
though limited by pain.
Pertinent Results:
ADMISSION LABS
=======================
___ 03:42PM BLOOD WBC-3.1* RBC-2.89* Hgb-9.2* Hct-29.2*
MCV-101* MCH-31.8 MCHC-31.5* RDW-17.3* RDWSD-64.3* Plt ___
___ 03:42PM BLOOD Neuts-80.9* Lymphs-11.0* Monos-3.6*
Eos-2.9 Baso-1.0 Im ___ AbsNeut-2.49 AbsLymp-0.34*
AbsMono-0.11* AbsEos-0.09 AbsBaso-0.03
___ 03:42PM BLOOD ___ PTT-30.9 ___
___ 03:42PM BLOOD Glucose-196* UreaN-13 Creat-0.5 Na-140
K-4.1 Cl-106 HCO3-19* AnGap-15
___ 05:56AM BLOOD ALT-65* AST-78* AlkPhos-447* TotBili-0.3
RELEVANT IMAGING
=======================
___ CT PELVIS ORTHO WITHOUT CONTRAST
1. Diffuse osseous metastatic disease with acute fractures along
the left
iliac wing and right sacral ala. Smaller sites of fracture
noted involving the left sacral ala and adjacent to the left SI
joint in the left iliac bone.
2. 3.3 cm left adnexal lesion. If patient is postmenopausal,
consider
nonurgent pelvic ultrasound for further characterization.
___ CT CHEST WITH CONTRAST (compared to ___ CT chest;
awaiting impression when compared to ___ imaging in
Atrius)
Multifocal consolidation, left lung, predominantly upper lobe,
nature and
chronicity indeterminate. Under the appropriate circumstances
this could be radiation change or, on the other hand, acute
pneumonia.
New pleural nodulation, left major fissure, probably malignant,
despite
generalized improvement in the extent of left pleural thickening
and previous bilateral pleural effusions now minimal.
Generally blastic transformation of extensive osseous metastases
throughout the chest cage is usually an indication of treatment
impact. Nevertheless there has been mild to moderate loss of
height several thoracic vertebrae which may predict impending
more severe compression.
As before the most severe lytic involvement, in the manubrium
and sternal body have resisted blastic transformation and are
associated with extensive tumor involvement of the retrosternal
soft tissue, but this is entirely stable since ___.
At most 2 new right lung nodules, could be residual of previous
infection or, alternatively, metastases. No adenopathy or left
lung metastases.
___ CT ABDOMEN/PELVIS WITH AND WITHOUT CONTRAST
1. There has been interval hepatic volume loss and capsular
retraction, most likely treatment effect. The hepatic
metastasis have become more confluent, but appears fairly
similar in size compared to prior.
2. Extensive bony metastatic disease is again noted, however
there appears to have been osteoblastic transformation
suggesting treatment effect. Acute linear fractures of the
pelvis are again noted appearing similar compared to prior CT
pelvis done ___ and reference is made to that report.
3. Bilateral adnexal masses appear similar compared to prior
imaging. These could be better characterized with pelvic
ultrasound.
4. For chest findings reference is made to CT chest report of
the same date.
DISCHARGE LABS
=======================
___ 05:52AM BLOOD WBC-2.2* RBC-2.66* Hgb-8.7* Hct-26.6*
MCV-100* MCH-32.7* MCHC-32.7 RDW-17.3* RDWSD-61.9* Plt ___
___ 05:52AM BLOOD Neuts-55 ___ Monos-13 Eos-5 Baso-1
Myelos-4* NRBC-6.6* AbsNeut-1.21* AbsLymp-0.48* AbsMono-0.29
AbsEos-0.11 AbsBaso-0.02
___ 06:01AM BLOOD Glucose-84 UreaN-11 Creat-0.5 Na-140
K-4.5 Cl-106 HCO3-23 AnGap-11
___ 06:01AM BLOOD Calcium-8.4 Phos-3.5 Mg-2.1
Brief Hospital Course:
====================
PATIENT SUMMARY
====================
___ with h/o metastatic breast cancer since ___ currently
treated with gemcitabine, hypertension, central diabetes
insipidus, who presented to the ED with atrumatic acute on
chronic left hip pain, found to have pathologic fractures of the
left hip and right hip. Orthopedics deemed these nonoperative.
This admission, she was provided pain control for NSAIDs and
opioids with sufficient control. Radiation Oncology saw the
patient and mapped her, with plans to start radiation therapy at
___ on ___.
====================
TRANSITIONAL ISSUES
====================
[] Radiation therapy: The patient underwent radiation planning
this admission. She will start her radiation therapy on ___
at ___.
[] Pain control: We instructed the patient to wean ibuprofen
from 600mg TID standing to PRN after 1 week, starting on
___. Please follow up with patient regarding pain
medication use.
[] Bilateral adnexal masses: Seen on CT this admission,
measuring 36 mm in diameter on the left and 35 on the right.
Please evaluate further with a pelvic ultrasound if clinically
indicated.
[] Orthopedics follow-up: If the patient has persistent left hip
in 1 month, she may benefit from seeing the ___
clinic. She can call ___ to make an appointment.
====================
ACUTE ISSUES
====================
#Acute left hip pain
#Left pathologic iliac wing and sacral ___
#Right pathologic sacral ___
Patient with known bony metastases diffusely. Had been receiving
gemcitabine, was C3D4 on admission. Atraumatic. Ortho deemed
these nonoperative, can fully bear weight. For pain control,
gave one day of Toradol then standing ibuprofen 600mg TID with
PPI as prophylaxis, also standing Tylenol 2g daily. Also on
small doses of opioids as needed. Briefly on dextromethorphan as
adjuvant. Additionally with lidocaine patch with good effect.
Radiation Oncology saw the patient and mapped her for treatment,
which she will start on ___, at ___, and
will receive 5 fractions, with the last day on ___.
#Metastatic breast cancer
Diagnosed in ___. ER/PR+. Known mets to the bone diffusely and
liver. Been through multiple lines of treatment, most recently
on gemcitabine, was C3D4 on admission. Restaging CT was obtained
this admission. CT chest read was compared to patient's ___
imaging in the ___ system; the reading radiologists were
requested to compare the images to the patient's most recent CT
chest from ___ which is in the Atrius system. CT A/P
showed changes c/w treatment effect. She will see Dr. ___ to
consider additional systemic therapy.
====================
CHRONIC ISSUES
====================
#Central diabetes insipidus
Continued home desmopressin. Na normal this admission.
#Hypertension
Continued home atenolol.
#CODE STATUS: DNR/DNI
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Atenolol 25 mg PO QHS
3. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
4. Desmopressin Acetate 0.1 mg PO QHS
5. Desmopressin Acetate 0.05 mg PO QAM
Discharge Medications:
1. Docusate Sodium 200 mg PO BID
RX *docusate sodium 100 mg 2 tablet(s) by mouth twice a day Disp
#*120 Tablet Refills:*0
2. lidocaine 4 % topical DAILY for 12 out of 24 hours
Can use 3 patches on left hip.
RX *lidocaine [Lidocaine Pain Relief] 4 % apply up to 3 patches
onto left hip for 12 hours out of 24 Disp #*50 Patch Refills:*0
3. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q6H:PRN Pain -
Severe
5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
RX *polyethylene glycol 3350 17 gram/dose 1 dose by mouth twice
a day Refills:*0
6. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
7. Acetaminophen 500 mg PO Q6H
RX *acetaminophen 500 mg 1 tablet(s) by mouth every six (6)
hours Disp #*120 Tablet Refills:*0
8. Ibuprofen 600 mg PO Q8H
RX *ibuprofen 600 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*60 Tablet Refills:*0
9. Atenolol 25 mg PO QHS
10. Desmopressin Acetate 0.1 mg PO QHS
11. Desmopressin Acetate 0.05 mg PO QAM
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
#Pathologic fractures of bilateral hips secondary to bony
metastases
#Metastatic breast cancer
SECONDARY DIAGNOSES
#Central diabetes insipidus
#Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was our pleasure taking care of you at the ___
___!
WHAT BROUGHT YOU TO THE HOSPITAL?
- You had new left hip pain.
WHAT HAPPENED IN THE HOSPITAL?
- We found that you had suffered fractures in the pelvis due to
underlying breast cancer metastases. These fractures are
thankfully small.
- The Orthopedic Surgeons saw you and determined that you do not
need an operation for these fractures.
- The Radiation Oncologists saw you. They started planning for
radiation therapy to the bony metastases. This will help provide
pain control in the long term but will take a few weeks to work.
- You received pain control with medications and lidocaine
patches.
WHAT SHOULD YOU DO ONCE YOU LEAVE THE HOSPITAL?
- Please take your medications as prescribed and attend your
doctor's appointments.
- Please receive your radiation therapy at the ___
___ starting tomorrow, ___, at 3pm. The address is ___.
- For your pain medications, please use ibuprofen 600mg up to 3
times daily after only 1 more week. Starting on ___, please
try to use the ibuprofen only up to 600mg twice daily. For
Tylenol, you can use up to 2g daily.
We wish you all the best,
Your ___ Care Team
Followup Instructions:
___
|
10688859-DS-10
| 10,688,859 | 23,772,038 |
DS
| 10 |
2179-11-05 00:00:00
|
2179-11-08 13:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with a history of pAF (on apixaban), CAD (s/p stent
___, CVA, CKD (baseline Cr 1.7-1.8) and non-insulin dependent
type 2 DM who presented with weakness. On ___ felt
abdominal "discomfort, not pain" and like he was "not himself."
Was also feeling weak. Went to ___, where he
reports some medications were changed (cannot provide details)
but no interventions. Discharge summary notes he was found to be
in Afib with RVR and had ___ with hyperkalemia. Given IVF, IV
Lasix, albuterol in ER at ___. Dilt increased to 240 and metop
XL increased to 100 daily for rate control. Glipizide dose
lowered. Dc'd metformin and losartan. Rec'd kayexalate for
hyperK. He was discharged on ___, felt well ___, then weak
again so came to ED here ___ evening.
In the ED, initial VS were 98.5 88 171/87 20 99% RA. Exam
notable for "shuffling gait, strength intact, no dizziness on
standing, chornic left hand tremor." Labs notable for BUN 48, Cr
2.1 from baseline 1.7, WBC count 13. CXR and CT head with no
acute process. EKG showing afib. Received unclear amount of
IVFs, and repeat BMP showed BUN 37, Cr 1.7. Decision made to
admit to medicine.
On the floor, the patient feels well and denies CP, SOB,
abdominal pain, n/v, constipation, bloody stool. Had one loose
stool 11am today.
REVIEW OF SYSTEMS:
per above
Past Medical History:
Atrial fibrillation
CAD s/p stent ___
stroke
diabetes, not on insulin
hypertension
hyperlipidemia
CKD b/l Cr 1.7-1.8
hypothyroidism
gout
Social History:
___
Family History:
denies any significant family history
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.5 PO 144/80 L Lying 83 16 98 Ra
GENERAL: NAD, pleasant, responding appropriately
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
moist oral mucosa. seborrheic keratosis on forehead
NECK: supple neck, no JVD
HEART: regular rate, irregular rhythm, no murmurs, rubs or
gallops, normal S1/S2
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no ___ edema, moving all 4 extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: grossly intact
SKIN: no significant rash
DISCHARGE PHYSICAL EXAM:
VS: 97.6 PO 160 / 74 74 18 96 Ra
GENERAL: NAD, pleasant, responding appropriately
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
moist oral mucosa. seborrheic keratosis on forehead
NECK: Neck veins flat sitting upright
HEART: RRR, no m/r/g
LUNGS: CTAB
ABDOMEN: Soft, NT/ND, BS+
EXTREMITIES: no ___ edema whatsoever, moving all 4 extremities
with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: grossly intact
SKIN: no significant rash
Pertinent Results:
LABS
----
___ 08:20PM BLOOD WBC-13.1* RBC-3.46* Hgb-11.1* Hct-32.3*
MCV-93 MCH-32.1* MCHC-34.4 RDW-12.6 RDWSD-42.6 Plt ___
___ 05:08AM BLOOD WBC-11.6* RBC-3.71* Hgb-12.0* Hct-34.5*
MCV-93 MCH-32.3* MCHC-34.8 RDW-12.8 RDWSD-43.3 Plt ___
___ 08:20PM BLOOD Neuts-78.9* Lymphs-7.6* Monos-7.0 Eos-5.4
Baso-0.4 Im ___ AbsNeut-10.32*# AbsLymp-1.00*
AbsMono-0.92* AbsEos-0.70* AbsBaso-0.05
___ 08:20PM BLOOD Plt ___
___ 08:20PM BLOOD Glucose-209* UreaN-48* Creat-2.1* Na-137
K-4.4 Cl-105 HCO3-19* AnGap-17
___ 10:40AM BLOOD Glucose-183* UreaN-37* Creat-1.7* Na-139
K-5.1 Cl-105 HCO3-19* AnGap-20
___ 05:08AM BLOOD Glucose-122* UreaN-39* Creat-1.8* Na-135
K-4.6 Cl-102 HCO3-22 AnGap-16
___ 10:40AM BLOOD CK-MB-2 cTropnT-<0.01
___ 12:05AM BLOOD CK-MB-2 cTropnT-<0.01
___ 10:40AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.0
STUDIES
-------
-EKG: afib
CXR ___:
IMPRESSION:
Findings suggest aspiration/aspiration pneumonia. Suspected
associated mild
pulmonary edema.
-CT head ___:
IMPRESSION:
1. No definite evidence of acute intracranial hemorrhage or
acute large
territorial infarct. Please note MRI of the brain is more
sensitive for the
detection of acute infarct.
2. Left basal ganglia probable calcification, as described. If
continued
concern for acute intracranial hemorrhage, consider short-term
followup
imaging.
3. Atrophy, probable small vessel ischemic changes, and
atherosclerotic
vascular disease as described.
-CXR ___: no acute process. ?atelectasis at L base
-Renal US ___ at ___: mild b/l renal cortical atrophy. no
hydronephrosis or renal calculus.
-TTE ___ at ___: LVEF 60%, no RWMAs, RV systolic function nml.
atria normal sized. increased septal thickness. no aortic
stenosis or regurg. mild MR. ___ TR. no pericardial effusion.
Brief Hospital Course:
___ yo M with history of paroxysmal A fib, CAD s/p stenting in
___, CKD (baseline Cr 1.7-1.8) and NIDDM type 2 admitted with
___ was likely pre-renal, as it resolved with IV fluid
resuscitation. Patient did have an episode of shortness of
breath that was likely related to pulmonary edema from receiving
IV fluids vs possible aspiration pneumonitis. He was treated
with nebulizers and IV Lasix with improvement in his symptoms.
He had a leukocytosis that was attributed to stress response and
possible aspiration pneumonitis. Pt was continued on all of his
home medications for his chronic issues. No major changes were
made to his medication regimen, and he was discharged with an
albuterol inhaler for wheezing as needed
TRANSITIONAL ISSUES
===================
- Please check chemistry panel at next PCP appointment to ensure
that patient is staying adequately hydrated
#CODE: full confirmed
#CONTACT: 1. daughter ___ ___. 2. son ___
___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Apixaban 2.5 mg PO BID
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Vitamin D 1000 UNIT PO DAILY
6. Cyanocobalamin 1000 mcg PO DAILY
7. Diltiazem Extended-Release 240 mg PO DAILY
8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
9. Levothyroxine Sodium 100 mcg PO DAILY
10. Metoprolol Succinate XL 100 mg PO DAILY
11. GlipiZIDE XL 2.5 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
RX *albuterol sulfate [Ventolin HFA] 90 mcg 2 puffs PO q4 Disp
#*1 Inhaler Refills:*3
2. Space Chamber Plus (inhalational spacing device) 1
miscellaneous Q6H:PRN
RX *inhalational spacing device [BreatheRite MDI Spacer] Use
with albuterol inhaler PRN Disp #*1 Cartridge Refills:*0
3. Allopurinol ___ mg PO DAILY
4. Apixaban 2.5 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Cyanocobalamin 1000 mcg PO DAILY
8. Diltiazem Extended-Release 240 mg PO DAILY
9. GlipiZIDE XL 2.5 mg PO DAILY
10. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
11. Levothyroxine Sodium 100 mcg PO DAILY
12. Metoprolol Succinate XL 100 mg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Acute kidney injury on chronic kidney disease
Atrial fibrillation
Leukocytosis
Hypoxemia
SECONDARY DIAGNOSES:
Coronary artery disease
Hypertension
Diabetes mellitus
Hypothyroidism
Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were seen at ___ for weakness.
WHILE YOU WERE IN THE HOSPITAL
-Your labs showed a reversible decrease in kidney function. We
think this was from dehydration. Your kidney function improved
with IV fluids.
-We continued the medications to control your heart rate for
atrial fibrillation
-You had a high white blood cell count that improved without
intervention. You had no signs of infection.
-You also had an episode where you became short of breath and
had lower levels of oxygen in your blood. You improved with
breathing treatments and medicine to pull fluid out of your
lungs. You also had a chest x-ray that showed that this could
have been from food or liquid passing into your lungs during
swallowing.
WHAT YOU SHOULD DO NOW
-We did not change any medications here. Please note that your
medications were changed earlier in the week at ___
___.
-Be sure to stay hydrated.
-Please take your metoprolol and diltiazem at different times of
the day so that your blood pressure does not drop too low
Followup Instructions:
___
|
10688859-DS-11
| 10,688,859 | 24,657,736 |
DS
| 11 |
2179-12-19 00:00:00
|
2179-12-19 17:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
"Feel lousy"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M ___ CAD, CVA, Afib on Apixiban presenting feeling
unwell. Endorses having "no energy" since yesterday with SOB and
missed this morning's doses of medications. Pt is unsure if
feeling lousy brought on the Afib or Afib brought on the sx's of
malaise. Pt and family state that this "feeling lousy" and SOB
has been worsening over the past few months, when the patient
has been in the hospital multiple times for evaluation of the A
fib. Denies CP, coughs, fevers, dysuria, changes to urine,
hematuria, or receiving the flu shot.
Pertinent ED course (including exam, labs, imaging, consults,
treatment):
- 500ml NS
- Meds: IV Diltzaem 10 mg bolus x3 and 30 mg PO x3, ceftriaxone
1 g,
REVIEW OF SYSTEMS: per HPI
Past Medical History:
Atrial fibrillation
CAD s/p stent ___
stroke
diabetes, not on insulin
hypertension
hyperlipidemia
CKD b/l Cr 1.7-1.8
hypothyroidism
gout
Social History:
___
Family History:
denies any significant family history
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VITALS: 98.9 PO, 191 / 83, 125, 18, 96 Ra
GENERAL: NAD, talkative man resting comfortably in bed
EYES: PERRL, EOMI, pink conjunctiva
ENT: trachea midline, no JVD, no JVP elevation, no swollen
lymph nodes
CV: irregularly irregular, no m/r/g, +1 b/l pedal pulses
RESP: b/l CTAB, no ronchi, wheezes, or crackles; shallow
breathing w/o recruitment of accessory muscles
GI: +BS, nonrigid, nondistended, and nontender to palpation
GU: deferred
MSK: moving all extremities appropriately
SKIN: no rashes or lesions
NEURO: CN II-XII grossly intact, moving all extremities
appropriately
PSYCH: affect, mood, and thought content appropriate
DISCHARGE PHYSICAL EXAM:
=========================
VS: 97.4 PO 154 / 86 69 18 96
Telemetry: Atrial fibrillation
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, pink conjunctiva
NECK: nontender supple neck, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Mild crackles in bilateral bases bilaterally, appears
mildly short of breath.
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, R arm has a fistula
in place. L arm has developing fistula.
PULSES: 2+ DP pulses bilaterally
NEURO: no gross motor or coordination abnormalities
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
=======================
___ 08:42AM URINE HOURS-RANDOM
___ 08:42AM URINE UHOLD-HOLD
___ 08:42AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 08:42AM URINE BLOOD-SM* NITRITE-NEG PROTEIN-600*
GLUCOSE-150* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM*
___ 08:42AM URINE RBC-1 WBC-45* BACTERIA-FEW* YEAST-NONE
EPI-1
___ 08:42AM URINE HYALINE-___ 08:42AM URINE MUCOUS-RARE*
___ 07:45AM GLUCOSE-199* UREA N-38* CREAT-1.6* SODIUM-139
POTASSIUM-5.6* CHLORIDE-110* TOTAL CO2-16* ANION GAP-19
___ 05:45AM GLUCOSE-234* UREA N-39* CREAT-1.8* SODIUM-138
POTASSIUM-5.2* CHLORIDE-105 TOTAL CO2-16* ANION GAP-22*
___ 05:45AM estGFR-Using this
___ 05:45AM cTropnT-<0.01
___ 05:45AM WBC-16.9* RBC-4.24* HGB-13.4* HCT-40.3 MCV-95
MCH-31.6 MCHC-33.3 RDW-14.2 RDWSD-49.2*
___ 05:45AM NEUTS-89.1* LYMPHS-3.6* MONOS-5.4 EOS-0.9*
BASOS-0.3 IM ___ AbsNeut-15.02* AbsLymp-0.61*
AbsMono-0.91* AbsEos-0.15 AbsBaso-0.05
___ 05:45AM PLT COUNT-237
___ 05:45AM ___ PTT-31.3 ___
PERTINENT LABS:
=======================
___ 07:45AM BLOOD WBC-13.4* RBC-3.64* Hgb-11.4* Hct-34.8*
MCV-96 MCH-31.3 MCHC-32.8 RDW-14.0 RDWSD-48.9* Plt ___
___ 07:20AM BLOOD WBC-13.5* RBC-3.57* Hgb-11.5* Hct-33.5*
MCV-94 MCH-32.2* MCHC-34.3 RDW-14.0 RDWSD-47.8* Plt ___
___ 07:10AM BLOOD WBC-10.8* RBC-3.41* Hgb-10.8* Hct-32.1*
MCV-94 MCH-31.7 MCHC-33.6 RDW-13.8 RDWSD-46.9* Plt ___
___ 12:10AM BLOOD Glucose-169* UreaN-39* Creat-1.7* Na-137
K-4.9 Cl-107 HCO3-17* AnGap-18
___ 07:20AM BLOOD Glucose-170* UreaN-40* Creat-1.7* Na-138
K-4.3 Cl-105 HCO3-17* AnGap-20
___ 07:10AM BLOOD Glucose-136* UreaN-42* Creat-1.8* Na-136
K-4.1 Cl-103 HCO3-19* AnGap-18
___ 07:45AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.0
___ 07:20AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.2
___ 07:10AM BLOOD Calcium-8.1* Phos-3.1 Mg-2.2
___ 07:45AM BLOOD proBNP-4309*
___ 05:45AM BLOOD cTropnT-<0.01
DISCHARGE LABS:
========================
___ 07:30AM BLOOD WBC-9.7 RBC-3.89* Hgb-12.2* Hct-36.9*
MCV-95 MCH-31.4 MCHC-33.1 RDW-13.9 RDWSD-48.6* Plt ___
___ 07:30AM BLOOD Plt ___
___ 07:30AM BLOOD Glucose-150* Creat-1.7* Na-136 K-3.8
Cl-100 HCO3-21* AnGap-19
___ 07:30AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.3
MICROBIOLOGY:
========================
___: URINE CULTURE (Final ___:
ESCHERICHIA COLI. 10,000-100,000 CFU/mL.
Pan-susceptible.
PERTINENT IMAGING:
========================
___ CXR: Mild pulmonary edema.
___ CXR: Interval worsening mild to moderate pulmonary edema.
Brief Hospital Course:
Mr. ___ is an ___ male with a past medical history of
atrial fibrillation with rapid ventricular rate on apixaban,
CAD, and CVA who presented with shortness of breath and malaise
likely due to symptomatic Afib w/ RVR with mild pulmonary edema.
ACUTE ISSUES:
============================
#Afib w/ RVR on apixaban (CHA2DS2-VASc 7): The etiology is
unclear given that patient endorses medication compliance and
denies any acute precipitating event. A possible source is that
the patient had a positive urine culture (discussed below) but
was asymptomatic and afebrile. Of note, patient has been
evaluated multiple times by cardiology with echocardiogram last
month, and the treatment plan was to treat atrial fibrillation
with medical management. During hospital course, the patient had
two episodes of rapid ventricular rate with HR to 170s, but each
episode was terminated successfully with 15mg IV diltiazem. He
was maintained on home regimen of Apixiban 2.5 mg PO BID. Rate
control medication dosages were increased: Patient was
discharged on 360mg diltiazem ER daily and 150mg metoprolol XL
daily. ___ cardiology team was notified of patient's
admission and planned to consider DCCV as outpatient
#Shortness of breath: Patient had trace pulmonary edema on CXR
upon admission. This was thought likely a component of flash
pulmonary edema in setting of atrial fibrillation and fluid
resuscitation. He did not appear volume-overloaded but was
gently diuresed with 2 x 40mg IV Lasix and had improvement in
shortness of breath. He was instructed on warning signs for
increased weight gain, edema, and shortness of breath.
#Positive urinalysis and culture: Patient was overall
asymptomatic without fevers but had leukocytosis on
presentation. Infection could be trigger for atrial
fibrillation, so patient was treated with 10-day course of
antibiotics (ceftriaxone) and discharged with Keflex for
completion on ___.
#HTN: Patient was hypertensive to 190s upon admission, likely
due to not having taken home antihypertensives on the day of
admission. Hypertension improved with better control of atrial
fibrillation. Maintained on isosorbide dinirate 20 mg PO TID
(fractionated from imdur 60) and metoprolol (see above)
CHRONIC ISSUES:
=========================
#CAD: Patient has a remote history of MI and had stent placement
in about ___. After stent placement, EF was 65% with left
atrial enlargement and normal RV size and function. He has
severe disease of his LAD noted by catheterization at ___ in
___ that is not appealing for percutaneous or surgical
revascularization. Last ECHO in ___ showed mild regional
dysfunction. Maintained on home aspirin 81 mg PO DAILY and
Atorvastatin 80 mg PO QPM.
#CKD (baseline 1.7-1.8): Likely secondary to T2DM. Patient was
admitted w/ Cr 1.6, which remained stable for duration of
hospitalization.
#Gout: Maintained on home allopurinol ___ mg PO DAILY
#T2DM, non insulin-dependent: Home meds were held, and patient
was started on sliding scale insulin.
#Hypothyroidism: Maintained on home Levothyroxine Sodium 100 mcg
PO DAILY
TRANSITIONAL ISSUES:
=========================
[ ] Change in medication dose: diltiazem 240mg daily to 360mg
daily and metoprolol from 100mg daily to 150mg daily
[ ] Patient instructed to weigh himself daily and bring
measurements to doctor's appointments.
[ ] Monitor fluid status as outpatient
[ ] Consider antihypertensive medications such as ACE-inhibitor
as an outpatient, given that patient had elevated SBP to
150s-160s during admission on home meds
[ ] Patient should complete 10-day antibiotic course on ___
[ ] Outpatient discussion of possible ___ for atrial
fibrillation with cardiologist
>30 minutes spent on discharge planning
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. albuterol sulfate unknown oral Q4H:PRN
2. MetFORMIN (Glucophage) 500 mg PO DAILY
3. Allopurinol ___ mg PO DAILY
4. Apixaban 2.5 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Diltiazem Extended-Release 240 mg PO DAILY
8. GlipiZIDE 2.5 mg PO DAILY
9. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
10. Levothyroxine Sodium 100 mcg PO DAILY
11. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Medications:
1. Cephalexin 250 mg PO Q8H Duration: 7 Days
RX *cephalexin 250 mg 1 tablet(s) by mouth three times a day
Disp #*18 Tablet Refills:*0
2. Diltiazem Extended-Release 360 mg PO DAILY
Please start this medication on ___.
RX *diltiazem HCl 360 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
3. Metoprolol Succinate XL 150 mg PO DAILY
Please start this medication on ___.
RX *metoprolol succinate 100 mg 1.5 tablet(s) by mouth once a
day Disp #*45 Tablet Refills:*0
RX *metoprolol succinate [Toprol XL] 50 mg 3 tablet(s) by mouth
daily Disp #*90 Tablet Refills:*0
4. Allopurinol ___ mg PO DAILY
5. Apixaban 2.5 mg PO BID
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. GlipiZIDE 2.5 mg PO DAILY
9. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
10. Levothyroxine Sodium 100 mcg PO DAILY
11. MetFORMIN (Glucophage) 500 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
=========================
Atrial fibrillation with rapid ventricular rate
SECONDARY DIAGNOSIS:
==========================
Mild pulmonary edema
Urinary tract infection
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
WHY WERE YOU ADMITTED?
- You were admitted due to shortness of breath and feeling
lousy.
WHAT WAS DONE FOR YOU IN THE HOSPITAL?
- You were diagnosed with an abnormal and very fast heart rhythm
called atrial fibrillation with rapid ventricular rate.
- The doses of your medications were increased to control your
abnormal heart rhythm.
- We also gave you some medication to help with some extra fluid
in your lungs. This helped you breathe better.
WHAT SHOULD YOU DO WHEN YOU GET HOME?
- New medication: Keflex for your urine infection.
- It is important to take your medications as prescribed. The
doses of your medications, metoprolol and diltiazem, have been
increased.
- Weigh yourself daily. If you gain more than 3lbs in 1 day or
5lbs in 1 week, please call your primary care doctor and
cardiologist.
- If you have shortness of breath, please call your primary care
doctor or cardiologist immediately.
- We did not prescribe another albuterol inhaler because it is
unclear whether you need it. You do not have a history of
asthma.
- We will notify your PCP and cardiologist that you have been
discharged from the hospital. Please call your PCP ___
(___) and cardiologist Dr. ___ (___) to
see them in ___ weeks.
It was a pleasure taking care of you!
- Your ___ Team
Followup Instructions:
___
|
10688859-DS-9
| 10,688,859 | 22,250,100 |
DS
| 9 |
2179-08-14 00:00:00
|
2179-08-14 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:
Afib to 140s with no symptoms
Major Surgical or Invasive Procedure:
Left heart catheterization (___)
History of Present Illness:
___ w/ pAF (on Apixaban), CAD (s/p stent ___, stroke, T2DM,
HTN, HLD who transferred with Afib w/ RVR and NSTEMI.
Pt was scheduled for colonoscopy today. He was supposed to stop
his Apixaban 3 days beforehand (last day ___. He decided
to hold all of his medications (rather than just holding
Apixaban). He presented for colonoscopy and was found to be in
atrial fibrillation with a rapid ventricular rate of 140s. Labs
notable for TropT of 0.72. Given 500cc IV fluids, 20mg
diltiazem with improvement in heart rate to ___. Given 120mg
diltiazem ER, Aspirin 324mg, lovenox 80mg (given @1330).
Transferred to ___ ER for further management.
In the ED initial vitals were: 98.6 94 160/90 18 96% RA
- EKG: afib w/ rate 112, non-specific ST-T wave changes, no STE
- Labs/studies notable for: Cr 1.6 (at baseline), Phos 1.9, H/H
12.8/38.7 (normal hgb at baseline), TropT 1.32
- CXR nl
- Patient was given: metoprolol 5mg IV, metop XL 25mg,
pantoprazole 40mg PO, Atorvastatin 80mg
- Seen by cardiology who recommended aspirin, home beta blocker,
heparin gtt to start 12 hours after last lovenox dose,
atorvastatin 80mg daily and NPO after MN for possible cath in
the morning
On the floor, VS: 97.6 158/88 95 18 97RA
Pt reports that he has been feeling well in his usual state of
health without any recent symptoms. He denies any chest pain or
palpitations. No shortness of breath. No PND, orthopnea,
edema.
Past Medical History:
He has a history of an MI and he is status post
coronary angioplasty and stenting in the past. He has a history
of hypertension. He has had type 2 diabetes for several years.
He also has a history of gout.
Social History:
___
Family History:
No family history of cardiac disease.
Physical Exam:
Admission physical exam:
===================
VS: 98.6 94 160/90 18 96% RA
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. No JVD
CARDIAC: Irregular. Normal S1, S2. No murmurs, rubs, or gallops.
No thrills or lifts.
LUNGS: Respiration is unlabored with no accessory muscle use. No
crackles, wheezes or rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
NEURO: CN II-XII intact, moving all four extremities
Discharge physical exam:
=======================
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. No JVD
CARDIAC: Regular. Normal S1, S2. No murmurs, rubs, or gallops.
No thrills or lifts.
LUNGS: CTAB with no crackles
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
NEURO: CN II-XII intact, moving all four extremities
Pertinent Results:
Admission labs:
============
___ 03:40PM BLOOD WBC-9.7 RBC-4.09* Hgb-12.8* Hct-38.7*
MCV-95 MCH-31.3 MCHC-33.1 RDW-13.5 RDWSD-47.4* Plt ___
___ 03:40PM BLOOD Neuts-67.7 Lymphs-14.0* Monos-8.6
Eos-8.7* Baso-0.6 Im ___ AbsNeut-6.54* AbsLymp-1.35
AbsMono-0.83* AbsEos-0.84* AbsBaso-0.06
___ 03:40PM BLOOD Plt ___
___ 03:40PM BLOOD Glucose-222* UreaN-28* Creat-1.6* Na-141
K-3.9 Cl-106 HCO3-22 AnGap-17
___ 03:40PM BLOOD CK(CPK)-494*
___ 03:40PM BLOOD CK-MB-35* MB Indx-7.1* proBNP-6168*
___ 03:40PM BLOOD Calcium-8.7 Phos-1.9* Mg-2.1
Discharge labs:
===========
___ 06:00AM BLOOD WBC-9.0 RBC-3.74* Hgb-11.7* Hct-35.4*
MCV-95 MCH-31.3 MCHC-33.1 RDW-13.3 RDWSD-46.0 Plt ___
___ 06:00AM BLOOD Glucose-158* UreaN-35* Creat-1.7* Na-141
K-4.7 Cl-106 HCO3-22 AnGap-18
___ 06:00AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.1
Diagnostics:
==========
Left heart catheterization
Dominance: Right
No coronary stents seen on fluoroscopy.
* Left Main Coronary Artery
The LMCA is normal.
* Left Anterior Descending
The LAD is diffusely diseased in mid and distal segments with 5
separate stenoses ranging from 70-
90%.
The ___ Diagonal is a large vessel with 80% ___ and 70% mid
stenoses.
* Circumflex
The Circumflex has mild irregularities.
The ___ Marginal is 100% occluded ,and fills distally via
collaterals (from both right and left coronaries).
* Right Coronary Artery
The RCA has mild irregularities.
The Right PDA has a 30% ___ stenosis
Intra-procedural Complications: None
Impressions:
2 vessel CAD.
Recommendations
Since patient is asymptomatic and LAD/D1 have diffuse disease
would recommend treat medically.
Dr ___ CT surgery reviewed angiogram - LAD is
clearly not a suitable target for CABG.
If significant angina symptoms could consider targeted PCI
procedure, although poor outflow from distal
LAD disease could be problematic.
Echo:
The left atrium is moderately dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). No atrial septal defect is seen by 2D or
color Doppler. The estimated right atrial pressure is ___ mmHg.
Left ventricular wall thicknesses and cavity size are normal.
There is mild regional left ventricular systolic dysfunction
with hypokinesis of the mid-lateratl wall. (clips 34, 35) The
remaining segments contract normally (LVEF = 50 %). The
estimated cardiac index is normal (>=2.5L/min/m2). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened (?#). There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity size with mild regional systolic dysfunction in a
somewhat atypical location c/w diagonal/OM disease or focal
myocarditis. Moderate mitral regurgitation. Moderate pulmonary
artery systolic hypertension.
Brief Hospital Course:
___ year old male with atrial fibrilation on apixaban, coronary
artery disease, stroke, diabetes, hypertension, hyperlipidemia
who was transferred with AFIB with RVR and elevated trop. On
presentation, patient reported he stopped taking his medications
for a few days. Endorsed no palpitations, shortness of breath,
chest pain. EKG with afib w/ RVR, trop 1.32, 1.34, 1.14. Echo:
Normal left ventricular cavity size with mild regional systolic
dysfunction in a somewhat atypical location c/w diagonal/OM
disease or focal myocarditis. Moderate mitral regurgitation.
Moderate pulmonary artery systolic hypertension, EF 50%. LHC
with:
* Left Main Coronary Artery
The LMCA is normal.
* Left Anterior Descending
The LAD is diffusely diseased in mid and distal segments with 5
separate stenoses ranging from 70-90%.
The ___ Diagonal is a large vessel with 80% ___ and 70% mid
stenoses.
* Circumflex
The Circumflex has mild irregularities.
The ___ Marginal is 100% occluded ,and fills distally via
collaterals (from both right and left coronaries).
* Right Coronary Artery
The RCA has mild irregularities.
The Right PDA has a 30% ___ stenosis.
Patient was optimized on medical management with changes to
medications below given extensive LAD disease not amenable to
PCI. Of note, course complicated by hypertensive emergency with
flash pulmonary edema in the setting of pre contrast IV
hydration. Patient was given NTG drip, morphine, labetolol 10mg,
hydralazine 10mg, 20IV lasix x3 for treatment. He required a
___ mask at 50% for a few hours and then was weaned off of
supplemental oxygen. He was kept an extra day as his HR were too
high with afib/ aflutter. Patient now at baseline on discharge
and rate well controlled.
Transitional issues:
1. Apixiban dose change from 5mg BID to 2.5mg BID in the setting
of chronic kidney disease. Recommend TEE before cardioverting as
an outpatient
2. New medications: diltiazem ER 180mg daily, Imdur 60mg daily,
metoprolol succinate 50 mg daily
3. Follow up with cardiology for optimal medical management.
Triple therapy deferred in his case due to risk of bleeding
4. Discharged on ___ event monitor to assess for
conversion pauses. Data can be reviewed at next outpt
cardiologist appointment.
5. Consider TEE/___ as outpatient if ongoing issues with AF.
Code: Full
Contact: ___ (daughter) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Apixaban 5 mg PO BID
4. MetFORMIN (Glucophage) 500 mg PO BID
5. GlipiZIDE XL 10 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Losartan Potassium 50 mg PO DAILY
8. Levothyroxine Sodium 100 mcg PO DAILY
9. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Diltiazem Extended-Release 180 mg PO DAILY
RX *diltiazem HCl 180 mg 1 tablet(s) by mouth once per day Disp
#*30 Tablet Refills:*0
2. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
RX *isosorbide mononitrate 60 mg 1 tablet(s) by mouth once per
day Disp #*30 Tablet Refills:*0
3. Apixaban 2.5 mg PO BID
RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice per day
Disp #*60 Tablet Refills:*0
4. Allopurinol ___ mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. GlipiZIDE XL 10 mg PO DAILY
8. Levothyroxine Sodium 100 mcg PO DAILY
9. Losartan Potassium 50 mg PO DAILY
10. MetFORMIN (Glucophage) 500 mg PO BID
11. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
=============
Type 2 NSTEMI
Atrial Fibrillation
Hypertensive emergency
Secondary diagnosis
===================
Chronic Kidney Disease
Diabetes Mellitus
Gout
Hypertension
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you here at ___
___.
You were admitted because your heart was beating fast. An EKG
was done of your heart which showed a fast irregular heart rate.
Your troponin level was elevated, a marker that often indicates
a heart attack, so a catheterization was done. There were
significant blockages in one of your heart arteries that we are
treating medically.
Your hospital course was complicated by high blood pressure
causing fluid to back up into your lungs. We gave you lasix to
help you urinate out that extra fluid and blood pressure
medications to bring your pressures down. You recovered very
well. We've added a few more medications to your regimen to help
maintain your blood pressure and heart rate. We are also sending
you with a heart monitor to monitor your heart rates when you
leave the hospital. Please follow up with your cardiologist if
you start to experience any symptoms such as dizziness or
lightheadedness.
Please ask the nurse prior to discharge to review your
medications and what they look like in the event you are
instructed to stop taking a specific medication.
We are happy to see you feeling better.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10689134-DS-4
| 10,689,134 | 29,357,439 |
DS
| 4 |
2141-12-11 00:00:00
|
2141-12-12 14:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa(Sulfonamide Antibiotics) / Latex / Iodinated Contrast
Media - IV Dye
Attending: ___
Chief Complaint:
LGIB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/complaint of bloody stools since this AM x4. Patient
thinks she has probably been bleeding for a few days, as she has
had vague abdominal discomfort and bloating for a few days.
However, only noticed blood in stool today. Most recent BM (~8PM
___ had frank red blood, filling up the toilet bowel (about
one medium sized bottle of coke). Denies dark stools, maroon
stools. Patient nauseous for a few months. No vomiting. Patient
on a bowel regimen including miralax for constipation. Patient
is not on blood thinners. No fevers, no chills. Hx of complete
hysterectomy. Patient now incontinent of stool since yesterday.
Patient denies history of colon cancer and has always been up
to date with her colonoscopies. She last had one in ___ which
was difficult due to large bowel loops but did show diverticula
(per GI note).
Patient endorses SOB but this is chronic for her; no chest pain
or leg swelling. Endorses mild abdominal tenderness and nausea.
In the ED, initial vitals: 97.6 87 ___ 98% RA
Labs were significant for wbc 11, hgb 10, sodium 129
Exam pertinent for: rectal: frank red blood, no hemorrhoids
In the ED, she received tramadol 100 mg
Vitals prior to transfer: 98.0 78 107/65 17 100%
Past Medical History:
BACK PAIN
HYPERPARATHYROIDISM
ARTHRITIS
ESSENTIAL TREMORS
Social History:
___
Family History:
No history of colon cancer. No history of MI. Other cancers, but
does not recall which.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 98.1 122 / 70 77 18 97% RA
GEN: Alert, lying in bed, no acute distress; pleasant
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD, flat JV
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, mildly-tender with deep palpation, non-distended
EXTREM: Warm, well-perfused, no edema
NEURO: CN II-XII grossly intact, motor function grossly normal
Discharge
----------------
VITALS: 98.3
PO 147 / 75 73 20 99 RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MM dry, oropharynx clear, TTP along
the right TMJ area.
NECK: Supple, JVP not elevated, no LAD
RESP: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
ABD: +BS, soft, nondistended, TTP in the LLQ and under the
ribcage bilaterally. No hepatomegaly.
GU: no foley
EXT: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: CNs2-12 intact, motor function grossly normal
Pertinent Results:
Admission
----------------
___ 08:25PM K+-3.9
___ 08:10PM GLUCOSE-95 UREA N-18 CREAT-0.8 SODIUM-139
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-22 ANION GAP-16
___ 08:10PM estGFR-Using this
___ 08:10PM WBC-9.5 RBC-3.47* HGB-10.0* HCT-30.8* MCV-89
MCH-28.8 MCHC-32.5 RDW-14.2 RDWSD-45.3
___ 08:10PM PLT COUNT-261
___ 05:16PM GLUCOSE-87 NA+-129* K+-GREATER TH CL--104
TCO2-20*
___ 05:16PM HGB-11.3* calcHCT-34
___ 03:45PM VoidSpec-UNABLE TO
___ 03:45PM WBC-11.4* RBC-3.62* HGB-10.3* HCT-32.4*
MCV-90 MCH-28.5 MCHC-31.8* RDW-15.2 RDWSD-48.1*
___ 03:45PM NEUTS-76.7* LYMPHS-15.5* MONOS-6.5 EOS-0.5*
BASOS-0.4 IM ___ AbsNeut-8.71* AbsLymp-1.76 AbsMono-0.74
AbsEos-0.06 AbsBaso-0.05
___ 03:45PM PLT COUNT-282
___ 03:45PM ___ PTT-30.5 ___
Imaging
-------------
Final Report
EXAMINATION: CT Colonography
INDICATION: ___ year old woman with ___ year old female with
history of
hyperparathyroidism, spinal stenosis who presents with bright
red blood per
rectum x 1 day with LLQ pain on palpation. She also has 20 lb
weight loss over
4 months. // Please assess for malignancy.
TECHNIQUE: Axial contiguous slices were obtained from the lung
bases to the
pubis symphysis after insufflation of intrarectal air in the
prone and supine
positions. Intravenous contrast was not administered.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 1.5 s, 18.0 cm; CTDIvol = 0.6 mGy
(Body) DLP =
11.4 mGy-cm.
2) Spiral Acquisition 5.2 s, 40.6 cm; CTDIvol = 2.0 mGy
(Body) DLP = 80.3
mGy-cm.
3) Spiral Acquisition 5.3 s, 41.6 cm; CTDIvol = 6.4 mGy
(Body) DLP = 267.4
mGy-cm.
Total DLP (Body) = 359 mGy-cm.
COMPARISON: CT abdomen from ___
FINDINGS:
CT COLONOGRAPHY: Unfortunately, the study is very limited.
There is
significant fluid within the sigmoid and right colon with minor
retained fecal
matter. Additionally, there is underdistention of the sigmoid,
left colon,
and transverse colon.
The sigmoid colon is very redundant and demonstrates mild
diverticulosis
CT ABDOMEN WITHOUT IV CONTRAST: The liver, gallbladder, spleen,
adrenals, and
pancreas are unremarkable within the limits of this non enhanced
CT. A 4.7 cm
exophytic simple cyst is seen arising from the mid pole of the
right kidney.
A 1.9 cm simple cyst is seen in the lower pole of the left
kidney. These were
present previously in ___ and have mildly increased in size
since. The
stomach and small bowel loops are unremarkable. There is no
free fluid, free
air, or adenopathy.
There is moderate amount sclerotic disease of the abdominal
aorta without
aneurysmal dilatation. There is no retroperitoneal hematoma.
CT PELVIS WITHOUT IV CONTRAST: The bladder and rectum are
within normal
limits. There is no free fluid.
BONE WINDOWS: There are no suspicious osseous lesions.
Multilevel
degenerative disc disease is seen in the lower thoracic and
lumbosacral spine.
LOWER CHEST: There is minimal subsegmental atelectasis at the
lung bases. A
fat containing Bochdalek's hernia is seen on the right.
IMPRESSION:
Very limited study due to retained fluid and underdistention of
the colon.
RECOMMENDATION(S): A repeat study or conventional colonoscopy
is recommended.
NOTIFICATION: The findings were discussed with ___,
M.D. by ___
___, M.D. on the telephone on ___ at 2:00 ___, 35 minutes
after
discovery of the findings.
BY ELECTRONICALLY SIGNING THIS REPORT, I THE ATTENDING PHYSICIAN
ATTEST THAT ___ HAVE REVIEWED THE ABOVE IMAGES FOR THE ABOVE
EXAMINATION(S) AND AGREE WITH THE FINDINGS AS DOCUMENTED ABOVE.
___, MD
___, MD electronically signed on ___ ___
2:14 ___
Discharge
---------------
___ 06:18AM BLOOD WBC-9.4 RBC-3.23* Hgb-9.5* Hct-29.4*
MCV-91 MCH-29.4 MCHC-32.3 RDW-14.8 RDWSD-48.8* Plt ___
___ 06:18AM BLOOD Plt ___
___ 06:18AM BLOOD Glucose-106* UreaN-12 Creat-0.7 Na-141
K-4.1 Cl-107 HCO3-21* AnGap-17
___ 06:18AM BLOOD Calcium-9.5 Phos-2.5* Mg-2.1
___ 05:37AM BLOOD calTIBC-213* Ferritn-218* TRF-164*
Brief Hospital Course:
For her GI bleed, likely lower based on hematochezia, hx of
diverticula. BUN/Cr ratio not elevated and no maroon or black
stools. Patient does endorse intermittent nausea for months.
Patient w/o family history of colon cancer and notes she was up
to date on her colonoscopy screenings but it is our
understanding those colonoscopies were suboptimal preps.
Standing weights confirm a 23 lb weight loss over last 6 months
and family attributed to this stress (daughter has metastatic
brain cancer and ___ takes care of her). She had a CT ABD
non-con for "Abd Pain and bloating" 2 months ago, but this test
was cancelled given a contrast allergy listed. She has known
dilated biliary ducts, but MRCP in ___ was without pancreatic
masses or compression of the ducts. It is reassuring that her
H&H has been stable which would argue against a slow blood loss
anemia typical of GI malignancies; rather her blood loss was
acute. As far as her contrast allergy, her PCP is unclear how
that was added to her chart and has no knowledge of it, but
recommended not pursuing contrast imaging at this time. Fe
studies are not consistent with a slow blood loss.
Her CT colonography was poor study ___ to a poor prep. After
discussion with the Gastroenterology consult team they felt she
was safe for discharge but she should have this study repeated
as an outpt. She had a normal b.m. without blood on the day of
discharge. She will schedule it with her PCP who is outside
HCA.
We are arranging for ___ and ___ services.
Transitional Issues
[]Please get follow up H&H
[]Please schedule outpt CT colonography
[]Pt may resume Atenolol for benign tremor as this affects her
quality of life, but this medication was held during her
admission.
[]Pt does not have a history of stroke or MI, thus her primary
prevention Aspirin was held during admission and at discharge.
Given the risks/benefits, this may cause more harm and we
recommended stopping completely, but this discussion can
continue as outpt.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 1500 mg PO DAILY
2. Vitamin D ___ UNIT PO 1X/WEEK (___)
3. Aspirin 81 mg PO DAILY
4. Atenolol 25 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. TraMADol 100 mg PO Q8H
7. Acetaminophen 1000 mg PO Q8H
Discharge Medications:
1. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth Q8H:PRN Disp #*21
Tablet Refills:*0
2. Simethicone 120 mg PO QID:PRN bloating/gas
RX *simethicone [Gas Relief Extra Strength] 125 mg 1 capsule by
mouth QID:PRN Disp #*60 Capsule Refills:*0
3. Acetaminophen 1000 mg PO Q8H
4. Atenolol 25 mg PO DAILY
5. Calcium Carbonate 1500 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. TraMADol 100 mg PO Q8H
8. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
LGIB
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came to us because of blood in your stools. We believe this
came from somewhere in your colon. We consulted our GI doctors
who ___ your bleeding had stabilized and did not warrant a
colonoscopy. Instead, we attempted a CT colonography or virtual
colonoscopy; however, the bowel prep was not sufficient and the
radiologist were not able to visualize your colon. You should
follow up with your PCP to have this repeated. Your vitals signs
and blood levels are stable.
We had you work with our physical therapist who felt you should
stay another night in the hospital because you are at risk for
falls. They wanted to provide more physical therapy to make you
more safe to be home, but, because of family obligations, you
elected to go home today. We have set up a physical therapist
and ___ to come see you starting ___. If you have any
bleeding in your stools while at home, you must return to the
emergency room!
We wish you all the best,
Your ___ Team.
Followup Instructions:
___
|
10689166-DS-11
| 10,689,166 | 28,768,474 |
DS
| 11 |
2120-02-16 00:00:00
|
2120-02-18 10:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Trauma: pedestrian struck
Major Surgical or Invasive Procedure:
___ ORIF Left distal radius fracture
History of Present Illness:
___ woman medflighted from ___ s/p ped struck. Per
report, pt was crossing the street when she was struck by a car
moving at high speed. Pt hit the windshield with her face hard
enough to spider the glass. No LOC at scene, pt A&Ox2 with full
recall of the event at OSH. Pt intubated for airway protection
during transfer. Per outside records, pt sustained multiple
facial fx, L radial ulnar fx, R SDH, and SAH.
Past Medical History:
___: OSA, hyperthyroidism
PS: none
Social History:
___
Family History:
noncontributory
Physical Exam:
PHYSICAL EXAMINATION; upon admission: ___
HR: 80 BP: 137/60 Resp: 15 O(2)Sat: 100% on the vent Normal
Constitutional: Boarded and collared, intubated and
pharmacologically sedated.
HEENT: Both eyes are nearly swollen shut, the last one
being less so in the pupil the left is 1 mm and nonreactive.
She has diffuse facial and forehead ecchymoses. She has
blood in the mouth. She has blood in the nares. She also has
a nasal bridge laceration.
There is a lot of swelling and some deformity over both
maxillae.
Collared
Chest: Breath sounds symmetrical
Cardiovascular: Heart sounds are normal
Abdominal: Soft
GU/Flank: Foley catheter is in place and draining clear
yellow urine.
Extr/Back: Spine is without step-offs.
Upper
extremities show a deformity in the left wrist area with
intact distal pulses. This is a closed injury.
She has a tense right thigh ecchymosis which was not present
according to the med flight crew earlier.
She has a left knee abrasion which is minimal.
Distal pulses in both feet are normal.
Pertinent Results:
___ CT Head
Stable appearance of right frontal contusions. Bifrontal and
probable left occipital subarachnoid blood. Right and possible
left subdural hematomas. Multiple calvarial, facial, anterior
and middle skull base fractures as above including mildly
displaced right frontal bone fracture, all better assessed on
prior facial CT.
___ CT ___
1. No fracture or malalignment of the cervical spine.
2. Focal retro-dens density concerning for epidural hematoma -
MR may be
considered for further characterization.
3. Enlarged thyroid gland with multiple partially calcified
nodules. Nonurgent ultrasound should be considered if not
already performed.
___ MR ___
1. Abnormal signal at C5-C6 disc space with an associated disc
bulge, while this could all be related to degenerative changes,
an acute disc bulge cannot be excluded. Otherwise, mild
multilevel degenerative changes of the cervical spine.
2. Mild increased signal in the posterior paraspinal soft
tissues, which may represent edema, or muscle strain/ligamentous
injury.
3. Increased signal along the prevertebral space, which may
represent edema in this patient that appears to be intubated and
has a nasogastric tube.
4. Enlarged and heterogeneous thyroid gland. Corrrelation with
ultrasound is advised if clinically indicated.
___ R Forearm X-Ray
There is no elbow joint effusion. There are no signs for acute
fractures or dislocations. Peripheral catheters are seen within
the right
wrist and right antecubital region. Mineralization is normal.
Bony
structures are intact. There are mild degenerative changes of
the first CMC joint.
___ pelvis, RLE films
There are degenerative changes of both hips, which are mild to
moderate.
There is some mild joint space narrowing and spurring of both
hip joints. No acute fractures or dislocations are seen. There
are moderate degenerative changes of the lower lumbar spine with
disc space narrowing particularly at L4-L5. Focused imaging of
the right femur show no acute fractures. There are some mild
degenerative changes of the right knee joint with joint space
narrowing medially and laterally. There is some surrounding
soft tissue swelling. A Foley catheter is seen.
___ R ankle
1. No acute fracture.
2. Soft tissue swelling.
3. Corticated densities adjacent to the medial malleolus
suggestive of prior avulsion injuries likely of the deltoid
ligament.
___ Left hand, wrist
There has been improved alignment of the distal radius fracture
with less
impaction. There is again seen a transverse facture which has
intra-articular extension in joint space. Fine bony detail is
limited by the overlying splint material. There is also a small
ulnar styloid fracture which is unchanged. Mild degenerative
changes of the first CMC joint is seen. There are no bony
erosions.
___ CT Maxillofacial
There is a displaced right paramedian fracture of the frontal
bone. Known orbitofrontal parenchymal hemorrhages, subarachnoid,
intraventricular, and subdural hematomas are evaluated on
concurrent NECT. There are comminuted fractures involving the
lateral, medial, and anterior walls of the maxillary sinus.
The fractures extend into the ethmoids bilaterally. The
sinuses, particularly the naris, are filled with blood as are
the sphenoid sinuses. The right lateral pterygoid plate is
fractured (402B:82). No mandibular fracture is seen. The
bilateral nasal bones are fractured. Extraconal hemorrhage
extends into the right orbit and orbital fat herniates into the
right maxillary sinus (402B:54). The globes appear intact, but
there is some suggestion of telecanthus. The greater wing of
the right sphenoid is fractured. Bilateral diastasis of the
frontozygomatic sutures is seen. No definite fracture of the
left orbital floor is seen. ET and NG tubes are seen coursing
through the oropharynx. Extensive facial soft tissue edema and
right lateral frontal subgaleal scalp hematoma are again noted.
IMPRESSION:
1. Unilateral right LeFort 1, 2, and 3 fractures as described
above.
2. Minimal herniation of right intraorbital fat into the
maxillary sinus.
3. Displaced right paracentral frontal bone fracture.
4. Inferior displacement of the right medial inferior rectus
muscle, but no definite entrapment.
5. Diastatic frontozygomatic sutures.
___ Repeat CT Head
1. Stable right orbito-frontal hemorrhagic contusions.
2. Stable right parietal vertex subdural hematoma. No mass
effect.
3. Small foci of subarachnoid and intraventricular hemorrhage,
unchanged.
4. Extensive facial fractures described on concurrent sinus CT.
___: video swallowing:
IMPRESSION: No frank aspiration. Penetration with thin and
nectar barium consistencies. For further details, please refer
to full report by speech and swallow division
___: left wrist x-ray:
IMPRESSION:
1. Interval placement of fiberglass cast.
2. Slight improvement of intra-articular distal radius fracture
with minimal volar displacement. Unchanged ulnar styloid
fracture.
___: portable abdomen:
No evidence of radiopaque metal
___: MR abdomen:
IMPRESSION: Limited study demonstrating bifrontal hemorrhagic
contusion with small subarachnoid hemorrhage, right greater than
left. Recommend repeating the study after adequate
premedication and sedation.
___: MR of orbit:
IMPRESSION: Limited study demonstrating bifrontal hemorrhagic
contusion with small subarachnoid hemorrhage, right greater than
left. Recommend repeating the study after adequate
premedication and sedation
___: MR of the head:
IMPRESSION:
1. Slow diffusion along the optic nerves, left more than right,
suspicious for injury to the optic nerve either related to
ischemia or edema particularly on the left.
2. Intraparenchymal hematoma in the right frontal lobe as
described. Small areas of slow diffusion in the right cerebellar
peduncle and left occipital lobe, probably ischemia vs shear
injury.
3. Subdural and subarachnoid blood products.
4. Extensive sinus disease with blood products in the maxillary
sinuses.
5. Multiple facial fractures. Please refer to CT scan of
___ for
additional details.
6. Other findings as described.
Brief Hospital Course:
The patient arrived intubated but was moving all extremities in
the emergency room and making purposeful movements directed
towards the endothracheal tube. Imaging studies done at the OSH
showed multiple facial fractures, a SDH, SAH and a left radial
fracture. Because of the head injury, the patient was started on
keppra.
Upon admission to the ___, the patient was admitted to the
intensive care unit for vital sign and neurological monitoring.
She developed an episode of hypotension and required dopamine
infusion for cardiovascular support which was weaned off. The
patient's hemodynamic status remained stable. A PICC line was
placed on HD #2 because of poor iv access. While in the
intensive care unit, the patient was maintained on ventilatory
support. The neurosurgery service was consulted and recommended
a repeat head cat scan which remained unchanged. There was a
question of edema and ligamentous injury of C5-C6, as well as
within the paraspinal and prevertebral soft tissue. A ___
collar was recommended with neurosurgical out-patient follow-up.
Because of the multiple facial fractures, the plastic surgery
service recommended surgical intervention after the swelling
subsided. They also recommended follow-up with the opthamology
service who closely followed the patient because of a concern
for left optic neuropathy. To further evalute this, the patient
underwent further testing on the day of discharge. The patient
was placed on sinus precautions and started on broad spectrum
antibiotics. She was transitioned to amoxicillin prior to
discharge. The facial fractures prevented placement of a
___ tube and an oral gastric tube was placed to provide
nutrition. The patient's hematocrit decreased on HD #3, likely
reatled to fluid shifts, and the patient was given 2 units
packed red blood cells. The hematocrit remained stable
throughtout the remainer of the hospital course. The patient
was successfully weaned and extubated on HD #4 and was making
purposeful movements of all extremities. The patient was
transferred to the surgical floor.
During the hospital course, the patient had bouts of delirium
which limited participation in daily care. With the addition of
zyprexa, the patient became more oriented to her surroundings
and by the time of discharge was alert, oriented, and
conversant. On HD # 9, because of prior failed attempts in
tolerting oral supplements, a speech and swallow study was done
and the patient was cleared for thin liquids and soft ground
solids.
On HD #10, the patient was taken to the operating room for an
ORIF of the left distal radius fracture, left carpal tunnel
release, and a tenotomy of the brachioradialis tendon. The
operative course was stable with a 20cc blood loss. The patient
was extubated after the procedure and monitored in the recovery
room. A sling was applied to the left arm for support and the
patient was started on oral analgesia for post-operative pain.
As part of discharge planning, the patient was evaluated by
physical therapy and recommendations made for discharge to an
extended care facility. Social worker was available to provide
support to the patient and family. The right PICC line was
removed prior to discharge.
The patient was discharged to a rehabilitation facility on HD
#13 with stable vital signs. Her electorlytes normalized and the
hematocrit stabilized at 27. Follow-up appointments were
scheduled with Neurosurgey, Orthopedics, Plastic surgery, and
opthamology.
Medications on Admission:
methimazole 5', ASA 81', ranitidine OTC
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
last dose ___
3. Artificial Tear Ointment 1 Appl BOTH EYES 6X/DAY
4. Artificial Tears ___ DROP BOTH EYES TID
5. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
6. Docusate Sodium (Liquid) 100 mg PO BID
7. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES BID
8. Heparin 5000 UNIT SC TID
9. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR QID:PRN after
each bowel movement
10. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
hold for systolic blood pressure <110, hr <60
11. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
12. Methimazole 5 mg PO DAILY
13. Senna 1 TAB PO BID constipation
14. Quetiapine Fumarate 50 mg PO HS
15. OLANZapine (Disintegrating Tablet) 7.5 mg PO QID
hold for increased sedation and notify team
16. Aspirin EC 81 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Trauma:
bifrontal SAH
right subdural hemorrhage
suprasellar cistern hemorrhage
Right maxillary/frontal/zyg/ethmoid fracture
depressed fracture right anterior wall maxillary sinus
depressed fracture right orbital floor
bilateral nasal bone fractures
nondisplaced left zygomatic arch fracture
Left distal radial fracture/ulnar styloid fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital after you were struck by a
car. Initially you were brought to an outside hospital where
you had a breathing tube enroute to maintain your airway. You
had radiographic images taken and you were found to have a small
bleed in your head, facial fractures, a right frontal bone
fracture, and a left radial fracture. You also were found to
have a ligamentous injury to your neck and had a special collar
applied which you will need to wear until your follow-up visit.
You were seen by several consulting services who provided your
care. You were monitored in the intensive care unit and when
your vital signs stabilized, you were transferred to the
surgical floor. You have progressed nicely and are now being
discharged to a rehabilitation facility where you can further
regain your strength and mobility.
Followup Instructions:
___
|
10689216-DS-9
| 10,689,216 | 25,165,140 |
DS
| 9 |
2183-12-09 00:00:00
|
2183-12-10 13:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
RUQ Abdominal Pain
Major Surgical or Invasive Procedure:
___: Esophagogastroduodenoscopy
___: Laparoscopic cholecystectomy
History of Present Illness:
___ is a ___ year old female who presents with
RUQ pain. The pain has been coming and going for the past few
months and is worse after she eats, radiates to her shoulder and
resolves after a few hours of eating. She also has mild nausea
but no vomiting or changes in her stools. She has been worked up
for this outpatient and was found to have biliary colic and is
scheduled for a lap chole on ___. However her pain acutely
worsened today leading to her presentation to the ED.
ROS: a 12 point pertinent review of systems was completed and
negative unless stated above.
Past Medical History:
PMHx:
NODULAR ACNE
OBGYN HX
ANXIETY
HYPERTENSION
ASTHMA
SMOKER
ADENOMYOSIS AND FIBROID UTERUS
CHRONIC FATIGUE
H/O ABNORMAL MAMMOGRAM
PSHx:
BREAST BIOPSY ___
DILATION AND CURETTAGE
Social History:
___
Family History:
Father with hx of colon cancer and lung cancer. Sister with
fibroids.
Physical Exam:
Physical Exam on Admission:
Vitals:
Gen: Well appearing, AAOx3, NAD
HEENT: No scleral icterus, midline trachea, neck supple
CV: RRR
Pulm: Breathing unlabored on room air
Abd: Soft, RUQ tenderness but neg ___ sign, nondistended.
Ext: Warm and well perfused, no edema
Discharge Physical Exam:
VS: T: 98.2 PO BP: 128/75 L Lying HR: 81 RR: 18 O2: 97% Ra
GEN: A+Ox3, NAD
HEENT: No scleral icterus
CV: RRR, grade 1 systolic murmur
PULM: CTA b/l
ABD: soft, obese abdomen. Appropriately tender at incision
sites. Laparoscopic sites with gauze and tegaderm c/d/I, no s/s
infection.
EXT: no edema b/l
Pertinent Results:
LIVER OR GALLBLADDER US (SINGLE ORGAN): ___
Cholelithiasis without evidence of acute cholecystitis. No
biliary ductal dilatation.
LABS:
___ 07:41AM GLUCOSE-108* UREA N-17 CREAT-1.3* SODIUM-142
POTASSIUM-5.4 CHLORIDE-103 TOTAL CO2-27 ANION GAP-12
___ 07:41AM ALT(SGPT)-17 AST(SGOT)-12 ALK PHOS-66 TOT
BILI-0.2
___ 07:41AM CALCIUM-10.6* PHOSPHATE-4.0 MAGNESIUM-1.5*
___ 07:41AM WBC-8.1 RBC-5.47* HGB-11.4 HCT-37.3 MCV-68*
MCH-20.8* MCHC-30.6* RDW-16.3* RDWSD-39.0
___ 07:41AM PLT COUNT-334
___ 01:02AM ___ PTT-31.5 ___
___ 08:48PM URINE UCG-NEGATIVE
___ 08:48PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 08:48PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-TR* BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 08:48PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 08:48PM URINE MUCOUS-RARE*
___ 07:37PM GLUCOSE-104* UREA N-16 CREAT-1.3* SODIUM-136
POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-21* ANION GAP-12
___ 07:37PM ALT(SGPT)-18 AST(SGOT)-15 ALK PHOS-76 TOT
BILI-<0.2
___ 07:37PM LIPASE-43
___ 07:37PM ALBUMIN-4.1
___ 07:37PM WBC-9.9 RBC-5.64* HGB-11.8 HCT-39.3 MCV-70*
MCH-20.9* MCHC-30.0* RDW-17.3* RDWSD-40.4
___ 07:37PM NEUTS-46.5 ___ MONOS-7.5 EOS-2.4
BASOS-0.5 IM ___ AbsNeut-4.59 AbsLymp-4.21* AbsMono-0.74
AbsEos-0.24 AbsBaso-0.05
___ 07:37PM PLT COUNT-338
Brief Hospital Course:
Patient is a ___ year old female with pmh significant for biliary
colic. Patient presented to the emergency department with
complaints of worsening abdominal pain. Gallbladder ultrasound
showed cholelithiasis without evidence of acute cholecystitis.
She had an EGD performed which was normal.
On HD2, the patient was taken to the operating room and
underwent laparoscopic cholecystectomy. This procedure went
well (reader, please refer to operative note for further
details). After a brief, uneventful stay in the PACU, the
patient was transferred to the surgical floor.
Pain was managed with oxycodone and acetaminophen. Diet was
advanced to regular which the patient tolerated. During this
hospitalization, the patient voided without difficulty and
ambulated early and frequently. The patient 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.
The patient reported shortness of breath and left shoulder pain.
A chest x-ray was obtained which was normal and an EKG showed
normal sinus rhythm. The patient has a systolic murmur which
she notes has been present since birth.
At the time of discharge, the patient was doing well. She was
afebrile and their vital signs were stable. The patient was
tolerating a regular diet, ambulating, voiding without
assistance, and their pain was well controlled. The patient was
discharged home without services. Discharge teaching was
completed and follow-up instructions were reviewed with reported
understanding and agreement.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
2. ALPRAZolam 0.5 mg PO BID:PRN anxiety
3. ALPRAZolam 2 mg oral DAILY
4. BuPROPion (Sustained Release) 150 mg PO BID
5. Fluticasone Propionate 110mcg 2 PUFF IH QAM
6. Fluvoxamine Maleate 150 mg PO QAM
7. Fluvoxamine Maleate 200 mg PO QPM
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. Metoprolol Tartrate 50 mg PO BID
10. ___ (norethindrone (contraceptive)) 0.35 mg oral QHS
11. Omeprazole 20 mg PO QPM
12. QUEtiapine Fumarate 75 mg PO QHS
13. Spironolactone 100 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
4. ALPRAZolam 0.5 mg PO BID:PRN anxiety
5. ALPRAZolam 2 mg oral DAILY
6. BuPROPion (Sustained Release) 150 mg PO BID
7. ___ (norethindrone (contraceptive)) 0.35 mg oral QHS
8. Fluticasone Propionate 110mcg 2 PUFF IH QAM
9. Fluvoxamine Maleate 150 mg PO QAM
10. Fluvoxamine Maleate 200 mg PO QPM
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Metoprolol Tartrate 50 mg PO BID
13. Omeprazole 20 mg PO QPM
14. QUEtiapine Fumarate 75 mg PO QHS
15. Spironolactone 100 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Biliary colic
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 with abdominal pain and were
found on ultrasound to have gallstones within your gallbladder.
You had an upper endoscopy performed which showed that your
stomach and small intestine were normal. You then proceeded to
surgery and had your gallbladder removed laparoscopically. This
procedure went well. You are now ready to be discharged home to
continue your recovery with the following discharge
instructions:
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10689622-DS-21
| 10,689,622 | 27,268,685 |
DS
| 21 |
2147-08-24 00:00:00
|
2147-08-24 17:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
increased weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with PMH of MS, seizure disorder transfered from nursing
facility for increased weakness and altered mental status. She
was at her baseline yesterday, feeding herself and oriented, but
requiring assistance for all ADLs. This morning per report she
was unable to feed herself breakfast. At mid-day, when being
turned by staff, she was unable to support herself with the
bedrail as she usually does. Staff noted right-sided weakness
in particular. According to her facility her blood pressure is
a little lower than her baseline.
.
Per family report, ___ years ago the patient was living at home,
mobile without an aide, fully alert and oriented, with limited
help for ADLs. Since that time she has had three "seizures"
that have substantially reduced her capabilities. ___ years ago
she came back about 80% and was able to live at home but needed
help with bathing and used a walker. In ___ she was
able to regain some mobility. A year ago in ___
she had a severe "seizure" event and was in the ICU in an
induced coma, trach, PEG. After this event she was not able to
recover enough to be at home and moved to ___ for
full-time care. She has been stable at her new baseline since
that time. She can feed herself, but is otherwise dependent for
all ADLs. She can speak relatively normally, but has short-term
memory loss. She can read and write. She is followed by a
Neurologist at ___ for her MS and for these seizure events. It
is not clear at this writing if these are seizures, MS flares,
or a combination of the two.
.
Per family report, each time that the patient has one of these
seizure-like events, she is initially non-responsive, then
slowly regains function. She goes through periods of repeating
words, then is confused, then finally makes sense again. She
does not typically have motor manifestations, shaking, or
stereotyped movements. They describe her current state as
typical of immediate reaction to these events.
.
In the ED, initial vitals were T 98.8 BP 133/59 HR 62 RR 18
O2sat 98% 2L NC. CT abdomen and pelvis showed moderate
pericardial effusion, but no clear abdominal pathology. Bedside
echo confirmed small pericardial effusion, but no tamponade.
Labs revealed troponin 0.08 with normal lactate. She was given
aspirin. She was initially hypotensive to high ___ on
presentation, but with 2L IVF responded to SBP 130s. She was
placed on 2___ as she was observed to desat with sleep to the
high ___. Limited records were available from the nursing home.
.
On the floor, the patient is initially responsive only to
sternal rub. Her family is present and provides background
history, but was not present this morning and cannot speak to
the events that led to her admission.
Past Medical History:
Multiple Sclerosis
Seizures
Aphasia
Lack of coordination
Muscle weakness
? H/o delirium
H/o UTI's
? R sided deficit from prior stroke?
Dysphagia (per report, but patient able to feed self)
Anxiety
Depression
Hypothyroidism
T2DM
HTN
Social History:
___
Family History:
Mother passed away from ___ trauma (?), sister with ___ and
seizures. Daughter reports that there is a family history of
seizures.
Physical Exam:
Admission Physical Exam:
Vitals: T: 97.7 BP: 139/90 P: 69 R: 20 O2: 98% 2___
General: No acute distress, responsive only to sternal rub
HEENT: Sclera anicteric, MMM, OP clear.
Neck: supple, no LAD, JVP not visible secondary to patient
position
Lungs: CTAB, no wheezes, rales, ronchi
CV: RRR, nl S1 S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding, + PEG (not in use)
GU: + foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Resists eye opening, cannot assess CN ___ patient
cooperation. No obvious asymmetry of face or pupils. Patient
able to grip examiner's fingers following sternal rub and verbal
cueing, right stronger than left. Not able to cooperate with
motor or sensory exam.
.
Discharge Physical Exam:
General: No acute distress, alert and oriented x2 (self,
hospital, season and year)
HEENT: Sclera anicteric, MMM, OP clear. Seborrheic rash around
mouth and below nares.
Neck: supple, no LAD, JVP not elevated
Lungs: CTAB, no wheezes, rales, ronchi
CV: RRR, nl S1 S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding, + PEG (not in use)
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII tested and largely intact with some residual
horizontal nystagmus. RUE and RLE weakness and lack of control.
LUE ___ strength, good grip, able to use to feed herself. LLE
4+/5.
Pertinent Results:
Admission Labs:
___ 01:30PM BLOOD WBC-11.6* RBC-4.08* Hgb-12.4 Hct-37.8
MCV-93 MCH-30.3 MCHC-32.7 RDW-13.9 Plt ___
___ 01:30PM BLOOD Neuts-59.2 ___ Monos-5.2 Eos-0.3
Baso-0.6
___ 08:24PM BLOOD ___ PTT-27.8 ___
___ 01:30PM BLOOD Glucose-99 UreaN-24* Creat-0.9 Na-133
K-4.0 Cl-99 HCO3-24 AnGap-14
___ 01:30PM BLOOD ALT-39 AST-32 CK(CPK)-59 AlkPhos-265*
TotBili-0.3
___ 01:30PM BLOOD Lipase-28
___ 01:30PM BLOOD CK-MB-2 cTropnT-0.08*
___ 01:30PM BLOOD Calcium-8.4 Mg-2.0
___ 08:14PM BLOOD Albumin-3.5 Calcium-8.6 Phos-3.3 Mg-2.0
___ 01:49PM BLOOD Lactate-1.6
.
Interim Labs:
___ 08:14PM BLOOD WBC-10.1 RBC-3.82* Hgb-11.9* Hct-34.7*
MCV-91 MCH-31.1 MCHC-34.3 RDW-13.8 Plt ___
___ 07:30AM BLOOD WBC-9.6 RBC-4.36 Hgb-13.2 Hct-40.4 MCV-93
MCH-30.1 MCHC-32.6 RDW-13.7 Plt ___
___ 07:00AM BLOOD WBC-9.4 RBC-4.01* Hgb-12.1 Hct-37.0
MCV-92 MCH-30.1 MCHC-32.6 RDW-13.4 Plt ___
___ 07:30AM BLOOD WBC-7.8 RBC-3.92* Hgb-12.1 Hct-35.9*
MCV-91 MCH-30.8 MCHC-33.7 RDW-13.2 Plt ___
___ 07:00AM BLOOD WBC-7.2 RBC-3.74* Hgb-11.6* Hct-34.0*
MCV-91 MCH-31.0 MCHC-34.2 RDW-13.4 Plt ___
___ 07:20AM BLOOD WBC-9.2 RBC-3.94* Hgb-11.8* Hct-35.4*
MCV-90 MCH-30.0 MCHC-33.4 RDW-13.6 Plt ___
___ 08:14PM BLOOD Glucose-104* UreaN-18 Creat-0.6 Na-141
K-3.9 Cl-107 HCO3-27 AnGap-11
___ 07:30AM BLOOD Glucose-81 UreaN-15 Creat-0.5 Na-142
K-4.5 Cl-106 HCO3-25 AnGap-16
___ 07:00AM BLOOD Glucose-96 UreaN-9 Creat-0.5 Na-141 K-3.8
Cl-106 HCO3-27 AnGap-12
___ 07:30AM BLOOD Glucose-96 UreaN-10 Creat-0.6 Na-142
K-3.8 Cl-107 HCO3-26 AnGap-13
___ 07:00AM BLOOD Glucose-101* UreaN-11 Creat-0.6 Na-140
K-3.8 Cl-104 HCO3-27 AnGap-13
___ 01:30PM BLOOD CK-MB-2 cTropnT-0.08*
___ 08:14PM BLOOD CK-MB-3 cTropnT-0.05*
___ 07:30AM BLOOD CK-MB-3 cTropnT-0.03*
___ 08:14PM BLOOD Albumin-3.5 Calcium-8.6 Phos-3.3 Mg-2.0
___ 07:30AM BLOOD Albumin-3.8 Calcium-9.3 Phos-3.2 Mg-2.0
Cholest-321*
___ 07:00AM BLOOD Calcium-9.5 Phos-3.1 Mg-1.8
___ 07:30AM BLOOD Calcium-9.4 Phos-2.9 Mg-1.9
___ 07:00AM BLOOD Calcium-9.4 Phos-3.2 Mg-1.9
___ 07:30AM BLOOD %HbA1c-5.3 eAG-105
___ 07:30AM BLOOD Triglyc-203* HDL-64 CHOL/HD-5.0
LDLcalc-216*
___ 07:30AM BLOOD Ammonia-28
___ 07:30AM BLOOD TSH-0.078*
___ 08:14PM BLOOD Prolact-20
___ 07:30AM BLOOD Free T4-1.4
___ 07:30AM BLOOD Phenyto-18.7
.
Discharge Labs:
___ 06:30AM BLOOD WBC-9.9 RBC-3.81* Hgb-11.4* Hct-34.8*
MCV-91 MCH-29.9 MCHC-32.7 RDW-13.9 Plt ___
.
Microbiology:
___ CULTURE-FINAL
___ CULTURE-PENDING
___ 2:02 pm URINE Source: Catheter.
GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML.
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.
SENSITIVITIES: MIC expressed in MCG/ML
_______________________________________________________
PROTEUS MIRABILIS
| PSEUDOMONAS AERUGINOSA
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFEPIME-------------- <=1 S 2 S
CEFTAZIDIME----------- <=1 S 4 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 2 I <=0.25 S
GENTAMICIN------------ <=1 S 2 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
Imaging:
ECG ___:
Sinus rhythm. Diffuse non-specific ST-T wave changes. No
previous tracing available for comparison.
.
CXR ___:
SUPINE AP VIEW OF THE CHEST: The heart size is top normal with a
left ventricular predominance. The mediastinal contours are
unremarkable. Pulmonary vascularity is not engorged. A 7-mm
calcified nodule is noted in the right lung base, compatible
with a granuloma. No focal consolidation, pleural effusion or
pneumothorax is present. No acute osseous abnormality is seen.
IMPRESSION: No acute cardiopulmonary process.
.
CT ___ without Contrast ___:
FINDINGS: There is no evidence of intracranial hemorrhage,
edema, shift of midline structures, major vascular territorial
infarction. The ventricles and sulci are prominent, consistent
with central atrophy. Subcortical and periventricular white
matter hypodensities, primarily within the left frontal and
pareital lobes are non-specific, and may reflect the sequela of
chronic microvascular infarction or demyelination. No suspicious
osseous lesions are identified. The visualized paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
IMPRESSION: Subcortical and periventricular white matter
hypodensities, primarily within the left frontal and parietal
lobes may reflect demyelination or chronic small vessel ischemic
changes. No acute intracranial hemorrhage or mass effect. Please
note that MRI is more sensitive for the evaluation of multiple
sclerosis.
.
CT Abdomen and Pelvis ___:
FINDINGS: There is a moderate simple pericardial effusion.
Atelectasis is noted at the lung bases. The distal esophagus is
diffusely dilated, which may be due to presbyesophagus.
ABDOMEN: The hepatic dome is excluded on this examination. The
remainder of the liver enhances homogeneously on this single
phase examination. The gallbladder is partially collapsed. There
is mild fatty replacement of the pancreas. No intra- or
extra-hepatic biliary ductal dilation. Spleen is normal in size.
The adrenals and kidneys are normal. Percutaneous gastrostomy
tube terminates in the gastric body. There is a tiny
diverticulum arising from the first portion of the duodenum. The
distal small bowel is normal.
PELVIS: Note is made of a retrocecal appendix, which is
nondilated and filled with air. A single cecal diverticulum is
also present, with internal air-fluid level, but no focal
inflammatory changes.
Foley catheter is present in the bladder, with locules of
non-dependent air. There is apparent mild wall thickening likely
due to underdistention. The distal ureters are normal. Adnexa
are within normal limits. The uterus and cervix have a bulky
appearance, with multiple underlying fibroids, some of which
demonstrate contrast hyperenhancement. There is no free fluid in
the pelvic cul-de-sac. Retroperitoneal and mesenteric lymph
nodes are not pathologically enlarged,
measuring 6-8 mm in the left paraaortic region. Scattered
calcifications and atheromatous plaques are present throughout
the abdominal aorta and iliac arteries, with involvement of the
celiac and renal artery ostia. Abdominal aorta is normal in
caliber. Retroperitoneal and mesenteric lymph nodes are not
pathologically enlarged. Moderate facet hypertrophy is noted in
the lower lumbar spine. There are small diffuse disc bulges at
L3-L4 through L5-S1, with effacement of the
ventral thecal sac outline. Please note that CT cannot visualize
intrathecal detail. Moderate degenerative changes also noted in
the bilateral sacroiliac joints. Focal sclerosis in the inferior
right ilium could represent a bone island.
IMPRESSION:
1. No acute abdominal process.
2. Fibroid uterus.
3. Moderate pericardial effusion.
.
EEG ___:
IMPRESSION: This is an abnormal continuous ICU video EEG study
because of diffuse severe suppression and slowing of background
over the left temporal and, at times, left posterior quadrant
consistent with an underlying subcortical dysfunction. In
addition, there were frequent and, at times, briefly periodic
left posterior quadrant spike and wave discharges indicative of
a potential epileptogenic area; however, no electrographic
seizures were present.
.
MR ___ with and without Contrast ___:
FINDINGS: The cerebral sulci, ventricles, and extra-axial CSF
containing spaces demonstrate diffuse enlargement in keeping
with global cerebral volume loss. There are extensive
periventricular, deep white matter, peduncular and brain stem
FLAIR/T2 signal abnormalities, which project into the corpus
callosum in a classic MS-like configuration. Some of the lesions
demonstrate low signal on T1; none demonstrates enhancement or
abnormal diffusion. There are no additional lacunes within the
gray matter that would suggest a strong superimposed component
of small vessel ischemic disease. Flow voids of the major
intracranial vessels are preserved. The visualized paranasal
sinuses and mastoid air cells are clear. The orbits and osseous
structures are unremarkable.
IMPRESSION:
1. Extensive supra- and infratentorial FLAIR/T2 white matter
abnormalities in a classic MS like distribution. Given the lack
of prior studies, the dynamics of demyelinating disease cannot
be assessed. There is no evidence of abnormal diffusion or
contrast enhancement.
2. Associated global cerebral volume loss.
3. No evidence of acute intracranial abnormality such as
hemorrhage or infarct.
Brief Hospital Course:
___ with PMH of MS, seizure disorder transfered from nursing
facility for increased weakness and altered mental status.
.
# Altered mental status: Per Neurology consultation, this could
represent toxic metabolic encephalopathy, recrudescence of old
deficit from CVA due to hypoperfusion, seizure, or new CVA. The
patient's mental status changed throughout the evening of
admission, becoming more alert and awake although not at
baseline. 24-hour EEG monitoring was performed and found no
seizure activity, but did reveal residual neurological deficit.
MR of the ___ showed no sign of stroke. Her home
anti-epileptic regimen was continued without changes, and her
phenytoin and Keppra levels were found to be therapeutic.
.
# Troponin elevation: On admission, the patient was found to
have elevated troponin at 0.03. This peaked at 0.08, CK and MB
normal. Unclear etiology of troponin leak and heart strain,
possibly related to neurological deficit at the time.
.
# Pericardial effusion: Small pericardial effusion noted on CT
abdomen and confirmed on bedside echo in the ED. Etiology not
clear, may be secondary to inflammatory process. As there was
no hemodynamic instability, there was no need for definitive
diagnosis. Most pericardial effusions that do not cause
hemodynamic instability are not clearly linked to an underlying
cause.
.
# Hypotension: The patient was hypotensive in ED to SBP ___,
but rapidly recovered to normal pressure. Hypotension may have
been due to mental status, although septic picture was of
initial concern. The patient's blood and urine cultures showed
no growth and her blood pressure normalized. Her home
anti-hypertensives were continued after this point.
.
# UTI: Patient found to have likely nosocomial UTI ___ Foley
placement, given increased inflammation on UA. Augmentin was
started ___ for planned 7 day course. Given her clinical
improvement and lack of fever, it was not clear whether this
represented bacturia rather than a full UTI. Given the risk of
seizure with Cipro treatment, the Neurology team advised that
this medication be avoided unless she developed fever or other
symptoms. It was agreed with her PCP that placing ___ PICC for IV
therapy would be difficult and that the patient might remove it,
therefore this should be reserved for necessary treatment for
severe infection. Another oral antibiotic option would be
fosphomycin; we asked the laboratory to check for sensitivity to
this medication. Cipro and/or fosphomycin would be options for
future treatment in the event she develops clinical signs of
infection. This approach was discussed with the PCP.
.
# Facial rash: Patient observed to have seborrheic rash around
mouth and below nares, waxes and wanes. Appears to be
semi-chronic. She is on treatment with Augmentin, which should
cover typical skin flora.
.
# Anxiety and depression: continued Seroquel
.
# MS: Previously treated with multiple regimens, currently
refractory. Continued home regimen.
.
# Hypothyroid: continued levothyroxine. TSH was found to be
low, but free T4 normal.
.
.
Code: FULL (per SNF, to confirm with family)
Communication: Patient, daughter, son, son-in-law
Emergency Contact: ___ (daughter, HCP) ___
.
___ Issues:
- Completion of antibiotic course for UTI
- fosphomycin sensitivity pending
- confirm resolution of skin rash
- Plan follow-up with ___ neurologist Dr ___.
Please also follow-up with an epilepsy specialist, at ___ or
elsewhere.
Medications on Admission:
- Keppra 1500 twice daily
- Metoprolol 12.5 mg twice daily
- Seroquel 25mg twice daily
- Clonodine 0.1 mg three times a day
- Colace 100 mg three times daily
- Oxycodone 2.5 mg three times a day
- Motrin 400-600 mg prn
- Levothyroxine 150 mcg daily
- Lisinopril 40 mg daily
- Ferrous sulfate 325 mg daily
- Levo-carnitine 10 mL daily
- Gabapentin 600 mg daily at 2pm
- Gabapentin 400 mg twice daily
- Dilantin 150 mg at 8am
- Dilantin 100 mg at 2pm and 100 mg at 8pm
- Tylenol extra strength q4
- Ipratropium nebs q4 prn
Discharge Medications:
1. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
3. quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
6. oxycodone 5 mg Capsule Sig: 0.5 Capsule PO three times a day.
7. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for pain.
8. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
9. levocarnitine 1 gram/10 mL Solution Sig: Ten (10) ml PO once
a day.
10. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily): at 1400.
11. gabapentin 400 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): at 0800 and ___.
12. phenytoin 50 mg Tablet, Chewable Sig: Three (3) Tablet,
Chewable PO DAILY (Daily): at 0800.
13. phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO BID (2 times a day): at 1400 and ___.
14. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q4H
(every 4 hours).
15. ipratropium bromide 0.02 % Solution Sig: One (1) treatment
Inhalation every four (4) hours as needed for wheeze.
16. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 2 days: last day ___.
17. levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a
day.
18. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
altered mental status
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
It was a pleasure taking care of you at ___
___. You came to the hospital after being found to
be confused and tired at your residential facility. We did
imaging of your brain that did not show a stroke or worsening of
your multiple sclerosis. Blood testing for infection and
metabolic problems was normal. We believe that you either had a
seizure or had a brief period of confusion known as
encephalopathy. We do not know what triggered this event.
Our Neurology team followed you during your stay. 24-hour EEG
monitoring revealed no seizure activity, but could not rule out
previous seizure. They recommend that you continue your usual
anti-epileptic regimen. They also strongly recommend that you
follow-up with an outpatient Neurologist who specializes in
seizure.
During your admission you were found to have a urinary tract
infection. This probably was not related to your confusion, as
it started after your confusion resolved. You were treated with
antibiotics.
We made the following changes to your medications:
- START Augmentin. This is an antibiotic to treat your urinary
tract infection. You will take this for a total of 7 days,
starting ___. Your last day of treatment will be ___.
Please follow-up with your treating Neurologist and primary care
physician as planned upon your return to ___ House.
Followup Instructions:
___
|
10689622-DS-22
| 10,689,622 | 22,347,219 |
DS
| 22 |
2148-12-08 00:00:00
|
2148-12-08 17:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
seizure, confusion
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
___ year-old right handed woman, nursing home resident with
history of MS, Epilepsy, multiple episodes of UTI, CHF with
unknown EF and COPD, presented here from nursing home for
further
evaluation and treatment.
Today at 2 am she asked for pain medication for a severe
headache that she had, she is not able to give us more details
about her headache,When the ___ home staff went to check on
her she found the patient sweaty with shaking movement in all
ext
and twitching in her face, at that point her eyes were open
without deviation and she was responsive to her name, alert and
oriented to herself and place. She did not lose her control of
her bladder or bowel movement.
And she did not have any tongue bite. At that time her BP was
140s, but she was tachycardic with HR of 120s.She was given
Tylenol and transferred here.
Shaking movement lasted about 45 min and stopped after she
received 2 mg of Ativan in BI ED.
Neurology was consulted at this point.She mentioned that in
previous days, she had burning sensation during urination and
high temperature.
Initial exam in triage BP was 204/95, T was 98.8, RR of 16 and
O2 sat of 100% on 2 lit.
ROS is positive for headache, shaking, tremor, right sided
weakness and bil lower ext weakness.
Past Medical History:
- MS : she was diagnosed at the age of ___, but problems started
approximately ___ years ago. She started to drag her left leg, and
required a cane. She has been on Copaxone in the past.
- Seizure Disorder: Patient is currently on three AEDs. she had
a
first seizure approximately ___ years ago which included
convulsions. The second seizure was ___ years ago, where she was
admitted to the ___ and intubated and "placed in a coma to
control her seizures", and she was admitted for a one month
period. During this hospitalization, she was tracheostomized and
gastrostomized. Her trach has since been removed, but the PEG
remains "in case anything happens again".
- UTIs: At least six prior urinary tract infections,per previous
note her daughter noted that she does get confused with her
infections
- CVA: Mild stroke( no more details) ___ years ago, residual
deficits?
- Hypertension
- Hypothyroidism
- "Balloon procedure of the left neck artery"
- CHF: EF unknown
- COPD
Social History:
___
Family History:
Mother passed away from head trauma (?), sister with
___ and seizures. Daughter reports that there is a family
history of seizures.
Physical Exam:
Physical Exam on Admission:
BP:204/105, PR:88, RR:16, O2 SAT: 100 ON 2L
General: Elderly woman, appears drowsy, eyes open at baseline
HEENT: Dry lips, NC/AT, no conjunctival icterus, neck is supple,
facial puffiness with bilateral eyelid swelling.
Pulmonary: Has bil crackles in base of Lungs, more prominent on
the right side.
Cardiac: Tachycardic,in sinus rhythm, S1S2.
Abdomen: diffusely tender without masses, soft, NT/ND, + PEG
tube, + Foley catheter
Extremities:warm and well perfused.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: The patient is drowsy. She is oriented to her
name but did not know where she is and why she is here, also she
was not oriented to time. Her speech is slurred with stutters
and
word finding difficulty. Inattentive: cannot name ___ forwards
or
backwards .Comprehension: follows simple commands without right
left confusion. Difficulty in naming high and low frequency
objects. Deferred memory testing.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk.
III, IV and VI: Slight exotropia of the left eye, which is not
new for her per previous exam,
EOM are intact and full, no nystagmus
V: Facial sensation intact to light touch and symmetric
VII: Slight NLF flattening on the left, occasional facial
twitching that is nonrhythmic and diffuse.
VIII: Hearing intact grossly
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Increased upper extremity tone with baseline flexed
posturing of the elbows and wrists. Tone is normal to low in
lower extremities with hyper extended ankles.She has MYOCLONUS
observed during the examination, also she has resting tremor
which is getting worse with posturing and activation.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 4+ 5- ___ 5- ? ? ? 5- 5-
R 1 ___ 2 2 ? ? ? 2 2
In summery she has right side hemiparesis, in R upper ext: able
to move fingers, in R lower ext she is not able to move even his
toes.
On the left side: able to move her arm, elbow and fingers
against
gravity with some resistance.In left lower she is able to flex
her ankle both dorsal and plantar.
-Sensory: Diminished sensation to light touch, mental status
limited the exam.
-DTRs:
Bi Tri Pat Ach
L 2+ 2+ 2+ 1
R 2+ 2+ 1 1
Plantar response: Extensor bilaterally
-Coordination: Intact FTN on the left side with resting tremor
getting worse during exam.
-Gait: Not tested
Physical Exam on Admission:
Vitals T 98.4 BP 140s-170s/60s-70s HR 76 RR 16 O2 98RA
MS: awake, alert, says she is "in a place where you go when you
are sick," cannot name hospital, says year is ___, cannot name
flashlight but chooses correctly when given options then
perserverates on flashlight
CN: face symmetric, EOMI
Motor: no pronator drift, coarse postural tremor in upper
extremities
Pertinent Results:
Labs on Admission:
___ 06:10AM WBC-11.2* RBC-4.52 HGB-13.6 HCT-42.4 MCV-94
MCH-30.0 MCHC-32.0 RDW-13.5
___ 06:10AM PLT COUNT-344
___ 06:00PM GLUCOSE-178* UREA N-10 CREAT-0.6 SODIUM-135
POTASSIUM-3.9 CHLORIDE-97 TOTAL CO2-25 ANION GAP-17
___ 06:00PM CALCIUM-9.7 PHOSPHATE-3.1 MAGNESIUM-1.7
___ 06:00PM CK(CPK)-120
___ 06:00PM CK-MB-2 cTropnT-<0.01
___ 05:30AM ALT(SGPT)-33 AST(SGOT)-26 ALK PHOS-387* TOT
BILI-0.3
___ 05:30AM ___ PTT-27.5 ___
___ 05:30AM BLOOD Phenyto-4.9*
Relevant Labs:
___ 08:22AM BLOOD %HbA1c-5.6 eAG-114
___ 08:22AM BLOOD Cortsol-15.0
___ 11:16PM BLOOD CRP-50.7*
___ 08:22AM BLOOD Phenyto-15.2
Studies:
CT head w/o contrast
No evidence of an acute intracranial process. MRI would be more
sensitive for assessing progression of multiple sclerosis or
detecting a source of worsening seizures, if clinically
warranted.
Chest x-ray portable
Increased right lower lung opacities raising the possibility of
aspiration given the seizure history. Low lung volumes and the
patient's
rotation could also account for this apparent increase.
Chest X-ray PA/lateral
Moderate-to-severe cardiomegaly is stable. Right PICC tip is in
the lower SVC. There are low lung volumes. Elevation of the
right hemidiaphragm is unchanged. Retrocardiac opacity is
consistent with atelectasis. There is no pneumothorax or
pleural effusions.
EEG ___
This telemetry captured no pushbutton activations. It showed
periodic sharp wave discharges broadly over the left hemisphere
throughout the recording. There is no clear associated clinical
abnormalities and discharges were not so rapid as to suggest
ongoing seizures, at least electrographically. The periodic
discharge pattern certainly indicates a risk for seizures,
non-convulsive or other. The background remained disorganized
and mildly slow in all areas.
EEG ___
This is an abnormal video EEG monitoring session because of
intermittent periodic lateralized epileptiform discharges in the
left
posterior quadrant at 1 Hz. This finding is indicative of
potential
epileptogenic area over the left posterior quadrant. This
activity becomes less continuous and shorter in duration as the
study progresses. The background activity is mildly diffuse slow
suggesting a mild encephalopathy of non-specific etiology.
MRI brain w/ and w/o contrast
1. No evidence of posterior reversible leukoencephalopathy
syndrome (PRES).
2. Chronic left ICA occlusion. Symmetric flow voids in the
MCAs bilaterally, representing reconstitution of flow via the
ACOM, left A1 and then left M1 pathway.
3. Numerous T2/FLAIR supratentorial and infratentorial white
matter
hyperintensities, in keeping with the patient's underlying
multiple sclerosis.
4. Hyperintense foci in the right medial thalamus and right
midbrain, new since ___.
5. No abnormal post-contrast enhancement or acute infarction.
LENIs
No sonographic evidence for right upper extremity deep vein
thrombosis.
Renal US w/ Doppler
Normal renal ultrasound without sonographic evidence for renal
artery
stenosis.
Labs on Discharge:
___ 08:22AM BLOOD WBC-10.3 RBC-3.76* Hgb-10.9* Hct-33.9*
MCV-90 MCH-29.1 MCHC-32.2 RDW-14.7 Plt ___
___ 05:54AM BLOOD Glucose-115* UreaN-6 Creat-0.5 Na-143
K-3.0* Cl-103 HCO3-28 AnGap-15
___ 08:22AM BLOOD Calcium-8.9 Phos-2.5* Mg-1.6
Brief Hospital Course:
Ms. ___ is a ___ year old right handed woman with hx of CHF,
COPD, MS, and epilepsy who presented ___ from nursing home for
concern of seizures and was found to be in nonconvulsive status
in the setting of a subtherapeutic dilantin level.
# Neuro:
Prior to presentation, patient reportedly awoke in the middle of
night with shaking vs rigors for 45 minutes while speaking. She
was thought to have PNA and UTI in the ED and was started on
vanc and zosyn. Also, dilantin level was 4.6. She was quite
encephalopathic on admission. When placed on EEG, she was found
to be having multiple seizures consistent with nonconvulsive
status. She was loaded with dilantin and once level was
therapeutic, her mental status improved. Ultimately, urine
culture was neg and PA/lateral chest xray did NOT show a
pneumonia, so discontinued antibiotics. Suspect seizures were
in the setting of subtherapeutic dilantin level alone rather
than infection. Did touch base with Dr. ___, Ms. ___
outpatient neurologist, during the admission and did not make
any changes to AEDs. Did find out that she has been admitted
for status multiple times in the past in the setting of refusing
medications in the past. On discharge, patient's mental status
was much improved to what appears to be her baseline per
daughter and Dr. ___ in the setting of her dementia and
MS. ___ will continue prior regiment of dilantin 100mg tid,
keppra 1500mg bid, vimpat 200mg bid on discharge.
# ___: Ms. ___ was hypertensive to 240 systolic in the ED,
which decreased to 180 after labetolol IV. On the floor, SBP
was 220 and patient had a headache, thus hypertensive emergency.
She was subsequently transfered to the ICU for blood pressure
control. Was briefly on nicardipine gtt and was then
transitioned to oral medications. However, continued to be
extremely hypertensive to 190s on the floor and required
frequent uptitration of anti-HTN meds. Now on oral medications,
but continues to be difficult to control. Did start a work up
for secondary causes of hypertension. Renal US without renal
artery stenosis, am cortisol was normal, renin/aldosterone
pending on discharge. Attempted CPAP as OSA can lead to
secondary HTN, but patient did not tolerate it. On discharge,
anti-HTN regiment is: amlodipine 10mg qd, HCTZ 25mg qd,
labetalol 800mg tid, captopril 150 tid, clonidine 0.2mg.
# PULM: COPD, continued inhalers prn.
# Endocrine: HbA1c checked, was 5.6.
# ID: Initially on Vanc/Zosyn as above but was discontinued as
urine culture neg and chest xray neg.
TRANSITIONS OF CARE:
- will follow up with Dr. ___ in ___ clinic
- aldosterone/renin/metanephrines/catecholamines pending on
discharge
Medications on Admission:
- Keppra 1500 twice daily
- Cymbalta 60mg qd
- Simvastatin 20mg qd
- Labetalol 400 mg q8
- Clonodine 0.2 mg three times a day
- Colace 100 mg three times daily
- Oxycodone 2.5 mg three times a day
- Motrin 400-600 mg prn
- Levothyroxine 150 mcg daily
- Captopril 100mg q8h
- Ferrous sulfate 325 mg daily
- Levo-carnitine 10 mL daily
- Dilantin 100 mg q 8
- Tylenol extra strength q4
- Ipratropium nebs q4 prn
- Prilosec 20mg qd
-
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
3. Amlodipine 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Captopril 150 mg PO TID
6. CloniDINE 0.2 mg PO BID
7. Duloxetine 60 mg PO DAILY
8. Hydrochlorothiazide 25 mg PO DAILY
9. Ipratropium Bromide Neb 1 NEB IH Q6H
10. Labetalol 800 mg PO TID
11. Lacosamide 200 mg PO BID
12. LeVETiracetam Oral Solution 1500 mg PO BID
13. Levothyroxine Sodium 150 mcg PO DAILY
14. Phenytoin Infatab 100 mg PO TID
15. Simvastatin 20 mg PO DAILY
16. Levocarnitine 1000 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
epilepsy- nonconvulsive status
hypertensive emergency
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with seizures and confusion.
Your dilantin level was low, and once we gave you extra
dilantin, the seizures stopped. Also, your blood pressure was
very high so we started you on some new blood pressure
medicines.
We have not made any changes to your seizure medications. We
did make multiple changes to your blood pressure medications.
An updated list is included below.
On discharge, please follow up with your neurologist, Dr.
___, as scheduled below.
Followup Instructions:
___
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2150-04-11 12:48:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
HPI: The patient is a ___ year-old right handed woman with a
history of MS, epilepsy including NCSE, frequent UTIs, CHF, COPD
on home O2 who presented to the ___ ED after seizure at her
nursing home. Neurology is consulted as part of a code stroke
protocol given her right sided weakness.
History is obtained from EMS and from her nursing home ___,
but the details are still unclear as the packet of NH info was
not present at the bedside. From what I can gather, the patient
was in her usual state until 5:25pm on ___ when her PCA noted
that her bilateral arms were intermittently shaking and she was
quite confused. For the next half hour or so she would shake
her
arms and stare ahead and was quite confused. Ambulance was
called at 5:54 given continuous seizure). EMS arrived at 18:25
and found the patient in bed with stable vital signs (on 4L NC,
home O2 requirement). She had bilateral arm (not leg) shaking.
Her eyes were open, staring straight ahead, and did not track
the
EMS staff. She was transported to ___ ED and given Ativan
2mg
IM. Her seizure stopped within 30 seconds of administration.
She started to mumble and by the time of arrival to the ED, her
language was somewhat more coherent. Given the right sided
weakness, code stroke was called. On my exam, NIHSS was 9 (see
above for deficits). She was complaining of bifrontal headache.
Notable findings in the ED include, UTI, phenytoin level 6.8
with
an albumin of 4.5. NCHCT normal. CXR done but poor study. She
was given fosphenytoin 800mg IV x1 and continued on home
phenytion and keppra. Ceftriaxone was started by ED for UTI.
Of note, her last ___ Neurology admission was in ___
when she presented in NCSE secondary to UTI and low phenytoin
levels. She was discharged on 3 AEDs at that time, but
currently
is no longer on the vimpat (still on phenytoin and keppra. She
is
followed by an outpatient (non BI) neurologist Dr. ___.
Cannot obtain ROS given patient's perseveration on headache and
she will not answer my questions.
Past Medical History:
- MS : she was diagnosed at the age of ___, but problems started
approximately ___ years ago. She started to drag her left leg, and
required a cane. She has been on Copaxone in the past.
- Seizure Disorder: Patient is currently on three AEDs. she had
a
first seizure approximately ___ years ago which included
convulsions. The second seizure was ___ years ago, where she was
admitted to the ___ and intubated and "placed in a coma to
control her seizures", and she was admitted for a one month
period. During this hospitalization, she was tracheostomized and
gastrostomized. Her trach has since been removed, but the PEG
remains "in case anything happens again".
- UTIs: At least six prior urinary tract infections,per previous
note her daughter noted that she does get confused with her
infections
- CVA: Mild stroke( no more details) ___ years ago, residual
deficits?
- Hypertension
- Hypothyroidism
- "Balloon procedure of the left neck artery"
- CHF: EF unknown
- COPD
Social History:
___
Family History:
Mother passed away from head trauma (?), sister with
___ and seizures. Daughter reports that there is a family
history of seizures.
Physical Exam:
Discharge Exam
General: Obese woman, appears older than stated age, in
moderate
distress regarding her headache
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Extremities: Warm, no edema.
Neurologic Examination:
- Mental Status - Awake, and alert, talking and yelling at
providers. AO x3. Speech is fluent, yet dysarthric at times.
Verbal comprehension is grossly intact. She refuses to recall 3
items or say ___ backwards. She will not
name items for me.
- Cranial Nerves - PERRL 2->1 brisk. Saccadic intrusions, but
no
nystagmus on EOM. There is mild left NLF blunting that is
previously recorded. Tongue midline. Appreciates light touch
on
face.
- Motor - Decreased tone in right arm. Increased tone in both
legs with legs planter flexed at rest. Difficult to assess
given
her unwillingness to participate in the exam. Moves all 4
extremities against gravity, but does not allow full evaluation
- Sensory - Grossly intact b/l
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 0
R 2 2 2 1 0
Plantar response mute on right, extensor on left bilaterally.
- Coordination - she does not participate in this part of the
exam
Pertinent Results:
___ 06:00AM BLOOD WBC-9.1 RBC-3.96* Hgb-11.5* Hct-36.0
MCV-91 MCH-29.2 MCHC-32.0 RDW-14.8 Plt ___
___ 06:00AM BLOOD Glucose-128* UreaN-13 Creat-0.7 Na-136
K-4.3 Cl-99 HCO3-23 AnGap-18
___ 07:25PM BLOOD CK(CPK)-231*
___ 07:00AM BLOOD Calcium-9.0 Phos-3.6 Mg-1.8
___ 06:10AM BLOOD Phenyto-14.8
Brief Hospital Course:
# Seizures
- Initially Neurology Evaluated patient for possible acute
stroke. However, on exam was found to be having a focal partial
seizure. Her seizure duration was at least 20 minutes, but
perhaps as long as 70 minutes. She required Ativan 2mg IM in
the ED to stop the seizure. Phyenytoin level on admission was
subtherapeutic at 6.8. She underwent a repeat phenytoin load in
the ED and subsequently was therapeutic. She was continued on
her home Keppra w/o change. She was placed on cvEEG which
revealed "abundant epileptiform discharges in the left temporal
region". He Phenytoin was increased to 100mg, 100mg, 200mg with
discharge level of 14.9. She will continue to require
outpatient ___ for her medication levels, epilepsy and MS.
#UTI
- Admission U/A and microscopy concerning for UTI. Given her
history of pseudomonal UTIs, she was started on Ceftazadime
while urine cultures were pending. Cultures speciated to
citrobacter and patient was switched to cefpodoxime 200mg q12h
to finish out a 6 day course on ___.
Medications on Admission:
Amlodipine 10 mg PO/NG DAILY
Aspirin 81 mg PO/NG DAILY
Atorvastatin 20 mg PO/NG DAILY
Clopidogrel 75 mg PO/NG DAILY
Clonidine Patch 0.2 mg/24 hr 1 PTCH TD - this is placed weekly
but day of placement unknown
Docusate Sodium 100 mg PO/NG BID
Duloxetine 30 mg PO BID
Gabapentin 100 mg PO/NG TID
Heparin 5000 UNIT SC TID
HydrALAzine 10 mg PO/NG QID
LeVETiracetam 1500 mg PO BID
Lisinopril 40 mg PO/NG DAILY
Labetalol 200 mg PO/NG TID
Omeprazole 20 mg PO DAILY
Polyethylene Glycol 17 g PO/NG DAILY
Phenytoin Sodium Extended 100 mg PO TID
Senna 8.6 mg PO/NG BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. Cefpodoxime Proxetil 200 mg PO Q12H
6. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD QSAT
7. Docusate Sodium 100 mg PO BID
8. Labetalol 200 mg PO TID
9. LeVETiracetam 1500 mg PO BID
10. Lisinopril 40 mg PO DAILY
11. Senna 8.6 mg PO BID
12. Polyethylene Glycol 17 g PO DAILY
13. Phenytoin Sodium Extended 200 mg PO Q2000
14. Phenytoin Sodium Extended 100 mg PO 0800, 1400
15. Omeprazole 20 mg PO DAILY
16. Clopidogrel 75 mg PO DAILY
17. Duloxetine 30 mg PO BID
18. HydrALAzine 10 mg PO QID
19. Gabapentin 200 mg PO TID
20. Heparin 5000 UNIT SC TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Seizure
Urinary Tract Infection
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive, abrasive.
Activity Status: Bedbound.
Discharge Instructions:
You were hospitalized following a seizure. In the hospital,
your blood levels of your anti-seizure medication (dilantin)
were found to be low. Your dose was increased and you
subsequently did well. Additionally, you were found to have a
urinary tract infection this hospitalization.
Followup Instructions:
___
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2162-10-06 10:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Sulfa(Sulfonamide Antibiotics) / quinidine / Ace Inhibitors
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Successful ultrasound-guided placement of ___ pigtail
catheter into the gallbladder.
History of Present Illness:
___ w h/o Factor V Leiden with recurrent DVT, PUD s/p partial
gastrectomy ___ years ago), C.diff, UTI, and cholelithiasis
presents with 24 hrs of abdominal and n/v. Patient was
discharged from the ED on ___ after negative workup for chest
pain. He had been feeling better, and then had a cheeseburger
and ___ fries and started experiencing ___ sharp, diffuse
abdominal pain with nausea and vomiting. Patient is blind (since
birth) and cannot comment on the contents of the emesis. He has
had no flatus since yesterday, and no bowel movement for ___
days. The pain has since reduced to ___ after treatment and
evaluation in the ED.
In the ED, initial vitals were: 9 98.6 89 173/72 18 99% RA (TMAX
of 101.1) while in the ED. Labs notable for: elevated LFTs and
INR of 2.9.
Imaging was notable for a CTA chest and abdomen showed mildly
distended gallbladder with trace pericholecystic fluid.
Pneumobilia and air in the gallbladder may be related to prior
sphincterotomy
to be correlated clinically and implies patency of the cystic
duct, although cholecystitis cannot be entirely excluded. No
pulmonary embolus or acute aortic abnormality.
A RUQUS showed distended gallbladder w/ sludge and stones with
trace pericholecystic fluid and no gallbladder wall thickening.
No biliary dilation.
Patient was seen by Acute Care Surgery who was concerned for
acute cholecystitis and patient was started on antibiotics
(cipro/flagyl).
Upon arrival to the floor, patient reports he is feeling much
better than yesterday. His abdominal pain is now ___ from
___.
He has mild nausea, but has not vomited since yesterday. He has
had chills and fever. He also reports about one week of a "cold"
w/ non-productive cough and runny nose. He denies SOB or CP.
ROS: Positive per HPI. Remaining 10 point ROS reviewed and
negative
Past Medical History:
Recurrent DVT (Factor V Leiden per chart)
Venous stasis ulcer
Thrombocytopenia
Blindness
Peptic ulcer disease
UTI
C.difficle
Goiter
Trigger finger
BPH / ED
CAD
HTN
Hyperlipidemia
MGUS
PUD s/p BII
Partial gastrectomy
Apppendectomy (although recent scan suggests intact appendix)
TURP
Carpal Tunnel Release
Social History:
___
Family History:
Parents not living and does not know medical history at this
time. Does not keep in touch w/ his siblings. He does not think
they had GI issues.
Physical Exam:
ADMISSION PHSYCIAL EXAM:
========================
VITAL SIGNS: 101.0 PO 164 / 100 R Lying 90 18 96 Ra
GENERAL: pleasant gentleman, NAD
HEENT: blind bl, oropharynx patent, edentulous
NECK: supple, no JVP at 45d
CARDIAC: RRR, no m, r, g
LUNGS: CTABL w/ crackles at the base
ABDOMEN: soft, obese abd w/ multiple surgical scars, diffuse abd
ttp w/ prominence in RUQ w/o rebound ttp or guarding
EXTREMITIES: non-pitting edema of lower ext w/ compression
stockings in place
NEUROLOGIC: no facial droop, tongue midline, motor intact,
sensory intact
DISCHARGE PHSYCIAL EXAM:
========================
Vital Signs: 98.9 PO 130 / 75 R Lying 58 18 98 Ra
Pertinent Results:
ADMISSION LABS:
===============
___ 12:00PM GLUCOSE-120* UREA N-12 CREAT-1.0 SODIUM-139
POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-29 ANION GAP-13
___ 12:00PM ALT(SGPT)-203* AST(SGOT)-126* ALK PHOS-92 TOT
BILI-1.1
___ 12:00PM LIPASE-35
___ 12:00PM ALBUMIN-3.8 CALCIUM-9.0 PHOSPHATE-2.6*
MAGNESIUM-1.6
___ 12:00PM WBC-7.3 RBC-4.77 HGB-11.4* HCT-36.6* MCV-77*
MCH-23.9* MCHC-31.1* RDW-13.5 RDWSD-37.8
___ 12:00PM NEUTS-77.6* LYMPHS-12.5* MONOS-8.8 EOS-0.4*
BASOS-0.3 IM ___ AbsNeut-5.65 AbsLymp-0.91* AbsMono-0.64
AbsEos-0.03* AbsBaso-0.02
___ 12:00PM PLT COUNT-107*
___ 04:50AM K+-4.7
___ 04:00AM URINE HOURS-RANDOM
___ 04:00AM URINE UHOLD-HOLD
___ 04:00AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 04:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-7.0
LEUK-NEG
___ 04:00AM URINE RBC-2 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 04:00AM URINE MUCOUS-RARE
___ 02:57AM LACTATE-1.7 K+-5.4*
___ 02:46AM GLUCOSE-125* UREA N-15 CREAT-1.0 SODIUM-136
POTASSIUM-5.3* CHLORIDE-98 TOTAL CO2-25 ANION GAP-18
___ 02:46AM ALT(SGPT)-271* AST(SGOT)-227* ALK PHOS-112
TOT BILI-1.7*
___ 02:46AM LIPASE-99*
___ 02:46AM ALBUMIN-4.1
___ 02:46AM WBC-6.2 RBC-5.20 HGB-12.4* HCT-40.1 MCV-77*
MCH-23.8* MCHC-30.9* RDW-13.6 RDWSD-38.1
___ 02:46AM NEUTS-84.7* LYMPHS-7.1* MONOS-6.3 EOS-1.1
BASOS-0.3 IM ___ AbsNeut-5.26 AbsLymp-0.44* AbsMono-0.39
AbsEos-0.07 AbsBaso-0.02
___ 02:46AM PLT COUNT-105*
___ 02:46AM ___ PTT-31.5 ___
___ 02:20AM cTropnT-<0.01
___ 12:58AM ___ COMMENTS-GREEN
___ 12:58AM LACTATE-1.7
IMAGING:
=======
+ ___ CTA chest and abdomen
1. Mildly distended gallbladder with trace pericholecystic
fluid. Pneumobilia and air in the gallbladder may be related
to prior sphincterotomy to be
correlated clinically and implies patency of the cystic duct,
although
cholecystitis cannot be entirely excluded. If clinical concern
is high, HIDA scan could be considered.
2. No pulmonary embolus or acute aortic abnormality.
3. Normal appendix.
+ ___ HIDA SCAN
Normal gallbladder filling without evidence of acute
cholecystitis.
Subtle filling defects within the gallbladder consistent with
known gallstones and gallbladder sludge.
Brief Hospital Course:
___ w h/o Factor V Leiden with recurrent DVT, PUD s/p partial
gastrectomy ___ years ago), appendectomy ___ years ago), and
cholelithiasis presented with abdominal pain, nausea and
vomiting:
# ABDOMINAL PAIN
# PNEUMOBILIA
# CHOLELITHIASIS
# FEVER
Patient presented with diffuse abdominal pain, n, v and fever
(___). RUQ pain on exam but no ___ sign. Elevated LFTs
(~200s) and Tbili (1.7). RUQUS and CTA abd showing distended
gallbladder w/ trace pericholestatic fluid, no gallbladder wall
edema, cholelithiasis and pneumobilia. He was started on IV
Cipro/flagyl and admitted to medicine initially. Had HIDA which
showed no defect in gallbladder filling. Fever and abdominal
pain w/ elevated LFTs were initially c/f acute cholecystitis,
but given no gallbladder wall edema and negative ___, this
was felt to be unlikely. There is a possibility there was an
obstructive stone which passed. Furthermore, the pneumobilia was
c/f possible fistula given no recent abdominal surgeries.
Ultimately the decision was made to transfer the patient to ___
for management of pneumobilia. Patient underwent MRCP which
showed no evidence of biliary enteric fistula.
# Heterozygous Factor V Leiden
# Recurrent DVTs
On warfarin at home w/ regimen of Warfarin 10 mg PO 2X/WEEK
(MO,FR) and Warfarin 7.5 mg PO 5X/WEEK (___) with a
goal INR ___. Given recurrent DVTs he is very high risk for
recurrent DVT. His warfarin was initially held in preparation
for a possible surgical intervention. INR was monitored and
trended down to 1.7 on ___.
# HTN: sbp 160s on admission. No concern for hemodynamic
instability. Continued amLODIPine 5 mg PO DAILY and Metoprolol
Tartrate 100 mg PO BID 1 CAP PO DAILY. Held Triamterene-HCTZ
(37.5/25) in the setting of fevers, infection.
# HLD: Simvastatin 20 mg PO QPM: held in the setting of elevated
LFTs. Likely ok to resume if LFTs not going up.
# BPH s/p TURP: Continued on tamsulosin 0.4 mg PO QHS.
# IgG-lambda monoclonal gammopathy: Per his most recent heme-onc
visit: monoclonal protein levels steadily rising over the past ___
years, and his level now exceeds 1500 mg/dL, warranting close
follow-up. He has stable renal function and calcium levels.
There are no apparent end-organ effects. His mild anemia relates
to alpha-thalassemia. No intervention is required at present
other than active surveillance. Follow-up with onc at routine
scheduled appointment.
================================================================
___ Course:
On ___ patient transferred to the Acute Care Surgery
Service for further care related to pneumobilia and ultrasound
showing distended gallbladder with sludge and stones and trace
pericholecystic fluid. On ___ HIDA scan showed Normal
gallbladder filling without evidence of acute cholecystitis.
Subtle filling defects within the gallbladder consistent with
known gallstones and gallbladder sludge. On ___ he underwent
MRCP to further evaluate cause of pneumobilia. Study was
consistent with acute cholecystits. There was no evidence of
biliary enteric fistula but study cannot rule out. On ___
interventional radiology placed a percutaneous 8 ___ pigtail
catheter into the gallbladder. Samples were sent for
microbiology evaluation. He was continued on antibiotics. On
___ the patient underwent T-tube cholangiogram to further
evaluate for fistula connection and no connection was
identified.
On ___ he was doing well, afebrile, pain was adequately
controlled, and he was tolerating a regular diet. Coumadin was
restarted on ___ at a dose lower than home dose due to
interaction with ciprofloxacin. His antibiotic regimen was also
adjusted at this time fro cipro/flagyl to Augmentin to avoid
interaction with Coumadin. At time of discharge INR 2.7 and
patient instructed to follow up in ___ clinic for repeat
INR and dosing.. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Metoprolol Tartrate 100 mg PO BID
4. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
5. Omeprazole 20 mg PO DAILY
6. Simvastatin 20 mg PO QPM
7. Tamsulosin 0.4 mg PO QHS
8. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
9. Warfarin 10 mg PO 2X/WEEK (MO,FR)
10. Warfarin 7.5 mg PO 5X/WEEK (___)
11. Ascorbic Acid ___ mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: change order
do not exceed 4 gram/24 hours
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 8 Days
end ___
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*16 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Senna 8.6 mg PO BID:PRN constipation
5. ___ MD to order daily dose PO DAILY16
PLEASE DOSE ACCORDING TO INR
Last INR ___ 2.7
6. amLODIPine 5 mg PO DAILY
7. Ascorbic Acid ___ mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Metoprolol Tartrate 100 mg PO BID
10. Multivitamins 1 TAB PO DAILY
11. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
12. Omeprazole 20 mg PO DAILY
13. Simvastatin 20 mg PO QPM
14. Tamsulosin 0.4 mg PO QHS
15. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
16. Warfarin 7.5 mg PO 5X/WEEK (___)
*please dose according to INR*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
pneumobilia
Acute Cholecystits
Cholelithiasis
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 Acute Care Surgery Service on ___
with an infection in your gallbladder. You had a percutaneous
cholecystostomy tube place to help drain the infection. Multiple
radiologic studies were done to evaluate for an abnormal
connection called a fistula to the bowel. The studies showed
normal connections to both the liver and small bowel and no
abnormal connections. You were given antibiotics to help treat
the infection and should continue to take them as prescribed.
Please follow up in the Acute Care Surgery Clinic at your
scheduled appointment to discuss future surgery.
You are now doing better, tolerating a regular diet, and ready
to be discharged to home with the following discharge
instructions.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
___
|
10689932-DS-10
| 10,689,932 | 22,522,037 |
DS
| 10 |
2139-09-01 00:00:00
|
2139-09-02 09:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
SOB, productive cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o recurrent pneumonia and chronic pansinusitis p/w
acute on chronic SOB and productive cough.
Patient has had a productive cough since a recent bout of
pneumonia ___ ___. Started seeing Dr. ___ ___
___ who began an extensive workup. Last week, she noted
increased SOB with exertion and presented to ___. She was
hypoxic (O2 sat ___ the ___ ___ the ED and was admitted over the
weekend. After discharge, she reports feeling worse than
baseline with increased SOB to point where she gets tired
walking to the bathroom. Her PCP prescribed azithromycin on ___
for possibility of symptoms being related to patient's
pansinusitis. Last night, she woke up with chest tightness,
panting for air and didn't improve with albuterol so decided to
return to ED. Usually sputum is clear or yellow, but today has
been slightly green and "chunky".
Prior to ___, patient had severe bronchitis ___ years ago
and was presumed to have asthma. She had an episode of pneumonia
___ ___, followed by presumed asthma/bronchitis ___
___ and ___. ___ ___, Dr. ___ her asthma
medications after which the patient reported no change ___ her
breathing status until last week.
___ the ED, initial VS were 98.8 93 138/94 22 91%RA. Received
albuterol nebs with some improvement. Labs were notable for
normal WBC count with increased eos (7.8%). CXR demonstrated
previously seen bibasilar consolidations.
On arrival to the floor, patient reports that she continues to
feel SOB after talking and continues to have productive cough.
She also notes rhinorrhea when she coughs.
Past Medical History:
Recurrent pneumonia
Chronic pansinusitis
___'s thyroiditis (never treated)
Diverticulitis
Social History:
___
Family History:
Aunt who had emphysema from secondary exposure to pipe smoke.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.8 138/65 100 20 91%RA
General: well-appearing woman, sitting up ___ bed, noticeably SOB
after a few sentences, NAD
HEENT: NCAT, EOMI, PERRL, MMM
Neck: supple, full ROM, no LAD, JVP not elevated
CV: RRR, no mrg
Lungs: low-pitched wheezes bilaterally (R>L)
Abdomen: flat, normal BS, soft, NTND, no HSM
GU: deferred, no Foley
Ext: R calf slightly larger than L calf, WWP, 2+ pulses
bilaterally
Neuro: motor function grossly normal
DISCHARGE PHYSICAL EXAM:
VS - T 98.2 BP 112/84 HR 84 RR 20 O2 82% RA-->98% post neb -->
85% on RA to 89% on 2.5L
General- thin female ___ NAD sitting upright ___ bed with no
accessory muscle use
HEENT- NCAT, EOMI, PERRL, MMM
Neck- supple, no LAD, JVP not elevated
CV- RRR, no mrg
Lungs- low-pitched expiratory noise throughout lung fields, no
crackles
Abdomen- flat, normal BS, soft, NTND, no HSM
Ext- WWP, 2+ pulses bilaterally
Pertinent Results:
ADMISSION LABS:
___ 09:00AM BLOOD WBC-10.8 RBC-4.92 Hgb-15.4 Hct-43.8
MCV-89 MCH-31.2 MCHC-35.0 RDW-13.8 Plt ___
___ 09:00AM BLOOD Neuts-63.1 ___ Monos-4.8 Eos-7.8*
Baso-1.8
___ 09:00AM BLOOD Glucose-95 UreaN-10 Creat-0.8 Na-141
K-4.6 Cl-102 HCO3-28 AnGap-16
___ 09:00AM BLOOD ALT-24 AST-27 LD(LDH)-220 AlkPhos-85
TotBili-0.5
___ 09:00AM BLOOD Albumin-4.4
PERTINENT MICROBIOLOGY:
___: No Mycobacteria on AFB culture. (prelim)
___ Acid Fast Culture: pending
___ Acid Fast Culture: pending
___ Sputum Culture-
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
1+ (___): MULTIPLE ORGANISMS C/W OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
ACID FAST SMEAR (Preliminary): NO ACID FAST BACILLI SEEN
___ Sputum Culture-
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS, CHAINS, AND
CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
ACID FAST SMEAR (Preliminary):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
___ CRYPTOCOCCAL ANTIGEN (Final ___: NOT DETECTED.
___ Sputum culture- AFB pending
IMAGING:
___ CXR: The lungs are hyperinflated. The previously seen
___ opacities on chest on the prior most recent chest CT
___ the lower lobes is still apparent on this study. There is no
evidence of pulmonary edema, pleural effusion or pneumothorax.
The cardiomediastinal and hilar contours are normal. IMPRESSION:
Bibasilar consolidations are still apparent, difficult to
compare to prior CT. Etiologies are either allergic or
infectious. (Prelim Report)
___ CTA Chest: 1. No evidence of pulmonary embolism.
2. Diffuse extensive bilateral bibasilar ___ opacities
with adjacent areas of focal consolidation persist although
there has been some resolution at the superior segment of the
lower lobes. As before this may be secondary to aspiration or
pneumonia. Small airways demonstrate evidence of mucous
plugging and bronchitis/bronchiectasis, consistent with
extensive small airways disease. Recommend follow up after
treatment to document resolution.
Brief Hospital Course:
___ with h/o recurrent pneumonia and ___ ___ opacities on
CT, p/w acute on chronic SOB and productive cough
# Productive cough and SOB- Patient has had productive cough for
several months with increasing shortness of breath x 1 week. She
has been followed closely as an outpatient by pulmonology. Daily
sputum cultures were obtained with smear negative for AFB,
culture pending. Per inpatient pulmonology consult team, patient
was treated for recurrent pneumonia with 7 day course of
levofloxacin, she was started on tiotropium, salmeterol, and
continuined on outpatient albuterol nebs, chest ___ and acapella.
She was weaned from oxygen but continued to have intermittent
shortness of breath with desaturations to 85% on room air. She
was discharged with home O2 for intermittent desaturations. She
will start outpatient chest ___ and continue to follow closely
with Dr. ___. If not improvement on levofloxacin, will
consider outpatient bronchoscopy.
TRANSITIONAL ISSUES:
# Several sputum cultures pending at time of discharge
# Galactomannan pending on discharge
# IgE pending on discharge
# Levofloxacin to continue through ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB or Wheezing
2. biotin 1 mg Oral Daily
3. budesonide (bulk) 0.5mg/2mL Suspension for Nebulization Nasal
Rinse BID
4. echinacea 1 drops ORAL PRN as directed
5. Fish Oil (Omega 3) ___ mg PO DAILY
6. lactobacillus combination ___ pill ORAL DAILY
7. Albuterol 0.083% Neb Soln ___ NEB IH Q4H:PRN Shortness of
Breath
8. Azithromycin 250 mg PO DAILY
9. Calcium Carbonate Dose is Unknown PO Frequency is Unknown
10. Vitamin D Dose is Unknown PO DAILY
11. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Albuterol 0.083% Neb Soln ___ NEB IH Q4H:PRN Shortness of
Breath
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB or Wheezing
3. budesonide (bulk) 0.5mg/2mL Suspension for Nebulization Nasal
Rinse BID
4. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 cap
INH daily Disp #*30 Capsule Refills:*0
5. Fish Oil (Omega 3) ___ mg PO DAILY
6. lactobacillus combination ___ pill ORAL DAILY
7. Multivitamins 1 TAB PO DAILY
8. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
RX *salmeterol [Serevent Diskus] 50 mcg 1 puff INH every 12
hours Disp #*1 Cartridge Refills:*0
9. Levofloxacin 750 mg PO DAILY Duration: 10 Days
through ___
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*10
Tablet Refills:*0
10. Home O2
ICD-9 V12.61
Please provide home oxygen via pulse dose for portability. ___ L
via NC with amb only for sats of 85%. ___ recovers to 92+ on 2L
AMB. Resting room air sat 92%
11. Outpatient Physical Therapy
ICD-9: V12.61
Please provide patient chest ___ for pulmonary hygiene
Discharge Disposition:
Home
Discharge Diagnosis:
- Recurrent pneumonia
- Bronchiectasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure caring for you at ___. You were admitted for
further evaluation and management of your difficulty breathing
and cough. You were started on levofloxacin to treat an
infection secondary to your underlying lung condition. You were
also continued on regular nebulizer treatment and chest physical
therapy with improvement ___ your breathing. You will likely
need to use oxygen at home for a short time until this infection
improves. You can use the oxygen when you feel short of breath.
You will need to continue antibiotics for a total of 14 days,
ending ___
Followup Instructions:
___
|
10689932-DS-9
| 10,689,932 | 27,554,774 |
DS
| 9 |
2139-08-23 00:00:00
|
2139-08-28 21:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Cough and Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o female with PMH significant for recurrent
pneumonia and question of asthma (in the past; mild obstruction
of PFTs with partial 9% response to bronchodilators, elevated
IgEs in the past) who presents with worsening cough and acute
onset shortness of breath. The pt. was in her usual state of
health until ___ when she was diagnosed with left lower lobe
pneumonia. Her previous episode of pneumonia was ___ years prior
but according to the pt. and her records was quite severe. For
her pneumonia in ___, she was prescribed a Z-Pak. Her
symptoms did not initially resolve at this time and the pt. was
given a course of Augmentin 875 BID for 14 days. She recovered
well. In ___, the pt. took a trip to ___. On return
home, she reports another episode of cough and fever, later
diagnosed as pneumonia in ___ with bilateral interstitial
changes. She completed an additional course of augmentin 500mg
BID for 10 days.
Since her episode of pneumonia in ___, the patient reports
malaise and coughing which has worsened over the last few weeks.
She also reports significant worsening nocturnal cough over the
last week associated with sputum production. Her sputum ranged
from clear to cloudy, to green like color with what she
describes as "crystal" like granuales. The night prior to
admission, patient woke up with a coughing spell associated with
acute onset nasal congestion. The pt. was unable to fully catch
her breath despite use of her proair inhaler (she has not been
using her inhaler regularly). This triggered her to present to
the ED. She denies any sick contacts (pt. has no grandchildren),
recent travel other than ___ as mentioned above, fevers,
chills, GERD-associated symptoms, nausea, vomiting, or diarrhea.
She also denies hemopytsis, difficulty swallowing, chest pain,
or palpitations. She does not notice anything that triggers her
coughing such as certain foods or lying down. Of note, per pt.,
pt. had a negative allergy work-up on ___ with some type of
skin testing. She also has noticed some weight loss over the
last few months but has made a recent effort to regain her
weight.
Patient is currently being worked up by Dr. ___ of
pulmonary for these symptoms. In ___, pt. had recently
stopped her montelukast and fluticasone without worsening of
symptoms. Pulmonary function tests performed showed declining
FEV1 with only 4% improvement following bronchodilation. A CT
scan was then performed (___) which showed airway disease
consistent with pneumonia.
On presentation to the ED, initial vs were: 97 89 163/86 14 89%.
A CTA was done which was negative for PE. Pt. was given
albuterol and tylenol and transferred to the floor. Vitals on
Transfer: 98.1 87 113/72 12 93% RA
Past Medical History:
1. Recurrent Pneumonia
2. ? of Asthma
3. ___'s thyroiditis
4. Pansinusitis.
Social History:
___
Family History:
Denies hx. of pulmonary disease, immune disorders other than MS
in her father and brother (both deceased ___ complications), or
hx. of recurrent infections.
Physical Exam:
ADMISSION PHYSICAL EXAM
itals: T 98.1 HR 97 BP 142/84 RR 18 Sat 92% on RA
General: Pt. sitting up in NAD
HEENT: NCAT, MMM, sclera anicteric, oropharynx is clear
Neck: Supple, thyroid is palpable and not enlarged
Lungs: Expiratory wheezes in right mid and lower lung fields.
Otherwise CTAB. No rales, rhonci, or egophany. No upper airway
wheeze
CV: RRR, S1/S2, no murmurs, rubs, gallops, or clicks
Abdomen: Soft, NT, ND, +BS, no rebound or guarding
Ext: WWP, No ___ edema
Skin: No rashes, petechiae, or ecchymosis
DISCHARGE PHYSICAL EXAM:
Vital Signs: 98.8 128/72 87 20 93%RA (Ambulatory ___ on day of
discharge 91-94% on RA)
General: NAD
HEENT: NCAT, EOMI, PERRL, MMM
Neck: Supple, no thyromegaly, no lymphadenopathy, full ROM, no
LAD, JVP <7CM at 45 degrees
CV: RRR, S1/S2, no murmurs, rubs, gallops, or clicks
Lungs: Good air flow with end expiratory wheeze at right lung
base, otherwise clear to auscultation bilaterally
Abdomen: Soft, nontender, nondistended, positive BS, no rebound
or guarding
Ext: WWP, 2+ pulses bilaterally, no ___ edema
Pertinent Results:
Admission labs:
___ 05:40AM WBC-13.7* RBC-5.01 HGB-15.6 HCT-45.0 MCV-90
MCH-31.1 MCHC-34.6 RDW-13.4
___ 05:40AM NEUTS-84.8* LYMPHS-8.2* MONOS-4.4 EOS-2.1
BASOS-0.5
___ 05:40AM PLT COUNT-264
___ 05:40AM GLUCOSE-101* UREA N-14 CREAT-0.9 SODIUM-140
POTASSIUM-4.7 CHLORIDE-104 TOTAL CO2-21* ANION GAP-20
Discharge labs:
___ 07:45AM BLOOD WBC-9.3 RBC-4.59 Hgb-14.1 Hct-40.8 MCV-89
MCH-30.7 MCHC-34.4 RDW-13.5 Plt ___
___ 07:45AM BLOOD UreaN-10 Creat-0.9 Na-141 K-4.2 Cl-104
HCO3-27 AnGap-14
Microbiology:
___ 2:29 pm SPUTUM Source: Induced.
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
FUNGAL CULTURE (Final ___: NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
Brief Hospital Course:
BRIEF SUMMARY STATEMENT: Ms. ___ is a ___ y/o female with PMH
relevant for multiple recent courses of pneumonia who presents
with worsening cough and shortness of breath. Pt. is currently
under workup for these symptoms. CT scans from early this month
and today show bibasilar tree in ___ opacities with focal
consolidation consistent with extensive small airways disease.
Recent expectorated sputum from ___ growing Mycobacterium
Avium Complex (MAC).
# Chronic cough, possible pneumonia, possible MAC infection:
Patient was admitted with acute on chronic worsening cough over
the last 1 weeks time. She had previously been treated for
multiple episodes of pneumonia (confirmed with chest xray) with
azithromycin and augmentin without improvement. She also is
currently being worked-up as an outpatient for her pulmonary
symptomatology. As part of this work-up, she had a sputum that
returned positive for mycobacterium avium complex (sputum from
___. Given this history, we attributed her elevated white
blood cell count and chief complaint likely secondary to a
community acquired MAC infection. On admission, the patient
reported chest tightness in audition to diffuse bilateral
wheezes. Her chest tightness and wheezes responded well to
albuterol nebulizer treatments. On the day of discharge, we
discussed with the covering physician for the patient's
pulmonologist additional testing or treatment that would be
beneficial. At this time, we elected to obtain an additional
induced sputum sample to help confirm the diagnosis of MAC.
Additionally, we performed an HIV test which was negative. The
patient was hemodynamically stable throughout admission with
oxygen saturation on room air at baseline. The patient was
discharged with close primary care and pulmonary follow-up.
CHRONIC ISSUES:
# ___ Thyroiditis: Recommended the patient continue to
follow-up with her outpatient endocrinologist.
# Question of Asthma: According to the patient, she has been
off her inhalers for >1 month as part of her pulmonary work-up.
She has a history of minimal response to bronchodilation on
pulmonary function tests. On this admission, the patient did
report moderate relief of chest tightness following albuterol
inhalers. As such, there may be a component of reactive airways
disease in addition to pt.'s pneumonia.
#Pansinusitis: Stable. The patient was discharged on her home
budesonide nasal rinse.
TRANSITIONAL ISSUES
- Pulmonary Follow-up: Patient will continue to be followed in
pulmonology clinic, and if further AFB/cultures return positive
for MAC she may need to start treatment, but no treatment
initiated this hospitalization.
- Echocardiogram - The patient has echocardiogram from ___
which showed mild pulmonary hypertension (estimated pulmonary
artery pressures of 32-35mmHg) with a small hyperdynamic left
ventricle. Consider repeat echocardiogram if suspicion
increases for cardiac etiology.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. budesonide (bulk) 0.5mg/2mL Suspension for Nebulization Nasal
Rinse BID
2. biotin 1 mg Oral Daily
3. Fish Oil (Omega 3) ___ mg PO DAILY
4. echinacea Uncertain Oral Uncertain
5. lactobacillus combination no.4 uncertain Oral uncertain
6. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB or Wheezing
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB or Wheezing
2. biotin 1 mg Oral Daily
3. budesonide (bulk) 0.5mg/2mL Suspension for Nebulization Nasal
Rinse BID
4. echinacea 1 drops ORAL PRN as directed
5. Fish Oil (Omega 3) ___ mg PO DAILY
6. lactobacillus combination ___ pill ORAL DAILY
7. Albuterol 0.083% Neb Soln ___ NEB IH Q4H:PRN Shortness of
Breath
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 neb inhaled every
4 hours Disp #*30 Vial Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-Dyspnea
-lung consolidations on CT of unknown significance
-positive AFB for mycobacterium avium complex
Secondary:
-recurrent pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you during your hospitalization at
___. You were admitted for increasing shortness of breath felt
to be related to the chronic infection in your lungs for which
you are followed by Dr. ___. We discussed your case with the
pulmonology team, who feel that you should use albuterol
nebulizers and the "acapella valve" to increase mucus clearance
from your airways, and continue to follow up in pulmonology
clinic.
Some of your labs were pending at the time of discharge. One of
our doctors, Dr. ___ call you with these results
as they become available.
Followup Instructions:
___
|
10690012-DS-12
| 10,690,012 | 21,176,648 |
DS
| 12 |
2144-01-15 00:00:00
|
2144-01-15 15:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Tetanus Toxoid,Fluid / Humira /
sulfasalazine / Otezla / steri strips / red meat / Macrobid /
acetoxolone
Attending: ___.
Chief Complaint:
Fatigue, nausea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with opioid dependency
and recurrent serous Fallopian tube cancer s/p
carboplatin/doxorubicin in ___ and now on re-treatment with
carboplatin/doxorubicin (C3D1 ___ who presents with fever,
malaise, and dysuria.
She reports her symptoms began shortly after her most recent
round of chemotherapy on ___. She has had intermittent fevers,
most recently up to 101 a few days ago. She reports blisters
presenting on the side of her right face and on her back.
Additionally, last night she noted urinary frequency and
dysuria.
She has also notes poor appetite and decreased PO intake. She
notes some dizziness today. She has had nausea without vomiting.
Her energy is very low. She has had similar symptoms after
chemotherapy previously though this time they are worse.
On arrival to the ED, initial vitals were 97.6 75 147/85 16 95%
RA. Labs were notable for fatigued-appearing, diffuse abdominal
tenderness worst in suprapubic area, and right CVA tenderness.
Labs were notable for WBC 3.3, H/H 8.9/28.5, Plt 132, INR 1.0,
Na
141, K 3.9, BUN/Cr ___, LFTs wnl, lactate 0.5, and UA with
trace leuks, positive nitrite, 1 WBC, and few bacteria.
Abdominal
CT showed no acute process. Patient was given ceftriaxone 1g IV,
reglan 10mg IV, Benadryl 25mg IV, gabapentin 800mg PO, and 2L
NS.
Initial plan was for discharge home with PO antibiotics for UTI
however she reported continued symptoms with lightheadedness so
decision was made to admit for failure to thrive. Prior to
transfer vitals were 98.1 78 114/78 16 98% RA.
On arrival to the floor, patient reports feeling slightly
better.
She denies headache, vision changes, weakness/numbness,
shortness
of breath, cough, hemoptysis, chest pain, palpitations,
abdominal
pain, vomiting, diarrhea, hematemesis, hematochezia/melena,
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:
- CERVICAL RADICULOPATHY
- PREDIABETES
- HYPERTENSION
- MENIERE'S DISEASE
- PSORIATIC ARTHRITIS
- LESION ORAL TONGUE
- RASH
- ABDOMINAL PAIN
- GAS AND BLOATING
- COLONIC ADENOMA
- STAGE ___ FALLOPIAN CANCER, ON ___ ___ ROUND ___
- LATERAL ___
- HISTORY OF IVDU
PSH:
- ___ Incisional hernia repair (primary w/o mesh) lower
hernia, Dr. ___
- LAPAROTOMY ___ diagnostic, exploratory, radical
cytoreductive surgery for advanced Mullerian cancer
- TAH/BSO ___
- OMENTECTOMY ___
- SIGMOID COLECTOMY ___
- THYROIDECTOMY for ? of cancer
Social History:
___
Family History:
Breast cancer in a maternal grandmother, colon
cancer in maternal grandmother and grandfather. No other
history
of ovarian, uterine cancers. Parents, mother and father with
high blood pressure and father with heart disease.
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
VS: Temp 98.3, BP 163/91, HR 70, RR 18, O2 sat 99% 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, mild suprapubic tenderness, non-distended, normal
bowel sounds.
EXT: Warm, well perfused, no lower extremity edema.
NEURO: A&Ox3, good attention and linear thought, gross strength
and sensation intact.
SKIN: Mild rash on bilateral flanks.
ACCESS: Right chest wall port without erythema.
=======================
DISCHARGE PHYSICAL EXAM
=======================
VITALS: ___ 0806 Temp: 97.38 PO BP: 156/94 HR: 76 RR: 18 O2
sat: 95% O2 delivery: RA
GENERAL: well nourished woman in no acute distress
HEENT: AT/NC, anicteric sclera, MMM
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABD: abdomen soft, nondistended, nontender in all quadrants
EXT: wwp, no cyanosis, clubbing, or edema
SKIN: Warm and well perfused, no excoriations or lesions
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
Pertinent Results:
=======================
ADMISSION LAB RESULTS
=======================
___ 11:04AM BLOOD WBC-3.3* RBC-2.94* Hgb-8.9* Hct-28.5*
MCV-97 MCH-30.3 MCHC-31.2* RDW-18.2* RDWSD-64.4* Plt ___
___ 11:04AM BLOOD Neuts-66.3 ___ Monos-8.3 Eos-0.9*
Baso-0.3 Im ___ AbsNeut-2.16 AbsLymp-0.78* AbsMono-0.27
AbsEos-0.03* AbsBaso-0.01
___ 11:04AM BLOOD ___ PTT-39.7* ___
___ 11:04AM BLOOD Glucose-114* UreaN-12 Creat-0.9 Na-141
K-3.9 Cl-102 HCO3-27 AnGap-12
___ 11:04AM BLOOD ALT-8 AST-14 AlkPhos-48 TotBili-<0.2
___ 11:04AM BLOOD Albumin-4.2
___ 07:50PM BLOOD Lactate-0.5
======================
DISCHARGE LAB RESULTS
======================
___ 05:22AM BLOOD WBC-4.0 RBC-2.93* Hgb-8.9* Hct-28.3*
MCV-97 MCH-30.4 MCHC-31.4* RDW-18.5* RDWSD-64.4* Plt ___
___ 05:22AM BLOOD Plt ___
___ 05:22AM BLOOD Glucose-118* UreaN-11 Creat-0.9 Na-142
K-4.1 Cl-103 HCO3-30 AnGap-9*
___ 05:22AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.3
======================
IMAGING AND REPORTS
======================
CT ABDOMEN/PELVIS ___
IMPRESSION:
1. No acute process in the abdomen/pelvis.
2. Subtle enhancement at the anterior abdominal wall, unchanged
from prior, may reflect postoperative changes though given
history of biopsy proven carcinoma in this region, close
attention on follow-up is advised.
3. Normal appearance of the appendix with similar adjacent
pocket of
loculated fluid, of doubtful clinical significance.
Brief Hospital Course:
Ms. ___ is a ___ female with opioid dependency
and recurrent serous fallopian tube cancer s/p
carboplatin/doxorubicin in ___ and now on re-treatment with
carboplatin/doxorubicin (C3D1 ___ who presents with fever,
malaise, and dysuria. She was treated for UTI and evaluated by
addiction psychiatry team regarding pain management. She was
discharged with reduced opioid regimen and plan to follow up at
___ per patient request.
ACUTE PROBLEMS:
===============
# Post-chemotherapy fatigue, dizziness, nausea
Ms. ___ completed her last session of chemotherapy on ___
and subsequently developed fatigue, dizziness and nausea. She
has experienced similar symptoms after previous sessions but
this time seemed much worse. She was admitted for failure to
thrive. Her symptoms improved with IV fluids and Zofran for
nausea. She was tolerating PO intake at the time of discharge.
# Goals of care
Patient expressed unhappiness with most recent round of
chemotherapy and thought she may not want to continue with
further treamtents due to intolerable side effects. Her
oncologist, Dr. ___, was notified. The patient requested to
seek a second opinion and made an appointment to be seen at ___
___.
# Chronic pain
# Opioid use disorder
# Depression
Patient has hx of OUD but has been in remission for ___ years and
is on methadone. She was recently prescribed opioids for
post-operative pain after hernia repair. Per Dr. ___ was
supposed to taper her pain medications but the patient
disagreed. Patient describes pain in her back and pelvis, which
she attributes to her tumors. However, her tumors have
reportedly decreased in size since starting chemotherapy.
Addiction psych evaluated her and thought much of her symptoms
were related to depression rather than pain. They agreed with
discharge plan to taper to BID dilaudid rather than TID. When
she sees Dr. ___ a new provider at ___, her opioid
plan can be reevaluated. Additionally, patient was advised to
discuss her medications for depression with her psychiatrist.
She may benefit from dose titration. She was continued on her
home methadone dose.
# Urinary Frequency/Dysuria
Patient with urinary symptoms with mildly positive UA. She
reports this has been ongoing for the last year. Her symptoms
improved with pyridium. This was not continued at discharge
given that it is not recommended for long-term use. However,
restarting can be considered for recurrent symptoms. She
received a three day course of ceftriaxone. She was also tested
for gonorrhea, chlamydia and trichomonas given chronicity of
symptoms; these were negative.
CHRONIC PROBLEMS:
=================
# Recurrent Fallopian Tube Cancer:
# Malignant Ascites: She is s/p C3 Carboplatin/Doxorubicin
Follows with Dr. ___. Requests second opinion and made an
appointment at ___. Does not have much social support
but seemed interested in social support groups.
# Mood Disorder
Follows with psychiatry (Dr. ___ and therapist ___.
Continue home buproprion, clonazepam, and methylphenidate. Per
addiction psych team, patient appears to be depressed and may
benefit from adjustment to her antidepressant regimen. Patient
stated her psychiatrist expressed reservations about changing
her regimen due to concern for drug interaction with
chemotherapy. This should be reevaluated given the patient's
symptoms.
# Hypertension
Continue home losartan and amlodipine
# Hypothyroidism
Continue home levothyroxine. Repeat TSH and FT4 as outpatient
# GERD
Continue home omeprazole
# Anemia/Thrombocytopenia: Secondary to malignancy and
chemotherapy. Stable.
===========================
TRANSITIONAL ISSUES
===========================
[ ] Discuss uptitrating antidepressant medications with
outpatient psychiatry
[ ] Planning to discharge on PO dilaudid 2 mg BID (tapered from
TID). She will receive enough to bridge her to her next visit at
___ and her plan can be reassessed at that time.
[ ] Patient's dysuria responded well to pyridium. This was given
for the recommended 3 day course. It may be restarted in the
future if her symptoms recur.
[ ] Please continue to provide patient with resources for social
support, including cancer support groups as she expressed
interest in this idea
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Bisacodyl 10 mg PO DAILY:PRN constipation
3. ClonazePAM 1 mg PO TID:PRN anxiety
4. Gabapentin 800 mg PO TID
5. HYDROmorphone (Dilaudid) 2 mg PO Q8H:PRN Pain - Moderate
6. Levothyroxine Sodium 200 mcg PO DAILY
7. Losartan Potassium 100 mg PO DAILY
8. Methadone 145 mg PO DAILY
9. Methylphenidate SR 54 mg PO QAM
10. Omeprazole 20 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. ValACYclovir 500 mg PO Q24H
13. Ondansetron ODT 4 mg PO Q8H:PRN nausea/vomiting
14. BuPROPion XL (Once Daily) 300 mg PO DAILY
15. Senna 8.6 mg PO BID:PRN constipation
16. Docusate Sodium 100 mg PO BID:PRN constipation
17. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Medications:
1. HYDROmorphone (Dilaudid) 2 mg PO BID
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth twice a
day Disp #*16 Tablet Refills:*0
2. amLODIPine 10 mg PO DAILY
3. Bisacodyl 10 mg PO DAILY:PRN constipation
4. BuPROPion XL (Once Daily) 300 mg PO DAILY
5. ClonazePAM 1 mg PO TID:PRN anxiety
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Gabapentin 800 mg PO TID
8. Levothyroxine Sodium 200 mcg PO DAILY
9. Losartan Potassium 100 mg PO DAILY
10. Methadone 145 mg PO DAILY
Consider prescribing naloxone at discharge
11. Methylphenidate SR 54 mg PO QAM
12. Omeprazole 20 mg PO DAILY
13. Ondansetron ODT 4 mg PO Q8H:PRN nausea/vomiting
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. Senna 8.6 mg PO BID:PRN constipation
16. ValACYclovir 500 mg PO Q24H
17. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
-Post chemotherapy failure to thrive
SECONDARY:
-Opioid use disorder
-Chronic dysuria
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted for feeling poorly after chemotherapy.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were given antibiotics for possible urinary tract
infection.
- You were given IV fluids to improve dizziness.
- Psychiatry evaluated you and recommended that you discuss
increasing your antidepressant medications with your outpatient
psychiatrist.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10690012-DS-7
| 10,690,012 | 25,567,330 |
DS
| 7 |
2141-09-12 00:00:00
|
2141-09-12 13:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Erythromycin Base / Tetanus Toxoid,Fluid / Humira /
sulfasalazine / Otezla
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ gravida 3, para 0 who initially presented to the
emergency room earlier this month with abdominal pain and she
was diagnosed with PID given low grade temp, +CMT, vaginal
discharge. She presented to you in followup on ___
at which time her acute symptoms were improved s/p ceftriaxone
and on her course of doycycline. Meanwhile, the patient has also
been followed by Dr. ___ ___ who given several months of
abdominal symptoms had ordered a CT scan which was performed on
___. CT was notable for omental stranding and
thickening concerning for an omental cake along with nodularity
alongside the appendix and peritoneal surfaces in the pelvis.
The ovaries appeared normal; however, there was a moderate
amount of loculated fluid and multiple nodular implants
adjacent to the left ovary. Additionally, there were some
prominent bilateral inguinal nodes, largest measuring 10 mm.
There was no other pelvic lymphadenopathy noted. Thus, she was
further counseled and sent for an omental biopsy on ___ and preliminary results have returned consistent with a
serous carcinoma of mullerian origin, thus she presents today
for further evaluation and management.
The patient reports that she continues to have significant
abdominal pain and distension. She also reports a lot of pain
at the site of the biopsy from two days ago. Additionally, she
endorses a decreased appetite and associated nausea, no
vomiting. She continues to struggle with constipation which is a
longstanding issue for her.
A complete 10 point review of systems is notable for subjective
fevers, nothing greater than 99.2 measured, and none current.
Endorses difficulty with swallowing, urinary frequency and
discomfort with urination, though no dysuria, easy bruising and
chronic fatigue and weakness. Otherwise, a complete 10-point
review of systems is negative. She denies any vaginal bleeding
or abnormal vaginal discharge.
Past Medical History:
PAST MEDICAL HISTORY:
* Prediabetes, previously took metformin, none current.
* Hypertension
* Meniere's disease
* Psoriatic arthritis
* History of colonic adenoma.
* Anxiety, depression
* History of substance abuse on methadone.
Health Maintenance:
* Last mammogram was a year ago. She has one scheduled next
week.
* Last colonoscopy ___ and has a followup plan for
___ years.
PAST SURGICAL HISTORY:
* Thyroidectomy at ___ ~ 8 to ___ years ago.
* Denies any other surgery.
PAST OBSTETRICAL HISTORY: Gravida 3, para 0. Uncertain but on
review today, reports three or four early pregnancy losses,
never
worked up.
PAST GYNECOLOGIC HISTORY:
* Menarche at age ___ with monthly periods with extremely heavy
bleeding and terrible abdominal cramps lasting seven days.
* Menopause in ___ and has had absolutely no postmenopausal
bleeding. * Is sexually active and uses condoms, of note was
sexually active for the first time in many years.
* History of OCP use for ___ years, roughly ___ years ago, no
history of hormone replacement therapy.
* Endorses a history of genital warts, gonorrhea, chlamydia and
PID ( ~ ___ years ago),
* Was told she had uterine fibroids but no issues with ovarian
cysts.
Social History:
___
Family History:
Breast cancer in a maternal grandmother, colon cancer in
maternal grandmother and grandfather. No other history of
ovarian, uterine cancers. Parents, mother and father with high
blood pressure and father with heart disease.
Physical Exam:
On day of discharge:
Afebrile, vitals stable
No acute distress
CV: regular rate and rhythm
Pulm: clear to auscultation bilaterally
Abd: soft, appropriately tender, mildly distended, no
rebound/guarding
___: nontender, nonedematous
Pertinent Results:
___ 03:19PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 03:19PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 03:19PM URINE RBC-<1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 01:45PM GLUCOSE-100 UREA N-13 CREAT-0.7 SODIUM-138
POTASSIUM-4.6 CHLORIDE-95* TOTAL CO2-26 ANION GAP-22*
___ 01:45PM estGFR-Using this
___ 01:45PM URINE HOURS-RANDOM
___ 01:45PM URINE HOURS-RANDOM
___ 01:45PM URINE UHOLD-HOLD
___ 01:45PM URINE UHOLD-HOLD
___ 01:45PM WBC-9.4 RBC-4.10 HGB-12.8 HCT-39.6 MCV-97
MCH-31.2 MCHC-32.3 RDW-12.2 RDWSD-43.3
___ 01:45PM NEUTS-70.8 ___ MONOS-5.9 EOS-2.8
BASOS-0.5 IM ___ AbsNeut-6.66* AbsLymp-1.81 AbsMono-0.56
AbsEos-0.26 AbsBaso-0.05
___ 01:45PM PLT COUNT-331
___ 01:45PM ___ PTT-28.6 ___
Brief Hospital Course:
Ms. ___ was admitted to the gynecologic oncology service for
management of abdominal pain, thought to be related to her
likely primary peritoneal adenocarcinoma.
She was given acetaminophen, gabapentin, and oxycodone, with IV
dilaudid for breakthrough pain. On ___hest
which showed no intrathoracic evidence of malignancy. On ___,
she underwent Abdominal ultrasound which showed no there is no
drainable fluid in the 4 abdominal quadrants. In the midline
pelvis, there is a sliver of fluid anterior to the bladder, not
drainable.
She was seen by the Chronic Pain service who recommended
increasing her gabapentin and adding tizanidine.
For her history of opioid dependence she was continued on her
home methadone during her admission. For her hypertension,
depression and hypothyroidism, she was continued on her home
medications.
By hospital day 2, she was tolerating a regular diet, voiding
spontaneously, ambulating independently, and pain was controlled
with oral medications. She was then discharged home in stable
condition with outpatient follow-up scheduled.
Medications on Admission:
AMLODIPINE [NORVASC] - Norvasc 10 mg tablet. 1 tablet(s) by
mouth
once a day
BUPROPION HCL [WELLBUTRIN] - Wellbutrin 75 mg tablet. 2
tablet(s)
by mouth once a day - (Prescribed by Other Provider: Dr ___
at
___ )
CLONAZEPAM - clonazepam 1 mg tablet. 1 tablet(s) by mouth three
times daily - (Prescribed by Other Provider: Dr ___ in
___
GABAPENTIN - gabapentin 300 mg capsule. 1 capsule(s) by mouth 3
times a day
LEVOTHYROXINE - levothyroxine 175 mcg tablet. one Tablet(s) by
mouth once daily
LOSARTAN - losartan 100 mg tablet. 1 tablet(s) by mouth once a
day
METHADONE [METHADOSE] - Methadose 10 mg/mL oral concentrate. 145
mg by mouth once daily - (Prescribed by Other Provider: ___ ___
METHYLPHENIDATE [CONCERTA] - Concerta 54 mg tablet,extended
release. 1 tablet(s) by mouth once a day - (Prescribed by Other
Provider: Dr ___ at ___ )
OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1
capsule(s) by mouth once a day
ONDANSETRON HCL - ondansetron HCl 4 mg tablet. 1 tablet(s) by
mouth every eight (8) hours as needed for nausea
OXYCODONE-ACETAMINOPHEN [ENDOCET] - Endocet 10 mg-325 mg tablet.
1 tablet(s) by mouth every eight (8) hours as needed for pain at
biopsy site take ___ pills up to every 8 hours as needed
VALACYCLOVIR - valacyclovir 500 mg tablet. 1 tablet(s) by mouth
once daily
Medications - OTC
BENZOCAINE [ORABASE (BENZOCAINE)] - Orabase (benzocaine) 20 %
mucosal paste. Apply thin layer to affected area up to 4 times
daily - (Not Taking as Prescribed)
CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3)
1,000
unit capsule. 1 capsule(s) by mouth once daily
LACTASE [LACTAID] - Lactaid 3,000 unit tablet. one or two
Tablet(s) by mouth before ingesting dairy - (Prescribed by
Other
Provider)
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
Do not exceed 4,000 mg in 24 hours.
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours
Disp #*50 Tablet Refills:*1
2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
Do not drink alcohol or drive.
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*15 Tablet Refills:*0
3. Tizanidine ___ mg PO TID
Do not drink alcohol or drive.
RX *tizanidine 2 mg ___ capsule(s) by mouth three times daily
Disp #*90 Capsule Refills:*2
4. Gabapentin 600 mg PO TID
RX *gabapentin 600 mg 1 tablet(s) by mouth three times daily
Disp #*90 Tablet Refills:*2
5. amLODIPine 10 mg PO DAILY
6. BuPROPion (Sustained Release) 150 mg PO BID
7. ClonazePAM 1 mg PO TID:PRN anxiety
8. Levothyroxine Sodium 175 mcg PO DAILY
9. Losartan Potassium 100 mg PO DAILY
10. Methadone 145 mg PO DAILY
11. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
abdominal pain from likely primary peritoneal adenocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the Gynecologic Oncology service for pain
management. You have recovered well and the team feels that you
are safe for discharge. Please follow the instructions below:
.
* Take your medications as prescribed. We recommend you take
non-narcotics (Tylenol, tizanidine, gabapentin) regularly for
the first few days post-operatively, and use the narcotic as
needed. As you start to feel better and need less medication,
you should decrease/stop the narcotic first.
.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
.
Call your doctor at ___ for:
* fever > 100.4
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
* chest pain or difficulty breathing
* onset of any concerning symptoms
Followup Instructions:
___
|
10690033-DS-4
| 10,690,033 | 26,306,810 |
DS
| 4 |
2117-12-04 00:00:00
|
2117-12-04 11:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Codeine
Attending: ___
Chief Complaint:
Lower Extremity Weakness, Fever, and Shortness of Breath
Major Surgical or Invasive Procedure:
Lumbar Puncture under Fluoroscopy with general anesthesia
History of Present Illness:
___ is a ___ year-old man with a history significant
for mid-thoracic disc herniation (with mild spinal cord
compression), mood disorder, and IV heroin abuse. He presented
to an OSH ___) for inability to walk today with
right leg numbness as well as a three-day history of mid and low
back pain.
He was crying intermittently when I came to evaluate him in the
___. He says he remembered me, and addressed me by name ("Dr.
___. He had my business card, and a red NeuroPin that I
had left with him at his request back in ___. He says that he
has been telling doctors in our ___ and the OSH to find Dr.
___ I was a good doctor and he dislikes Dr. ___
___ spine surgeon).
I saw him just before his discharge from our hospital back in
___ of this year (as a ___, while he was a
patient on the ortho-spine service). At that time, he had
presented with leg weakness and sensory loss; please see prior
note from Dr. ___ details of that presentation). The
ortho-spine service had decided surgery was not indicated for
his thoracic disc herniation; as a second opinion, Dr. ___
Neurosurgery likewise found no reason to operate in a clinic
consultation a couple months ago; Dr. ___ noted a
psychiatric greater than neurologic nature of his complaints and
exam (see note in ___ from ___. The patient is unhappy that
Drs. ___ did not decide to operate. Nonetheless,
he recovered following his hospitalization and a month of rehab
at "Radius" and then another month or so at ___.
Over the past few weeks, he says he has been living with his
mother. He says he was able to walk normally during that time,
until this morning.
About three days ago, he developed the acute onset of pain in
his mid-back and lower back. He cannot recall when exactly it
started, or what he was doing when it started. He denies any
trauma, heavy lifting, or unusual positions. He says he sleeps
on a tempur-pedic matress, which is comfortable. He denies
recent illness. He denies IVDU, painkiller use, or illicit
substance abuse; he finished taking Percocet back in ___ or
___, while he was in Rehab. He tried taking over-the-counter
pain medications for his back pain, but they did not help.
This morning, when he awoke, he says his Right leg was
completely numb (from the hip down to the toes) and he was
unable to move any part of it and therefore unable to walk, so
he went to ___. There, they gave him IV pain
medications and got T- and L- spine MR imaging. His VS have been
normal and stable save mild tachycardia at the OSH. Labs notable
for elevated tranaminases (both low-200s), elevated bicarbonate
(30 there, 33 here). No leukocytosis or fever. The ___ MRI
showed his known disc herniation, which does not appear
significantly different (on my review) from a few months ago.
The ___ imaging appears normal to me, but the ___ physicians
here were told (verbal report from an OSH ___ physician) that the
MRI showed an L4-5 disc herniation (we do not have a radiology
report
documenting this finding). I do not appreciate any
clinically-significant lateral or posterior herniation on my
review -- the spinal canal is widely patent, and all lumbar and
sacral nerve roots have ample epidural fat surrounding them
through their foramina bilaterally. If anything, there is a tiny
posterior disc extrusion at L5/S1, but again there is a
wide-open spinal canal behind it and the S1 nerve root is not
compressed.
The OSH transferred him here for treatment of this supposed L4-5
disc herniation. Our ___ physicians evaluated him, and called an
"Emergent CODE CORD" for Neurologic and Spine evaluation.
Regarding other symptoms, on ROS he denies any changes in
strength or sensation in his face or arms. He denies neck pain.
No fever or recent illness. He says he has had some mild urinary
incontinence of recent in bed at night, but that over the past
few days he has had more trouble getting urine out. He denies
abdominal or pelvic discomfort. Re. the elevated TAs, I asked
him if he has any history of liver disease, or hepatitis C or B.
He initially denied it, then said his doctor ___ have tested him
for hep C, then said, "I think maybe I have hep C?" and then
said he did not think so. He has a mild rash (?acne) with
red-based small pustules over his shoulders and chest.
Past Medical History:
1. IVDU heroin and cocaine
2. Mood disorder NOS
3. ADD
4. Cyst removed from penis ___ years ago
5. T5-6 Posterior disc herniation s/p 2 months of rehab
Social History:
___
Family History:
Father - history of drug addiction
Physical Exam:
Vital signs: 99.0F 80,reg 122/86 18 99%RA
General: Tearful. Avoids eye contact. Moderately cooperative
with
exam.
HEENT: Atraumatic. Anicteric. Mucous membranes are dry, with
grayish exudate covering the tongue. No lesions noted in
oropharynx. Pt has a Right-deviated uvula (palate is symmetric).
Neck: Supple, with full range of motion and no tenderness to
palpation of bones or muscles. No lymphadenopathy.
Pulmonary: Lungs CTA at both bases. Breathing non-labored except
with pain/tearfulness.
Cardiac: RRR. No M/G/R appreciated.
Abdomen: Slightly prominent relative to patient's thin stature.
He appears less wasted (better nourished) than on our prior
encounter, and endorses better nutrition in the past few months.
Soft, non-tender, and non-distended, + normoactive bowel sounds.
Extremities: Warm and well-perfused. No edema. There is a healed
(?stg I) ulcer between the Right toes d1-2; pt unaware. Intact
radial, DP pulses bilaterally.
Skin: pustular rash over the chest and shoulder; pt says this
___
be new past few days.
BACK: tenderness to palpation over T4-8 region (over spinous
processes) as well as upper-to-mid lumbar region
RECTAL: good tone, increases with cough. Normal anal wink and
cremasteric reflexes. Poor perianal/perineal hygeine.
*****************
Neurologic examination:
Mental Status:
Sad affect. Oriented x3. Able to relate history. Grossly
attentive. Speech was not dysarthric. Language is fluent with
intact repetition and comprehension. No paraphasic errors. Seems
to think before giving responses on sensory exam (inconsistent
at
times), and at one point says "no, that can't be right" when
describing dull pin sensation in RUE.
-Cranial Nerves:
II: PERRL, 2.5 to 2mm and brisk. Visual fields are full. No
papilledema, exudates, or hemorrhages on fundoscopic
examination.
III, IV, VI: EOMs full and conjugate; no nystagmus. No saccadic
intrusion during smooth pursuits. Normal saccades.
V: Facial sensation intact and subjectively symmetric to light
touch V1-V2-V3.
VII: No ptosis, no flattening of either nasolabial fold. Normal,
symmetric facial elevation with smile. Brow elevation is
symmetric. Eye closure is strong and symmetric.
VIII: Hearing intact and subjectively equal to finger-rub
bilaterally.
IX, X: Palate elevates symmetrically with phonation.
XI: ___ equal strength in trapezii bilaterally.
XII: Tongue protrusion is midline.
-Motor:
Spastic tone in the Left leg (at the knee, not ankle or hip).
Normal muscle bulk. Right leg not externally rotated on initial
observation from hall, but later externally rotated. Tone if
anything is a bit low at the right knee and ankle. No tremor or
asterixis. No fasciculations observed.
UEs:
Delt Bic Tri WE FF FE dIO
L 5 ___ ___
R 5 ___ ___
LEs:
- Give-way/pain-limited weakness in both IPs (but briefly
full-strength ___ bilaterally before give-way.
- Full power in both quads ___ bilateral)
- pain and give-way weakness of both hamstrings ___ Right, ___
left).
- TA, ___, and gastrocs give-way/poor-effort bilaterally (___)
-Sensory:
Patient claims total anesthesia to all modalities in the Right
thigh, leg, foot, and toes (pin, cold, LT, JPS). Intact to all
in
both arms and Left leg, including JPS in L great toe (except
cold). Eyes-closed Finger-to-nose testing revealed no gross
proprioceptive deficit (did not miss nose).
In contrast to the leg, he says that the left perianal region or
medial buttock are intact to pinprick, whereas on the left he
cannot sense anything.
-Reflexes (left; right):
Biceps (++;++)
Triceps (++;++) brisker on the Right
Brachioradialis (++;++) spread to finger-flexors on the left
Quadriceps / patellar (+++;++)
Gastroc-soleus / achilles (0;0)
Plantar response was mute on the Right and mute-to-flexor on the
left.
-Coordination:
Finger-nose-finger testing normal without dysmetria or intention
tremor. No dysdiadochokinesia noted on rapid-alternating hand
movements. HKS - pt says unable on either side.
-Gait: deferred (pain/weakness)
DISCHARGE PHYSICAL EXAM:
CV: ___ systolic murmur best heard at left sternal border noted
on exam.
SKIN: Erythematous, swollen, tense, tender rash around left
elbow at site of peripheral IV that patient dug out with a fork.
Rash extends distally to forearm. Well-demarcated with sharp
borders. No pus, exudate or drainage noted.
NEUROLOGIC EXAM:
MOTOR: Full strength throughout, except bilaterally ___
extensor hallicus longus. Weakness in lower extremities
bilaterally has resolved; ___ in IP, quad, ham, TA, gastroc, FDB
bilaterally.
SENSORY: Sensation to light touch, vibration and proprioception
intact throughout. Impaired sensation to temperature and pin
prick in entire right lower extremity and right torso up to
level of T6.
Pertinent Results:
___ 05:00PM BLOOD WBC-8.0 RBC-4.90 Hgb-14.2 Hct-43.1 MCV-88
MCH-29.0 MCHC-33.0 RDW-14.4 Plt ___
___ 09:20AM BLOOD WBC-10.0 RBC-4.17* Hgb-12.4* Hct-36.2*
MCV-87 MCH-29.7 MCHC-34.1 RDW-13.8 Plt ___
___ 07:00PM BLOOD Neuts-72.7* Lymphs-17.0* Monos-7.2
Eos-2.7 Baso-0.4
___ 09:20AM BLOOD ___ PTT-30.6 ___
___ 05:00PM BLOOD ESR-31*
___ 09:20AM BLOOD Glucose-96 UreaN-9 Creat-0.7 Na-138 K-4.2
Cl-101 HCO3-29 AnGap-12
___ 05:00PM BLOOD ALT-245* AST-299* AlkPhos-94 TotBili-0.6
___ 01:20PM BLOOD ALT-203* AST-139* AlkPhos-79 TotBili-0.3
___ 04:40AM BLOOD Albumin-4.4 Calcium-9.3 Phos-4.2 Mg-2.3
___ 04:50AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
___ 05:00PM BLOOD CRP-32.6*
___ 04:50AM BLOOD HIV Ab-NEGATIVE
___ 05:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:00PM BLOOD HCV Ab-POSITIVE*
___ 01:30AM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
___ 04:44PM URINE Color-Yellow Appear-Clear Sp ___
___ 04:44PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 10:34AM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-1* Polys-1
___ ___ 10:34AM CEREBROSPINAL FLUID (CSF) TotProt-21 Glucose-63
___ 10:34AM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-PND
IMAGING RESULTS
___ CXR (PA & LAT):
Cardiomediastinal contours are normal. Lungs are clear. No
evidence of pneumonia, pnuemothorax or pleural effusion.
___ MR ___ & W/O Contrast:
1. No evidence of osteomyelitis, discitis or epidural abscess in
lumbar spine
2. Stable small disc protrusion at L5-S1, which abuts but does
not deform or compress the traversing bilateral S1 nerve roots
___ MR ___ ___ & W/O Contrast:
1. No evidence of osteomyelitis, discitis, or epidural abscess
in the thoracic spine.
2. Unchanged T5-T6 disc herniation, larger on the left, that
indents the ventral spinal cord. Small signal abnormality in
cord at this level improved from ___ and stable from
___, compatible with mild residual edema or myelomalacia.
___ CXR (PA & LAT):
No acute cardopulmonary findings. There is no evidence of
aspiration or pneumonia.
___ ECHO:
Left atrium normal in size. Left ventricular wall thickness,
cavity size, and regional/global systolic function are normal
(LVEF 70%). Right ventricular chamber size and free wall motion
are normal. Aortic valve leaflets (3) are structurally normal
with no stenosis or regurgitation. Mitral valve structurally
normal with trivial regurgitation. Estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
No vegetation seen on heart valves.
___ LUMBAR PUNCTURE:
Successful fluoroscopic-guided lumbar puncture.
Brief Hospital Course:
Mr. ___ is a ___ year old man with a history of IVDU and T5-6
disc protrusion s/p rehab who was evaluated for lower extremity
weakness and worsening lower back pain.
# Neurologic:
Mr. ___ complained of weakness and sensory changes in his
lower extremities, and back pain over his lumbar spine. He was
found on MRI to have a stable T5-T6 posterior disc herniation
with cord compression and a small L5-S1 disc protrusion that did
not deform or compress bilateral S1 nerve roots. He was
evaluated by the orthopedic spine service who believed his discs
were stable and there was no necessary surgical intervention.
Over the course of his stay, Mr. ___ weakness has
completely resolved. He continues to experience sensory of
deficit to pain and temperature in his right leg and right torso
up to T6, consistent with his cord compression.
Due to his fever and elevated ESR and CRP on admission there was
concern for an epidural abscess. No evidence of abscess or
infection was seen on MRI of the thoracic or lumbar spine. A
lumbar puncture was attempted but could not be completed due the
patient's exquisite sensitivity to pain. A lumber puncture was
performed under fluoroscopy with general anesthesia. The CSF
showed no evidence of infection; WBC, protein and glucose within
normal limits. The patient's subjective report of pain was
likely elevated somewhat due to withdrawal demonstrated by
elevated ___ scores in the setting of known opiate addiction.
# Infectious Disease:
Mr. ___ spiked intermittent fevers as high as 101.8 during
his hospitalization. To determine if he had an active infection
a chest X-ray and urinalysis were preformed. They showed no
evidence of pneumonia or UTI, respectively. Due to his history
of IVDU an echocardiogram was also preformed that showed no
vegetation worrisome for bacterial endocarditis present on his
heart valves. The patient picked out a peripheral IV from his
left arm with a fork. He subsequently developed an erythematous,
hot, swollen rash over his forearm consistent with cellulitis.
He is currently being treated with Clindamycin.
HIV Ab tests were negative.
# Psych
Mr. ___ had a urine tox screen positive for opiates on
admission and admits to using heroin in the last month. He
experienced withdrawal symptoms during his hospitalization and
was severely agitated at times requiring restraints. There was
concern for substance abuse within the hospital; the patient
endorsed taking PO opiates that he brought with him. He was
evaluated by psychiatry and social work for opiate addiction. He
was advised to follow up with his out patient psychiatrist and
provided a list of resources including addiction day treatment
centers, crisis centers, and methadone clinics.
In order to adequately treat his pain per chronic pain
consultation, we decided to prescribe 5 days (30 pills) of
Oxycodone 20mg to control his pain. He was recommended to
follow up with his primary care physician, with whom we made
three attempts to contact to no avail prior to discharge, for
any additional medications.
# GI/ Hepatic
The patient had elevated AST and ALT on admission, and has a
history of IVDU. He tested positive for hepatitis C virus
antibodies. His hepatitis B serologies showed that he has active
hep B immunity.
# CV
Mr. ___ had a transthoracic echocardiogram preformed to
evaluate for valvular vegetation and bacterial endocarditis. He
was found to have no cardiac dysfunction with a LVEF of 70-75%,
no pulmonary hypertension or right heard strain, no valvular
disease, and no vegetations.
# Transitions of care
- Will follow up with out patient psychiatrist / primary care
physician for renewal of medications and discussion of substance
abuse therapy.
- Will follow up with primary care physician ___ 4 weeks
- Will complete a 10 day course of clindamycin for cellulitis
- CNS HSV PCR still pending at time of discharge
- Provided with a list of resources to seek aide with substance
abuse when the patient decides to pursue this course of action.
List of resources includes crisis centers, methadone clinics,
and addiction day treatment programs.
Medications on Admission:
1. Gabapentin 300mg TID
2. Clonazepam 3 mg TID
3. Ritalin 5 mg PO BID
4. Bupropion XR 150 BID
Discharge Medications:
1. Gabapentin 800 mg PO TID back pain (home med)
2. Clonazepam 1 mg PO TID anxiety
hold for sedation
3. MethylPHENIDATE (Ritalin) 5 mg PO BID
4. BuPROPion 75 mg PO BID
5. Clindamycin 300 mg PO Q8H
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every eight (8)
hours Disp #*27 Capsule Refills:*0
6. OxycoDONE (Immediate Release) 20 mg PO Q4H:PRN pain ___
not responsive to acetaminophen
hold for delerium or sedation
RX *oxycodone 20 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Resolved Lower Extremity Weakness
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were evaluated at ___ for
your chief complaint of lower extremity weakness with an
increase in back pain. At the time of your presentation to the
hospital, you were found to be short of breath and with a fever,
and as such we obtained a Chest X-Ray which did not reveal any
pneumonia or other lung or cardiac pathology. An Echocardiogram
further ruled out any cardiac issues; your heart function was
shown to be normal with no concern for infection. We also
obtained MRI studies of your spine which showed your T5/6 disk
herniation was unchanged from before. While a lumbar disk
herniation was observed on the study, no compression of the
nerve was identified.
Upon discharge, you will discharged with a 10 day course of
Clindamycin to treat your cellulitis; please complete this
course of medication even if your arm pain and swelling
improved.
We have made the following changes to your medications:
- Clindamycin 300mg every 8 hours
- Gabapentin 800mg every 8 hours
We have also given you a short course of medication to control
your pain.
- Oxycodone 20mg every 4 hours as necessary for pain
For any additional medical management, please contact your
primary care physician.
Upon discharge please follow up with the appointments listed
below.
It was a pleasure taken care of you, and we wish you all the
best.
Followup Instructions:
___
|
10690033-DS-5
| 10,690,033 | 22,771,293 |
DS
| 5 |
2117-12-11 00:00:00
|
2117-12-11 22:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending: ___.
Chief Complaint:
Right upper extremity cellulitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M w/ hx of T5-T6 ant cord compression from a disc
herniation with minimal signal change on ___, hx of IVDA, mood
disorders who presents w/ RUE cellulitis. He was recently
hospitalized from ___ for ___ weakness. During his
hospital course, he reports that he had IV's everywhere and
developed cellulitis of his left UE. This discharge summary
reports he removed the IV with a fork, but the patient does not
mention this and the issue is not pressed. He was treated with
clindamycin and his symptoms on this arm improved.
He reports his right arm 'was fine' until ___ night following
his 'discharge' when he noted that the medial aspect of his arm
became red (of note, he had a PICC in his R arm during the
previous admission). Since that time, the redness has
progressed, including outside the boundries he marked on ___.
He continued to take his clindamycin (rx for LUE cellulitis) as
directed. He reports having a fever to 102 on ___, a/w
diaphoresis but no chills/rigors. He denies touching or
manipulating the old PICC site on his right arm, but picks at
the scab during our conversation.
Of note, according to his prior d/c summary, the patient eloped
prior receiving a loading dose of fluconazole. He had been
discharged earlier in the day on ___, but after the paper
work had been finalized, the patient's blood culture returned
with ___ and ___ (in anaerobic bottle). He had been asked
to stay to receive a loading dose of fluconazole, but left prior
to this. He reports that he had been taking fluconazole for
this at home since his discharge. Regardless, he was given
fluconazole 400 mg in the ED.
He is most concerned about his back and leg pain. He reports
persistent and worsening back pain since his injury ___ to
the point where he pain was the worst it has ever been 2 weeks
ago (prior to his previous admission), when he had just been
weaned off chronic oxycodone. He says that his pain radiates to
his anterior right leg. He reports decreased sensation to touch
and temperature on R arm/leg/abdomen. He does not have any left
leg symptoms. He also reports some urinary incontinence since
his last admission which is new, not noticing when his bladder
is full. He reports that none of his medications are working for
him and he just wants to be on the right meds, particularly as
its getting worse. At his highest, his PCP had him on 15mg
Oxycodone q3prn and had recently weaned them.
In the ED, his initial vitals were 97.6, 93, 108/65, 18, 100%
RA. His exam notable for RUE erythema extending past the
previously marked boundies. There was also a note of decreased
rectal done and increased reflexes b/l. Neurology was consulted
and felt that there was no significant changes his neurologic
exam and report they will follow along on the consult service.
His labs were notable for WBC 9.4, hct 33.0 (baseline
36.0-39.0), and positive urine opiates. Blood cultures were
sent and he was given vancomycin 1gm, cefepime 2gms and
fluconazole 400 mg po x1. For pain he was given morphine 5 mg
IV and oxycodone/acetaminophen ___ x2. Vitals prior to
transfer: 98.0 89 119/70 17 100%
Past Medical History:
1. IVDU heroin and cocaine
2. Mood disorder NOS
3. ADD
4. Cyst removed from penis ___ years ago
5. T5-6 Posterior disc herniation s/p 2 months of rehab
6. LUE cellulitis
7. Candidemia
8. HCV
Social History:
___
Family History:
Father - history of drug addiction
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.2, 115/74, 79, 18, 100% on RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - +erythema over medial aspect of his right arm, extending
from 3 inches below the axilla to mid forearm, approximately ___
inches beyond the previously marked borders (on ___ by
patient), +warmth, +pain along medial arm extending to R
pectoralis. Swollen right arm.
BACK: Tenderness along the spine from around T5 and below with
greatest tenderness along lower Lumbar.
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ on left, ___ on right (limited by pain). Marked decreased
sensation to pressure on R arm, leg, abdomen.
DISCHARGE PHYSICAL EXAM:
VS: Tm 98.2 Tc 98.1 BP 124/74 HR 84 RR 18 SpO2 100% RA
Gen: well appearing, NAD, anxious
LUNGS: CTAB
HEART: RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses. No stigmata
of endocarditis.
SKIN - Swelling of R upper arm extending to elbow. +warmth,
+pain along medial arm extending to R pectoralis. - improving
L arm with induration slightly distal to elbow on anterior
surfac with resolving erythema - improving
BACK: Tenderness along the spine from around T5 and below with
greatest tenderness along lower Lumbar.
PSYCH - Patient very anxious.
Pertinent Results:
ADMISSION:
___ 04:15PM BLOOD WBC-9.4 RBC-3.77* Hgb-10.8* Hct-33.0*
MCV-88 MCH-28.6 MCHC-32.7 RDW-13.5 Plt ___
___ 04:15PM BLOOD Neuts-66.6 ___ Monos-5.2 Eos-5.5*
Baso-0.5
___ 11:15AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 04:15PM BLOOD Glucose-76 UreaN-8 Creat-0.7 Na-138 K-5.0
Cl-99 HCO3-28 AnGap-16
___ 11:15AM BLOOD ALT-93* AST-79* LD(LDH)-235 AlkPhos-80
TotBili-0.2
___ 04:15PM BLOOD Calcium-9.1 Phos-4.4# Mg-2.3
___ 04:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
ANEMIA STUDIES:
___ 11:15AM BLOOD calTIBC-248* VitB12-388 Folate-16.2
Ferritn-223 TRF-191*
URINE STUDIES:
___ 05:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
___ 05:30PM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
DISCHARGE:
___ 06:40AM BLOOD WBC-6.0 RBC-3.62* Hgb-10.4* Hct-32.4*
MCV-89 MCH-28.6 MCHC-32.0 RDW-13.9 Plt ___
___ 06:40AM BLOOD ___ PTT-39.5* ___
___ 06:40AM BLOOD Glucose-80 UreaN-7 Creat-0.7 Na-137 K-5.0
Cl-101 HCO3-28 AnGap-13
___ 05:50AM BLOOD ALT-106* AST-92* AlkPhos-145*
___ 06:40AM BLOOD Calcium-9.1 Phos-4.4 Mg-2.3
MICRO:
BCx ___ x 2: Pending (No growth to date)
BCx ___: Pending (No growth to date)
___ HCV VIRAL LOAD: 6.3 million
IMAGING:
___ TTE: The left atrium is normal in size. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. No masses or vegetations are seen on the aortic
valve. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. No mass
or vegetation is seen on the mitral valve. The estimated
pulmonary artery systolic pressure is normal. No vegetation/mass
is seen on the pulmonic valve. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___, no
change
___ Venous U/S R arm: IMPRESSION: Occlusive thrombus in the
right subclavian vein, right axillary
vein, one of the right brachial veins, and the right basilic
vein.
___ MRI T, L, C-Spine: IMPRESSION:
1. No evidence of discitis, osteomyelitis, or epidural abscess.
2. Unchanged disc protrusion at T5-T6 with indentation of the
ventral spinal
cord and associated signal abnormality within the cord at this
level which may
reflect edema or myelomalacia.
3. Stable small disc protrusion at L5-S1.
___ U/S L arm induration: IMPRESSION:
1. Diffuse edema and skin thickening, consistent with
cellulitis, without drainable fluid collection.
2. Superficial thrombophlebitis without underlying clot in the
visualized nearby deep vessels.
Brief Hospital Course:
___ with history of IVDU and T5-T6 disc herniation presenting
with worsening back pain now being treated for fungemia and RUE
DVT.
ACTIVE ISSUES:
# RUE DVT: The DVT was provoked in the setting of previous ___
placement. U/s revealed extensive DVT extending to subclavian
vein. Infectious Disease did not believe that the DVT was
super-infected. Patient was put on Lovenox 1mg/kg BID and
started on Warfarin with a goal INR ___. He was discharged with
an INR of 2.1 and a Warfarin dose of 1.5mg daily with follow up
with his PCP to check his INR. Coumadin dose will likely
require adjustment upon completion of antimicrobial therapy.
# Fungemia: Patient with +blood culture on ___ for ___
___. Of note there was concern that the patient
tampered with IV's on prior and current admission. Echo negative
for endocarditis and MRI spine showed no epidural abscess or
osteomyelitis. Per ophtho, no evidence of endogenous
endophthalmitis with a recommended follow up dilated fundus exam
in 2 weeks (___). He is to continue to take 400mg
Fluconazole daily for 14 days from negative blood cultures which
would make his last dose on ___. He should have his LFTs
checked as an outpatient in the setting of Fluconazole and
slightly elevated LFTs as inpatient.
# LUE Cellulitis: He has LUE cellulitis with associated
superficial thrombophlebitis. U/S of lfet arm induration to look
for fluid collection showed only edema. He was started on Keflex
___ Q6h and Bactrim DS BID for a 7 day course (Last day ___
# Bacteremia: One bottle with bacteroides. Likely related to
contamination from mouth. Currently not being treated. Blood
cultures pending final results.
# Back pain: Patient with chronic back pain, with T5-T6 disc
herniation and partial cord compression. Hx of chronic pain
medication use, was weaned off, then increased pain with his new
issues. He reports new urinary incontinence and also has known
bacteremia/fungemia. MRI entire spine showed no acute changes,
specifically, no evidence of osteomyelitis or epidural abscess.
Per previous note from PCP, she was not going to continue to
prescribe him Oxycodone cause of inconsistent urine tox screen.
PCP had set up for suboxone/methadone provider in the future. He
was discharged on limited Oxycodone to bridge him to PCP
___.
# Right leg pain/neuropathy: Patients leg pain is chronic, but
worsening. He was switched from gabapentin 800 mg TID to
Pregabalin 50mg TID by patients request and he reported
improvement with that medication change.
# Acute on chronic normocytic anemia: Patient with downtrending
hct (39.0 -> 31) that recovered slightly prior to discharge.
Etiology unclear, no overt s/sx or h/o bleeding. Anemia labs:
vit b12(N), folate(N), iron studies(all low but Ferritin N),
ldh(N) which appeared to represent Anemia of Acute Inflammation.
His smear showed some hypochromia, otherwise normal.
# HCV: Recently dx per patient. He has not has had hepatology
f/u. Pt was HIV negative on ___. LFTs have decreased from
previous d/c but slightly increased at end of stay (on
Fluconazole 400mg). HCV viral load ~ 6,300,000.
# H/o IVDU: Patient denies recent use, although documentation
implies he has used as recently as ___. On ___,
patient found to have "white powder" in IV after it was removed.
He reports having no idea how it became present. Search of his
room revealed no illegal substances. All medications were able
to safely be switched to PO's and IV's were all removed.
Oxycodone was given in a limited number with pain control plan
to be managed by PCP who has been addressing this issue.
CHRONIC ISSUES:
# Bipolar Disorder: We continued his home bupropion, patient
reports 100mg BID, most recent note from PCP ___ 150mg BID.
# ADHD: Patient continued on home Ritalin 20mg BID.
TRANSITIONAL ISSUES:
-INR f/u
-Check LFTs in setting of Fluconazole at PCP appointment
-___ Blood Culture final results
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from
PatientwebOMR.
1. Gabapentin 800 mg PO TID back pain (home med)
2. Clonazepam 1 mg PO TID anxiety
hold for sedation
3. MethylPHENIDATE (Ritalin) 20 mg PO BID
4. BuPROPion 100 mg PO BID
5. Clindamycin 300 mg PO Q8H
6. OxycoDONE (Immediate Release) 20 mg PO Q4H:PRN pain ___
not responsive to acetaminophen
hold for delerium or sedation
Discharge Medications:
1. BuPROPion 100 mg PO BID
2. Clonazepam 1 mg PO TID anxiety
hold for sedation
RX *clonazepam 0.5 mg 2 tablet(s) by mouth three times a day
Disp #*16 Tablet Refills:*0
3. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 tablet(s) by mouth four times a day Disp
#*14 Tablet Refills:*0
4. Acetaminophen 650 mg PO Q6H:PRN pain
do not exceed 3g
5. Fluconazole 400 mg PO Q24H
RX *fluconazole 200 mg 2 tablet(s) by mouth daily Disp #*22
Tablet Refills:*0
6. MethylPHENIDATE (Ritalin) 20 mg PO BID
RX *methylphenidate 10 mg 2 tablet(s) by mouth twice a day Disp
#*12 Tablet Refills:*0
7. Pregabalin 50 mg PO TID
RX *pregabalin [Lyrica] 50 mg 1 capsule(s) by mouth three times
a day Disp #*8 Capsule Refills:*0
8. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*7 Tablet Refills:*0
9. Warfarin 1.5 mg PO DAILY16
RX *warfarin [Coumadin] 1 mg 1.5 tablet(s) by mouth daily Disp
#*45 Tablet Refills:*0
10. OxycoDONE (Immediate Release) 15 mg PO Q3H:PRN pain
RX *oxycodone 15 mg 1 tablet(s) by mouth q3h Disp #*25 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Deep Venous Thrombosis
Fungemia
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
worsening back pain and arm redness. You were also found to have
a clot in your arm. You were started a blood thinning medication
called Coumadin. It is VERY IMPORTANT that you take this
medication as directed by your doctor. You will need to have
labs checked often to make sure that your Coumadin is in the
right level. You will be taking one and half tablets a day until
___ when you see your doctor. She will adjust your dose
according to your level.
You were also started on antibiotics Keflex/Bactrim for a skin
infection. Your last day will be ___.
On your last admission you were found to have fungus in your
blood. You were started a medication to treat this and will need
to have your labs checked next week to follow your liver
enzymes. Your last dose will be on ___.
Followup Instructions:
___
|
10690044-DS-5
| 10,690,044 | 21,515,959 |
DS
| 5 |
2119-05-08 00:00:00
|
2119-05-08 20:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weakness, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M with moderate AS, DM II, persistent atrial fibrillation,
CKD, and myositis ILD presents to the ED for generalized
weakness. Patient states over the last two weeks he has felt
very
weak and fell last week. He states he has been having trouble
walking. Patient had a recent prolonged hospital course for
interstitial lung disease. He states since taking the steroids,
he has had no trouble breathing or chest pain. He went to his
primary care physician who told him he should go to the ED. He
reported diarrhea the last couple days but denies dysuria.
Patient had a CT for his fall last week-broken nose with no
intracranial bleed. Patient states he has lost a lot of weight
in the last 2 weeks. He otherwise denies headache, blurred
vision, or dizziness.
In the ED, initial VS were 98.1 98 120/73 22 100% RA
BMP significant for BN 50/Cr 1.5. CBC with WBC 13.8, H/H
13.0/41.2.
He received MMF 1000 mg, PO Metoprolol succinate 12.5 mg BID,
atorvastatin 80 mg, tamsulosin 0.4mg, and IV CTX.
UA positive.
CXR showed chronic underlying interstitial abnormality as seen
previously without superimposed acute cardiopulmonary process.
Upon arrival to the floor, the patient tells the story as
follows. He reports he was sent here by his PCP because his PCP
thought he looked very weak. The patient agrees that he is very
week. He reports he is "barely able" to stand on his legs. He
endorses dyspnea occurring with exertion at home, usually after
he walks about 100 feet. He does, however, report that he was
able to wean off oxygen since he last discharge and is currently
not using oxygen at home. He otherwise denies fevers, chills,
shortness of breath, cough, abdominal pain, flank pain. He
endorses chronic urinary frequency and nocturia, and unable to
quantify if it has worsened in the last little while .
Review of the patient's recent records is as follows. The
patient
had a prolonged admission from ___ - ___ for hypoxic
respiratory failure, thought to be multifactorial in the setting
of severe AS, recent pneumonia, and possible COPD exacerbation.
The patient was treated with diuresis, empiric vanc/cefepime.
Pulmonary was consulted for possible progression of ILD.
Myositis
antibody was positive and the patient was started on MMF and
discharged on a prolonged steroid taper.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
PAST MEDICAL/SURGICAL HISTORY:
- HTN
- dCHF
- HLD
- BPH
- DM II
- Anxiety
- Presumed history of COPD
- Atrial fibrillation
DATA: I have reviewed the relevant labs, radiology studies,
tracings, medical records, and they are notable for:
___ 09:50PM BLOOD WBC: 13.8* RBC: 4.57* Hgb: 13.1* Hct:
40.1
MCV: 88 MCH: 28.7 MCHC: 32.7 RDW: 20.1* RDWSD: 64.0* Plt Ct: 185
___ 10:54AM BLOOD WBC: 13.8* RBC: 4.56* Hgb: 13.0* Hct:
41.2
MCV: 90 MCH: 28.5 MCHC: 31.6* RDW: 20.4* RDWSD: 66.5* Plt Ct:
174
___ 10:54AM BLOOD Neuts: 89.8* Lymphs: 5.6* Monos: 3.6*
Eos:
0.0* Baso: 0.1 Im ___: 0.9* AbsNeut: 12.34* AbsLymp: 0.77*
AbsMono: 0.49 AbsEos: 0.00* AbsBaso: 0.02
___ 09:50PM BLOOD Glucose: 103* UreaN: 48* Creat: 1.3* Na:
137 K: 4.1 Cl: 108 HCO3: 14* AnGap: 15
___ 10:54AM BLOOD Glucose: 149* UreaN: 50* Creat: 1.5* Na:
138 K: 4.9 Cl: 104 HCO3: 15* AnGap: 19*
___ 10:54AM BLOOD ALT: 43* AST: 36 CK(CPK): 120 AlkPhos: 87
TotBili: 0.5
___ 09:50PM BLOOD Calcium: 9.1 Phos: 3.1 Mg: 1.4*
___ 10:02PM BLOOD Type: ___ pO2: 151* pCO2: 28* pH: 7.33*
calTCO2: 15* Base XS: -9 Comment: GREEN TOP
CXR
Chronic underlying interstitial abnormality as seen previously.
No definite superimposed acute cardiopulmonary process.
I personally reviewed the EKG and my interpretation is irregular
rate, irregular rhythms, single PVC, q aves in V1-V3, consistent
with atrial fibrillation with prior anteroseptal infarct,
consistent with prior.
Past Medical History:
Moderate-severe AS
HTN
dCHF
HLD
BPH
DM II
Anxiety
Presumed history of COPD
Atrial fibrillation
Social History:
___
Family History:
No family hx of lung cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
VITALS: 97.4 PO 130/72 L Lying 106 20 97% RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
Mucous membranes dry
CV: Heart irregular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally, no wheezes, no rales, no crackles
GI: Abdomen soft, non-distended, non-tender to palpation
MSK: Neck supple, moves all extremities, ___ hip flexion, ___
shoulder abduction, ___ grip strength
EXT: no edema, warm, 2+ DP pulses bilaterally
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 PHYSICAL EXAM
___ 0720 Temp: 97.5 PO BP: 137/59 HR: 76 RR: 18 O2 sat: 98%
O2 delivery: Ra
GENERAL: Alert and in no apparent distress, elderly male.
EYES: Anicteric, conjunctival injection of L eye, pupils equally
round, + periorbital ecchymoses.
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
Mucous membranes dry
CV: Heart irregular, no murmur. No JVD
RESP: Lungs clear to auscultation with good air movement
bilaterally, no wheezes, no rales, no crackles
GI: Abdomen soft, non-distended, non-tender to palpation
MSK: Neck supple, moves all extremities, 4+/5 hip flexion/
extension, ___ in all other muscle groups throughout.
EXT: no edema, warm, 2+ DP pulses bilaterally
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs. strength per MSK exam above
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS:
___ 10:54AM BLOOD WBC-13.8* RBC-4.56* Hgb-13.0* Hct-41.2
MCV-90 MCH-28.5 MCHC-31.6* RDW-20.4* RDWSD-66.5* Plt ___
___ 10:54AM BLOOD Glucose-149* UreaN-50* Creat-1.5* Na-138
K-4.9 Cl-104 HCO3-15* AnGap-19*
___ 10:54AM BLOOD ALT-43* AST-36 CK(CPK)-120 AlkPhos-87
TotBili-0.5
___ 09:50PM BLOOD LD(LDH)-436*
___ 10:54AM BLOOD Calcium-9.4 Phos-3.4 Mg-1.4*
DISCHARGE LABS:
___ 07:50AM BLOOD WBC: 11.7* RBC: 4.17* Hgb: 12.0* Hct:
36.2* MCV: 87 MCH: 28.8 MCHC: 33.1 RDW: 20.0* RDWSD: 63.8* Plt
Ct: 149*
___ 07:50AM BLOOD Glucose: 173* UreaN: 27* Creat: 1.0 Na:
136 K: 4.6 Cl: 105 HCO3: 21* AnGap: 10
___ 07:50AM BLOOD Calcium: 8.5 Phos: 2.1* Mg: 2.0
Urine Culture
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH
SKIN
AND/OR GENITAL CONTAMINATION.
KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL. PREDOMINATING
ORGANISM.
INTERPRET RESULTS WITH CAUTION.
Cefazolin interpretative criteria are based on a dosage regimen
of 2g every 8h.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
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-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
CXR:
Chronic underlying interstitial abnormality as seen previously.
No definite superimposed acute cardiopulmonary process.
EKG: irregularly irregular rhythm, single PVC, Q in V1-V2,
nonspecific T wave flattening in multiple leads, QTc 444.
Brief Hospital Course:
___ M with moderate AS, DM II, persistent atrial fibrillation,
CKD, and myositis ILD on prednisone and cellcept presents to the
ED for generalized weakness found to have a metabolic acidosis
and ___.
TRANSITIONAL ISSUES:
[] F/u aldolase level
[] restart statin once strength normalizes
[] will need Nephrology appointment in ___
[] will need PCP appointment within ___ week from rehab discharge
[] please perform daily volume exam and restart furosemide 10 mg
as needed
[] Please check CBC, Chem 10, LFTs every 2 weeks (next ___ and
fax results to Attn:Dr ___ ___
[] decrease prednisone to 10 mg on ___
[] will need barium swallow outpatient
[] will need DEXA scan as outpatient
[] repeat cologuard/FIT/fecal globin testing outpatient given 60
lb weight loss
#Contact: ___ Relationship: Daughter; Phone
number: ___
#Code status full code, confirmed
[x] I spent over 30 min in discharge planning and coordination
of care.
HOSPITAL COURSE BY PROBLEM:
# Generalized weakness
# Hypomagnesemia:
Weakness, without focal deficit, with a recent diagnosis of ILD
myositis and ongoing treatment/uptitration of MMF and
down-titration of steroids. His exam on admission demonsrated
mild proximal muscle weakness (4+/5 strength in deltoids, hip
flexors and extensors, remainder of strength exam is within
normal limits). Rheumatology and Pulmonology were consulted. He
improved with correction of his magnesium and with
administration of IVF. Given onset of symptoms, steroid myopathy
was thought to be contributory, and prednisone was decreased to
20 mg on ___, with plan for taper to 10 mg on ___ and
thereafter. Symptoms did not seem consistent with myositis given
lack of myalgias, but aldolase pending at discharge. His high
dose statin was also held, but he had shown improvement even
prior to holding the statin.
# Acute on chronic kidney disease:
Cr increased to 1.5 from 1 likely due to hypovolemia in setting
of diarrhea and furosemide use. It improved with holding
diuretics and as diarrhea resolved. Cr at discharge 1.0. He was
evaluated by Renal in-house due to proteinuria which seems more
consistent with mild chronic renal disease, for which he will
have outpatient follow-up in ___.
# Metabolic acidosis: Patient with a persistent bicarbonate of
___, with now normal anion gap. He was seen by the
nephrology service who felt that this was due to volume loss int
he setting of diarrhea. It resolved in the hospital after IVF.
# Diarrhea: Per his wife, had dramatic increase in stool output
after increasing cellcept to 1500 mg po bid, which has since
normalized on its own. Stool studies sent and negative,
including for C.diff. Unlikely to be infectious, and appears to
be improving now that he has been on the 1500 mg po bid dose of
cellcept for a few days. No ongoing concerns.
# ILD: Diagnosed on his previous admission. Labs notable for an
aldolase of 8.3 and a myositis panel showed +PL-12 antibody.
Review of his CT scans between ___ and ___ showed
progressive fibrotic disease that is felt to be consistent with
myositis-ILD. Here he was stable from a respiratory standpoint
and asymptomatic. He was tapered to 20 mg prednisone on ___ with
plan to decrease to 10 mg on ___. He was continued on Cellcept
1500mg BID. His ppx with Bactrim and omeprazole was briefly held
in setting ___ but restarted on ___. He was continued on
Ca/Vit D.
# Urinary Tract Infection due to Klebsiella pneumoniae:
# Leukocytosis: Admission WBC of 13.8. CXR without superimposed
pneumonia. UA positive. Leukocytosis ___ also be chronically
elevated in the setting of steroids. UCx with multiple organisms
with Klebsiella predominance. Given immunosuppression, he was
treated for UTI. He received 4d IV ceftriaxone with plan to
transition to po cefpodoxime on ___ for 3 more days.
# Unintended weight loss: Patient reports a 60 lb unintentional
weight loss over the past six months. He has not had any recent
cross sectional imaging (at least not in our system). Reports
last sent in stool sample for ___ screening about ___ years ago.
SPEP and UPEP were sent and negative. Evaluated by nutrition and
started on supplements and MVI with minerals.
# Chronic HFpEF: Patient with a history of HFpEF, without
current evidence of exacerbation. He currently appears dry.
Lasix was held given volume status and ___. Here, 162.19 lb on
discharge (from 179.5 on previous discharge).
# Moderate AS: ___ 1.2cm w/ peak velocity 4.8 on ___ pMIBI
showed inferior, inferolateral fixed perfusion defect. TTE on
last admission showed moderate AS.
# DM: Patient has recently initiated insulin in the outpatient
setting. Here initially hypoglycemic but improved with
intermittent hyperglycemia and glucosuria on UA. Was managed on
10u glargine and SSI, transitioned to home regimen at discharge.
# Normocytic anemia: Stable, no e/o bleeding. thought to be in
the setting of chronic disease, critical illness, and frequent
phlebotomy
# HLD: held atorvastatin 80 mg PO QPM given myopathy
# BPH: Continued finasteride, Tamsulosin
# Persistent atrial fibrillation: metoprolol succinate 12.5 BID
and home rivaroxaban continued
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Atorvastatin 80 mg PO QPM
2. Finasteride 5 mg PO DAILY
3. GlyBURIDE 10 mg PO DAILY
4. GlyBURIDE 5 mg PO QHS
5. Rivaroxaban 15 mg PO DAILY
6. Tamsulosin 0.8 mg PO QHS
7. Mycophenolate Mofetil 1500 mg PO BID Myositis ILD
8. Omeprazole 40 mg PO DAILY
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. Vitamin D 800 UNIT PO DAILY
11. Tiotropium Bromide 1 CAP IH DAILY
12. MetFORMIN (Glucophage) 1000 mg PO BID
13. Metoprolol Succinate XL 12.5 mg PO BID
14. PredniSONE 30 mg PO DAILY
Tapered dose - DOWN
15. Furosemide 10 mg PO EVERY OTHER DAY
16. Glargine 10 Units Breakfast
Discharge Medications:
1. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 3 Days
2. Multivitamins W/minerals 1 TAB PO DAILY
3. Glargine 10 Units Breakfast
4. PredniSONE 20 mg PO DAILY
take 20 mg daily until ___
take 10 mg daily from ___ onwards
5. Finasteride 5 mg PO DAILY
6. GlyBURIDE 10 mg PO DAILY
7. GlyBURIDE 5 mg PO QHS
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. Metoprolol Succinate XL 12.5 mg PO BID
10. Mycophenolate Mofetil 1500 mg PO BID Myositis ILD
11. Omeprazole 40 mg PO DAILY
12. Rivaroxaban 15 mg PO DAILY
13. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
14. Tamsulosin 0.8 mg PO QHS
15. Tiotropium Bromide 1 CAP IH DAILY
16. Vitamin D 800 UNIT PO DAILY
17. HELD- Atorvastatin 80 mg PO QPM This medication was held.
Do not restart Atorvastatin until weakness resolved; PCP to
resume
18. HELD- Furosemide 10 mg PO EVERY OTHER DAY This medication
was held. Do not restart Furosemide until your doctor tells you
to restart it
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
proximal muscle weakness; steroid induced myopathy
hypomagnesemia
diarrhea
acute kidney injury
ILD myositis
Aortic stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your hospitalization
at ___!
Why were you hospitalized?
- You were admitted with weakness and falls.
What happened while you were in the hospital?
- We found that you were dehydrated on account of your diarrhea
and that your magnesium levels were low.
- You improved with IV fluids and after receiving some
magnesium.
- You were evaluated by the rheumatology and pulmonary teams for
your muscle weakness which was thought to be due to the steroids
and not the myositis. Your steroid plan was changed so you can
complete the taper more quickly.
What should you do after you leave the hospital?
- Get stronger in rehab!
- Take 20 mg prednisone daily until ___ then on ___ decrease
to 10 mg. Keep taking 10 mg until you see Dr. ___ in
clinic.
We wish you the best!
Sincerely,
Your ___ Care team
Followup Instructions:
___
|
10690266-DS-20
| 10,690,266 | 25,610,576 |
DS
| 20 |
2180-09-10 00:00:00
|
2180-09-12 21:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with history of peptic ulcer disease,
referred here for CT showing intra and extrahepatic biliary
ductal dilatation along with cholelithiasis for possible ERCP,
but also with melena for past three days. Pt initially presented
for melena for past three days in setting of distant ulcer, 3
weeks of intermittent epigastric pain. She takes aspirin daily,
denies taking increased NSAIDs or significant alcohol use. She
denies SOB, CP, lightheadedness, dizziness.
At ___, she was found to have hard stool in the
vault, guaiac positive with dark brown stool. Labs showed
sodium 122, hemoglobin 10.6. LFTs were unremarkable and normal.
CXR showed no acute process, and CT A/P showed intra and
extrahepatic biliary ductal dilatation along with
cholelithiasis, as well as an indeterminate low-density liver
lesion.
In the ___ ED, initial vitals were 96.9 78 139/69 18 99% RA.
Patient was guaiac positive. WBC count was 6.4K, hemoglobin
10.1. bicarbonate of 20 (anion gap 16), sodium of 122. IV
pantoprazole was given. GI was contacted. Vitals upon transfer
were 98 80 143/55 18 99% RA.
Currently,
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, or abdominal
pain. No recent change in bladder habits. No dysuria. Denies
arthralgias or myalgias. Ten point review of systems is
otherwise negative.
Past Medical History:
Hyponatremia
Hypertension
Hyperlipidemia
s/p Right mastectomy
s/p Right hip replacement
s/p Bilateral ankle fracture
s/p Left wrist fracture
s/p Hysterectomy
s/p C-section x 2
Social History:
___
Family History:
not related to current admission
Physical Exam:
Vitals: T: 98.2 BP: 130/72 P: 668 R: 16 O2: 100% on RA
GEN: Alert, oriented to name, place and situation. Fatigued
appearing but comfortable, no acute signs of distress.
HEENT: NCAT, Pupils equal and reactive, sclerae anicteric, OP
clear, MMM.
Neck: Supple, no JVD
Lymph nodes: No cervical, supraclavicular LAD.
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, non-tender, non-distended, + bowel sounds.
EXTR: No lower leg edema
DERM: No active rash.
Neuro: non-focal.
PSYCH: Appropriate and calm.
Pertinent Results:
___ 10:45PM estGFR-Using this
___ 10:45PM ALT(SGPT)-15 AST(SGOT)-25 ALK PHOS-114* TOT
BILI-0.6
___ 10:45PM LIPASE-27
___ 10:45PM ALBUMIN-4.1 CALCIUM-9.2 PHOSPHATE-2.8
MAGNESIUM-2.0
___ 10:45PM WBC-6.4 RBC-3.13* HGB-10.1* HCT-28.7* MCV-92
MCH-32.3* MCHC-35.2 RDW-12.4 RDWSD-40.9
___ 10:45PM NEUTS-72.5* LYMPHS-13.2* MONOS-9.0 EOS-4.6
BASOS-0.5 IM ___ AbsNeut-4.61 AbsLymp-0.84* AbsMono-0.57
AbsEos-0.29 AbsBaso-0.03
___ 10:45PM PLT COUNT-233
___ 10:45PM ___ PTT-28.5 ___
___ 07:18AM BLOOD WBC-3.8* RBC-3.16* Hgb-10.1* Hct-30.1*
MCV-95 MCH-32.0 MCHC-33.6 RDW-13.2 RDWSD-46.0 Plt ___
___ 07:18AM BLOOD Glucose-76 UreaN-8 Creat-0.6 Na-129*
K-4.6 Cl-97 HCO3-21* AnGap-16
___ 07:18AM BLOOD Calcium-9.4 Phos-3.0 Mg-1.8
EXAMINATION: MRCP
INDICATION: ___ year old woman with new intra/extra hepatic
biliary ductal
dilatation, melena // eval for pancreatic mass, stricture,
stone etc
TECHNIQUE: T1- and T2-weighted multiplanar images of the
abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 6 mL Gadavist
Oral contrast: None
COMPARISON: Reference CT abdomen pelvis dated ___
Lower Thorax: There is linear atelectasis in the left lower
lobe. There is no
pleural or pericardial effusion.
Liver: The liver is normal in signal and morphology. There is a
T2
hyperintense irregular lesion in segment 8 measuring
approximately 2 x 0.7 cm
which does not enhance possibly representing sequela from old
injury or
collapsed cyst.
Biliary: There is no intrahepatic biliary dilatation. The
gallbladder is
unremarkable. The common bile duct measures up to 8 mm, within
normal limits
for patient age. There is normal variability of the sphincter
of Oddi.
Layering material is seen in the distal common bile duct likely
representing
sludge. There is no evidence of stones within the common bile
duct. The
gallbladder demonstrates tiny layering stones or sludge with no
evidence of
cholecystitis.
Pancreas: The pancreas is normal in signal and atrophic. There
is no
pancreatic duct dilatation or focal lesions.
Spleen: The spleen is normal in size measuring 6.9 cm
Adrenal Glands: The adrenal glands are unremarkable
Kidneys: The kidneys enhance and excrete contrast symmetrically.
There are
scattered T2 hyperintense nonenhancing simple cysts in both
renal cortices
measuring up to 2.9 cm
Gastrointestinal Tract: Visualized loops of small and large
bowel are normal
in caliber with no evidence of obstruction
Lymph Nodes: There is no retroperitoneal or mesenteric
lymphadenopathy
Vasculature: The abdominal aorta is normal in caliber. Hepatic
arterial
anatomy is conventional. The portal and hepatic veins are
patent.
Osseous and Soft Tissue Structures: No destructive osseous
lesion. Multilevel
degenerative changes of the lumbar spine. A T2 bright lesion in
T12
consistent with hemangioma.
Pelvis: There is a 1.4 cm T2 bright well-circumscribed lesion
in the right
adnexa only visualized on the localizer and coronal SSFE
sequences (04:17).
IMPRESSION:
1. No evidence of biliary dilatation. Layering sludge within
the distal
common bile duct which is normal in caliber. The sphincter of
Oddi
demonstrates normal variability and there is no evidence of
stones.
2. T2 bright nonenhancing lesion in segment 8 of the liver
without concerning
features may represent sequela of old injury or collapsed cyst
3. 1.4 cm right adnexal cystic lesion.
RECOMMENDATION(S): If no prior imaging exists to document
stability of right
adnexal cyst, a follow-up pelvic ultrasound in ___ year is
recommended per
recommendations of the society radiologists in ultrasound.
NOTIFICATION: Change in wet read discussed by Dr. ___ with
Dr. ___
on the telephone on ___ at 10:42 AM, 15 minutes after
discovery of the
findings.
Brief Hospital Course:
___ year old female with history of peptic ulcer disease,
referred here for CT showing intra and extrahepatic biliary
ductal dilatation along with cholelithiasis
# Gastrointestinal bleed
Presumed based on report of melena, but stopped during the
hospitalization. Hct ___ and stable but unclear baseline. No
use of NSAIDs or other clear risk factors. All diagnoses
considered. Given PUD history, placed on PPI. She was advised
to have outpatient endoscopy and she preferred to discuss this
with her PCP at her ___ in ___. She was told to hold her
aspirin until ___
.
# Biliary dilatation:
LFTs unremarkable except for mild alkaline phosphatase
evaluation, CT finding of intra- and extrahepatic biliary
dilatation. MRCP obtained and bile duct found to be at the
upper limit of normal. There was mention of biliary sludge,
but given that the patient was asymptomatic (no GI symptoms)
with normal bilirubin, decision made not pursue ERCP.
.
# Chronic SIADH/Hyponatremia: sodium 122 on arrival, increased
to 129 on discharge,Observes 2 liter fluid
# Home meds: hold home metoprolol, aspirin
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lovastatin 20 mg oral DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Gabapentin 300 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Calcium Carbonate Dose is Unknown PO Frequency is Unknown
8. Ascorbic Acid ___ mg PO DAILY
9. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Fish Oil (Omega 3) 1000 mg PO DAILY
3. Gabapentin 300 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Lovastatin 20 mg oral DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Calcium Carbonate 1500 mg PO DAILY
9. Omeprazole 40 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
GI bleeding
Bile obstruction
PUD
chronic SIADH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for evaluation of black stool and a dilated
bile duct. Your black stool suggested loss of blood from your
stomach, but this stopped and your blood count was stable. We
have started you on a medicine called omeprazole to help heal
any source of bleeding (such as an ulcer) from your stomach. I
have faxed the prescription for the omeprazole to the ___ on
___ in ___. It is important that you see a
gastroenterologist at ___ after discharge for an
endoscopy. Do not take any aspirin until you see your PCP.
Also, taking daily vitamin C does not appear to have any clear
benefit to your health. For your arthritis, you can take
tylenol, ___ mg, three times daily.
We did an evaluation of your bile duct through an MRCP, and it
appears that there is no blockage of your bile duct. We saw a
cyst on your liver and your ovary, and if any additional testing
needs to be done, your PCP can arrange that. We are faxing a
copy of our reports to your PCP ___.
If you pass black stool at home like you did before, please
return to ___. HOwever, if it is just a small
amount of black stool, it likely represents old blood. You can
follow a regular diet.
Followup Instructions:
___
|
10690270-DS-6
| 10,690,270 | 28,376,369 |
DS
| 6 |
2176-07-30 00:00:00
|
2176-07-30 18:13:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
right face/neck numbness, ? right facial droop, right leg
weakness/numbness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ ___ man with a history of silent
right frontal and left parietal punctate strokes of unclear
etiology, HTN, HLD, IDDM, pulmonary sarcoid who is admitted to
the Neurology Stroke Service after presenting with a transient
episode of right foot heaviness followed by a second episode of
transient right lower face and neck numbness and possible right
facial droop. Both episodes yesterday lasted less than 20
minutes. The right facial and neck numbness was similar to
prior events in the past, although he does not recall ever
having a right facial droop. The right foot was weak, heavy and
numb and although he has had numbness in the past, the right
foot was never weak before. His symptoms resolved spontaneously
and did
not recur overnight. Of note, he has been 100% compliant to his
aspirin 81mg in the past month. There have been no infectious
symptoms over the past few weeks. Only new medication has been
amlodipine after his atenolol was stopped.
He went to ___ first , where CT head was normal.
BP 200/100s.
He has had a dry cough for several days, with occasional
productive cough.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. No bowel or bladder
incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
DM
HTN
HLD
right frontal and left parietal punctate strokes of unknown
etiology
second degree heart block
? pulmonary sarcoid
Social History:
___
Family History:
Non -contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals:
98.8 84 151/87 16 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM
Neck: Supple, no nuchal rigidity.
Pulmonary: CTABL
Cardiac: irregular rhythm, on heart monitor some beats do not
have p waves and some beats have prolonged PR interval
Abdomen: soft, nontender, nondistended
Extremities: mild edema, pulses palpated
Skin: bilateral shin ulcerations.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Pt. was able to name both high and low frequency
objects. Speech was not dysarthric. Able to follow both
midline
and appendicular commands. Mildly inattentive, able to name ___
backward but with hesitancy and has to attempt a second time.
Pt. was able to register 3 objects and recall ___ at 5 minutes.
There was no evidence of neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1mm, both directly and consentually; brisk
bilaterally. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch in all distributions
VII: No facial droop, facial musculature symmetric and ___
strength in upper and lower distributions, bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5
R ___ ___ ___ 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 0
R 1 1 1 1 0
- Plantar response was flexor bilaterally.
- Pectoralis Jerk was absent, and Crossed Adductors are absent.
-Sensory: No deficits to light touch, pinprick, proprioception
throughout.
-Coordination: No intention tremor noted. No dysmetria on FNF or
HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Holds right foot in eversion. Has difficulty walking on
toes, primarily on right side.
DISCHARGE EXAM: no acute deficits.
Pertinent Results:
LABORATORY DATA:
___ 04:55AM BLOOD WBC-9.4 RBC-4.77 Hgb-12.9* Hct-39.5*
MCV-83 MCH-27.0 MCHC-32.7 RDW-14.6 RDWSD-43.4 Plt ___
___ 08:47PM BLOOD Neuts-31.9* Lymphs-55.9* Monos-8.0
Eos-3.5 Baso-0.4 NRBC-0.2* Im ___ AbsNeut-3.88
AbsLymp-6.80* AbsMono-0.97* AbsEos-0.43 AbsBaso-0.05
___ 04:55AM BLOOD Plt ___
___ 04:55AM BLOOD Glucose-177* UreaN-12 Creat-0.9 Na-138
K-3.8 Cl-99 HCO3-28 AnGap-15
___ 08:47PM BLOOD ALT-26 AST-21 AlkPhos-73 TotBili-0.3
___ 04:55AM BLOOD Calcium-9.8 Phos-3.8 Mg-1.6 Cholest-146
___ 08:47PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:55AM BLOOD %HbA1c-8.2* eAG-189*
___ 04:55AM BLOOD Triglyc-113 HDL-48 CHOL/HD-3.0 LDLcalc-75
IMAGING:
MRI BRAIN: 1. Acute infarction in the posterior right putamen,
corresponding with the CT finding, with no associated mass
effect or hemorrhage. 2. Prominent pituitary gland measuring up
to 9 mm. Recommend correlation with pituitary hormones.
NCHCT/CTA:
1. Focal hypodensity in the posterior lateral right putamen,
consistent with a lacunar infarction of uncertain chronicity.
An MRI can be acquired for further evaluation. 2. No evidence
for dissection, vascular abnormality, or aneurysm. 3. A 4 mm
right upper lobe lung nodule with multiple prominent mediastinal
lymph nodes. From prior CT chests, the patient may have a
history of sarcoidosis. Recommend correlation with clinical
history.
ECHO ___:
The left atrium is elongated. A left-to-right shunt across the
interatrial septum is seen at rest. A small secundum atrial
septal defect is present. The estimated right atrial pressure is
___ mmHg. There is mild symmetric left ventricular hypertrophy
with normal cavity size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Atrial fibrillation. Small secundum atrial septal
defect with slight left to right flow at rest. Mild symmetric
left ventricular hypertrophy with preserved global and regional
biventricular systolic function. Mildly dilated thoracic aorta.
MRV PELVIS: no DVT
___: no DVT
Brief Hospital Course:
Mr. ___ is a ___ yo man with a history of obesity, HTN, HLD,
DM, and prior right frontal and left parietal punctate strokes
(on MRI ___ of unknown etiology followed in Stroke
Neurology by Dr. ___ who was admitted to the neurology
stroke service after presenting with 2 discrete transient
episodes of neurological deficits, each lasting less than 20
minutes. The first was right leg weakness and numbness and the
second was right lower face (V3)/neck numbness as well as
possible facial droop (unclear which side).
# STROKE: Mr. ___ was found to have a new, acute ischemic
stroke in the right putamen and capsular region (looks to be fed
by the lateral lenticulostriate region). Interestingly, his
radiologic acute stroke, did not account for his ipsilateral,
RIGHT sided presenting symptoms. Thus, we are concerned that he
may have had an initial bihemispheric process from a
cardioembolic phenomenon. As described below, there was no
atrial fibrillation found this admission. An ASD was found, but
no DVTs. His stroke risk factors include the following:
obesity, HTN (on lisinopril, HCTZ, amlod), HLD (LDL 75, on
atorva 40), DM (A1c 8.2%, on insulin and oral
antihyperglycemics). For secondary stroke prevention, we
switched him from asa 81 to Plavix 75. Further ___ monitoring
at home as per below.
# ___: AV CONDUCTION DELAY:
The patient was asymptomatic, but EKG showed a Mobitz type I
with non-conducting premature atrial contractions. This was
reviewed with our cardiology fellow and the recommendation was
to compare telemetry during activity. With a walking trial, his
rhythm improved tremendously and showed AV delay with
intermittent blocked PACs. His cardiologist was emailed this
info and a follow-up cardiology apt was arranged. ___ was
arranged as described below.
# ___: NO AFIB: Importantly, NO atrial fibrillation was
captured on telemetry despite RN documentation of such based on
computer characterization of telemetry. Instead, his rhythm is
best characterized as AV conduction delay with PACs.
Furthermore, although the echo report says "afib" there is no
clear documentation of this. A 28 day ___ was ordered at time of
discharge and due to lack of holter units the day of discharge,
this will be sent to his house.
# ___: atrial septal defect
An echo with bubble showed "Small secundum atrial septal defect
with slight left to right flow at rest." MRV pelvis and LENIs
did not show a DVT.
TRANSITIONAL ISSUES:
1) Patient given note to return to work on ___.
2) 28 day holter monitor ordered inpatient, but monitor will be
shipped to his house as there were no units left in lab on day
of discharge.
============================================
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done
2. DVT Prophylaxis administered? (x) Yes -SQH () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes -ASA () No
4. LDL documented? (x) Yes (LDL = 75) - () 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)
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 - did not qualify per ___ () 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 - plavix() Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - (x) No - (x) N/A
========================================
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Amlodipine 10 mg PO DAILY
3. GlipiZIDE XL 10 mg PO DAILY
4. lisinopril-hydrochlorothiazide ___ mg oral DAILY
5. Glargine 14 Units Bedtime
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Omeprazole 20 mg PO BID
8. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. GlipiZIDE XL 10 mg PO DAILY
3. Glargine 14 Units Bedtime
4. Omeprazole 20 mg PO BID
5. lisinopril-hydrochlorothiazide ___ mg ORAL DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
8. Atorvastatin 40 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Acute ischemic stroke
Diabetes
Atrial septal defect
Mobitz 1 Heart block
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 ___ Neurology Stroke service after having
right foot weakness/numbness and right face numbness. You had a
new stroke which we found on MRI. We performed an
echocardiogram of your heart which showed a small opening we
call a shunt. We did additional imaging of your legs which did
not show clots in your legs.
We monitored your heart rhythm while you were here. You will
need to continue monitoring of your heart at home. You will need
to call the ___ lab to arrange this ___.
Appointments have been made for you with your stroke
neurologist, Dr. ___ your cardiologist, Dr. ___. They
are listed below.
Best wishes,
___ NEUROLOGY STROKE TEAM
Followup Instructions:
___
|
10691024-DS-3
| 10,691,024 | 29,868,873 |
DS
| 3 |
2143-12-18 00:00:00
|
2143-12-18 23:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin
Attending: ___.
Chief Complaint:
Hypoglycemia
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ year old male with history of NIDDM, HTN, CAD, DVT, CRF, CHF
(EF ~40%), PVD (s/p 2 iliac aneurism repairs), hypothyroidism,
pneumonia x 2, and recently diagnosed colon cancer with
metastasis to liver, presenting to the ED after being brought in
by family due to altered mental status and cough.
Pt had a ruptured iliac aneurism for which he was hospitalized
at ___ and underwent repair in ___ and ___. He was
subsequently diagnosed with colon adenocarcinoma, imaging of
which later showed mets to liver and L bladder compression by
iliac stent/bilateral hydroureter/hydronephrosis. He also
recently suffered a fracture of the L femur. He came home from
rehab 3 weeks prior. Pt also noted to have
hydroureter/hydronephrosis and related compression of L bladder
___ stent in L ilac artery (on PET-CT in ___.
Per wife, pt was noted to have a productive cough associated
with nasal congestion 1 week prior. He also had one episode of
brown emesis 3d prior. During the past week the pt began to
complain of fatigue, dyspnea on exertion and persistent cough.
On the day of admission the wife notes that the pt appeared
unwell ("looked grey") and had AMS ("said he was talking to
God"). In addition, he complained of abdominal pain and of 2d
anuria. Of note, pt was started on glipizide by his PCP 1 week
prior (although, per pharmacy, pt has been on glipizide since
___.
In the ED, initial VS were: 97.6 65 103/56 16 99% 2L. Exam
notable for 2+ edema to shins (baseline per family), distended
abdomen with hernia. Labs notable for HCT 30.5 (baseline), WBC
6.8, Cr 3.2 (baseline 1.4-1.8), TnT 0.27/0.29, CK 44, Mg 3.6,
Phos 5.4. UA showed large leuk, 30 protein, 71WBC and few
bacteria. Initial EKG showed NSR 65, ST elevation < 2mm in V1-V2
without reciprocal changes (comparion ___ years ago) and he was
without chest pain. Given normal CK-MB normal, cards consult
felt that these changes were likely J point elevation and he
would not require a Cardiology admission. Troponin was ascribed
to renal failure (creatinine 3.2).
The patient was persistently hypoglycemic on oral intake and D50
boluses, with a D10 drip initiated. In addition, pt received
levofloxacin 750mg IV x 1. BCx were sent.
On arrival to the MICU, VS: T 97.6, P 85, BP 115/65, O2 97% on
2LNC. He is A+O x 2 and not able to answer questions in a fully
coherent manner. He denies pain, SOB, vomiting, nausea,
diarrhea, or rash.
Past Medical History:
Type II Diabetes Mellitus
Gout
h/o bowel perforation ___.
hypothyroidism
Social History:
___
Family History:
Noncontributory
Physical Exam:
On Admission:
General: A+O x 2, NAD, congested/rhonchorous breath sounds
HEENT: Dry MM
Neck: Elevated JVP
CV: RRR, no MRG
Lungs: Diffusely rhonchorous
Abdomen: Distended abdomen with large soft, partially-reducoble
mass in RUQ.
Ext: WWP; 2+ pitting edema in LLE to mid-shin; arthritic
deformities in RUE. Small ulcer on RLE ___ digit
Neuro: No focal deficits
.
On Discharge:
Vitals: 98.3 134/66 73 22 94% RA; FSBG 120; 1000 in / 1650 out
General: Oriented x ~2 (couldn't remember name of hospital), NAD
Neck: JVP does not appear to be elevated
CV: RRR, no MRG
Lungs: Crackles r>l, improved from ___
Abdomen: Distended abdomen with large soft, partially-reducoble
mass in RUQ.
Ext: WWP; 1+ presacral pitting edema in LLE to mid-shin;
arthritic deformities in b/l UEs. Small ulcer on RLE ___ digit
Neuro: No focal deficits
Pertinent Results:
Labs upon admission:
___ 09:00AM BLOOD WBC-6.8 RBC-3.14* Hgb-9.8* Hct-30.5*
MCV-97 MCH-31.1 MCHC-32.0 RDW-16.5* Plt ___
___ 09:00AM BLOOD Neuts-87.3* Lymphs-7.8* Monos-3.6 Eos-1.1
Baso-0.1
___ 06:15PM BLOOD ___ PTT-35.1 ___
___ 09:00AM BLOOD Glucose-36* UreaN-68* Creat-3.2*# Na-133
K-5.1 Cl-97 HCO3-22 AnGap-19
___ 09:00AM BLOOD ALT-12 AST-19 CK(CPK)-44* AlkPhos-113
TotBili-0.3
___ 09:00AM BLOOD Lipase-8
___ 09:00AM BLOOD CK-MB-5
___ 09:00AM BLOOD cTropnT-0.29*
___ 01:35PM BLOOD cTropnT-0.27*
___ 09:00AM BLOOD Albumin-3.2* Calcium-8.6 Phos-5.4*#
Mg-3.6*
___ 06:40AM BLOOD %HbA1c-4.7* eAG-88*
___ 01:35PM BLOOD TSH-3.1
___ 06:33AM BLOOD Cortsol-28.9*
___ 09:14AM BLOOD Lactate-2.0
Labs upon discharge:
___ 06:55AM BLOOD WBC-5.1 RBC-2.94* Hgb-9.1* Hct-28.7*
MCV-97 MCH-31.0 MCHC-31.8 RDW-16.1* Plt ___
___ 06:40AM BLOOD ___ PTT-37.7* ___
___ 06:55AM BLOOD Glucose-89 UreaN-52* Creat-1.5* Na-139
K-3.7 Cl-102 HCO3-27 AnGap-14
___ 06:55AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.4
Urine studies:
___ 01:20PM URINE Color-Yellow Appear-Hazy Sp ___
___ 01:20PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
___ 01:20PM URINE RBC-3* WBC-71* Bacteri-FEW Yeast-NONE
Epi-<1
___ 01:20PM URINE CastHy-9*
___ 01:20PM URINE Hours-RANDOM UreaN-270 Creat-122 Na-13
K-75 Cl-<10
___ 01:20PM URINE Osmolal-331
Blood culture ___: no growth to date (preliminary)
Urine culture ___: no growth (final)
Imaging:
___: ECHO: The left atrium is mildly dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is moderately dilated. There is moderate regional left
ventricular systolic dysfunction with mid- to distal anterior,
anteroseptal and apical akinesis (mid-LAD territory). The
remaining segments contract normally (LVEF = 35%). An apical
left ventricular mass/thrombus cannot be excluded. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Moderate (2+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Moderate regional left ventricular systolic
dysfunction, c/w CAD. Moderate mitral regurgitation. Mild
pulmonary hypertension. Cannot exclude apical LV thrombus.
___: ECHO: Optison study. Overall left ventricular systolic
function is severely depressed (LVEF= 30 %). No masses or
thrombi are seen in the left ventricle/LV apex using contrast.
RV with depressed free wall contractility. There is no
pericardial effusion.
___: ___: IMPRESSION:
No evidence of DVT in the bilateral lower extremities.
___: CXR: FINDINGS: As compared to the previous
radiograph, there is substantial improvement. The signs
indicative of pulmonary edema have substantially decreased.
There is a persistent left lower lobe atelectasis and plate-like
atelectasis at the right lung base as well as persistent
bilateral pleural effusions. No pneumothorax. Moderate
cardiomegaly.
Brief Hospital Course:
___ year old male with history of NIDDM, HTN, CAD, CRF, CHF (EF
~40%), PVD (s/p 2 iliac aneurism repairs), hypothyroidism,
likely metastatic colon cancer, presenting with persistent
hypoglycemia, ___, and cough.
#) Persistent hypoglycemia
Most likely ___ glipizide in the setting of worsening renal
failure and unclear duration of therapy. Glucose gtt continued
for two days. TSH is within normal limits as was AM cortisol
level. Glipizide discontinued. Sent to rehab with insulin
sliding scale as needed (likely he will only need this while on
a short course of prednisone for his gout). He will need his
glucose checked QID and qHS while at rehab and should see his
PCP upon discharge from rehab to follow up glucose control.
#) Acute kidney injury
Nephrology consulted and they thought this was related to ATN.
This may have been related to acute heart failure, as his kidney
function improved with IV Lasix. He then began to auto-diurese
and creatinine continued to trend toward baseline. He was
started back on his home Lasix dose at discharge.
#) AMS
Most likely ___ hypoglycemia. Resolved with correction of
hypoglycemia.
#) Cough/LLE opacity/Acute on chronic systolic heart failure
Initially concerning for pneumonia, so the patient was started
on vancomycin and cefepime. However, pt had edema and elevated
JVP on exam suggesting component of CHF exacerbation. ECHO
showing reduced EF to 30% with depressed free wall contractility
indicating that heart failure and volume overload may be a
contributing factor. Cough improved with diuresis. CXR was
repeated after diuresis and did not show a pneumonia, so
antibiotics were stopped. Cardiac meds were restarted prior to
discharge.
#) Elevated TnT
Pt evaluated by cardiology who saw no indication for
intervention and attributed TnT to ___.
#) Hyponatremia
Related to excess free water from this infusion. Hyponatremia
improved when D10w was stopped.
#) Hyperkalemia
Elevated potassium improved with diuresis and one dose
kayexelate.
#) Anemia
Per prior OSH studies, most consistent with anemia of chronic
disease. However, pt may also have slow GIB in setting of
untreated metastatic CRC. Pt was continued on supplemental
iron.
#) Colon cancer
Pt with colon cancer diagnosed several months ago with no active
treatment. Treatment was reportedly delayed due to hip
fracture. Patient has an appointment in early ___ at ___
___ for follow up and further work up and treatment should be
considered at that time.
#) Hx of DVT
Pt has a hx of soleal DVT in ___. We were not clear why pt was
not on Coumadin. We did bilateral lower extremity ultrasounds
that did not show any evidence of DVT, so we did not start
anticoagulation. Pt was on heparin subQ as PPX during his
hospital stay.
#) Hand and foot pain
Patient has a history of arthritis (appears to be rheumatoid
given exam findings) and gout. Pain was treated with Tylenol.
Appeared to have active flare of gout so started on prednisone
40mg for 5 days.
Transitional Issues:
- Full code during this admission.
- Prednisone to continue for 5 days for acute gout. He has been
placed on a sliding scale insulin regimen if he becomes
hyperglycemic. He will likely not need insulin on discharge
(note he was hypoglycemic on admission).
- Please check glucose TID with meals and qHS.
- Avoid sedating medications, frequent re-orientation.
- Medication teaching and adherence.
- Ensure that he makes follow up to his oncologist which has
been scheduled for ___ (his family knows the details).
- ACE-I should be consider once ___ fully resolves.
- Kidney function should be followed with lab testing on ___
to ensure ongoing improvement.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyanocobalamin 1000 mcg PO DAILY
2. Levothyroxine Sodium 150 mcg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Zinc Sulfate 220 mg PO DAILY
6. Omeprazole 20 mg PO BID
7. Ferrous Sulfate 325 mg PO BID
8. Gabapentin 300 mg PO BID
9. Probenecid ___ mg PO BID
10. Magnesium Oxide 400 mg PO TID
11. Senna 2 TAB PO HS
12. Tamsulosin 0.4 mg PO HS
13. Furosemide 20 mg PO DAILY
14. Multivitamins W/minerals 1 TAB PO DAILY
15. OxycoDONE (Immediate Release) 5 mg PO Q4-6H PRN pain
16. GlipiZIDE 2.5 mg PO DAILY
Discharge Medications:
1. Cyanocobalamin 1000 mcg PO DAILY
2. Ferrous Sulfate 325 mg PO BID
3. FoLIC Acid 1 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Gabapentin 300 mg PO BID
6. Levothyroxine Sodium 150 mcg PO DAILY
7. Magnesium Oxide 400 mg PO TID
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Omeprazole 20 mg PO BID
11. Senna 2 TAB PO HS
12. Tamsulosin 0.4 mg PO HS
13. Zinc Sulfate 220 mg PO DAILY
14. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
15. PredniSONE 30 mg PO DAILY Duration: 5 Days
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Hypoglycemia
Acute kidney injury
Altered mental status
Acute on chronic systolic congestive heart failure - LVEF 30%
Secondary Diagnoses:
Cough
Diabetes Mellitus
Coronary Artery Disease
Metastatic colon cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You came to the hospital because of low blood sugar and
confusion. You were found to have mild kidney damage as well.
Your glipizide was stopped and your sugars improved. You were
given intravenous fluids and your kidney function is improving.
You received an ultrasound of your lower legs which did not show
a clot. You developed gout and we started you on prednisone for
5 days to help with gout pain. You have a cough, which is most
likely secondary to a resolving upper respiratory viral
infection. You will be discharged to rehab from the hospital.
Please make an appointment to see your primary care physician
___ 1 week of leaving the rehab facility.
As we discussed during your hospitalization, you have colon
cancer and according to your family, you have an appointment
oncologist in the near future. Please keep that appointment as
scheduled. If you have questions or concerns regarding your
oncology care, please call your primary care physician. It is
very important that you see an oncologist to discuss treatment
as soon as possible.
Followup Instructions:
___
|
10691738-DS-10
| 10,691,738 | 26,999,525 |
DS
| 10 |
2187-05-22 00:00:00
|
2187-05-22 14:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bacitracin / Reglan / Accupril / plastic tape
Attending: ___.
Chief Complaint:
presyncope/atrial flutter
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a CAD c/b MI s/p CABG in ___, presenting with an
episode of diaphoresis, lightheadedness while defecating at
cardiac rehabilitation. He was noted to be pale. He denies any
chest pain/sob/palpitations during the incident. The episode
spontaneously resolved after several minutes. He denies any
lower extremity pain or edema. He was noted to be in atrial
flutter at the outside hospital Emergency Department which he
has no hx of. He does reports that he had some sob going up a
flight of stairs yesterday which he has never had. Also notes
that he woke up this morning at 3 am with a "rhythmic twitching
feeling" that lasted 15 minutes.
Of note, pt with MI in ___ managed medically without sx since;
s/p CABG ___ for 3VD, several days later AICD/ppm placed.
Re-presented ___ admission for CP/dyspnea - found to
have pleural effusions and diuretic reg increased, no ___. TTE
that admission was without pericardial effusion. CP was
attributed to sternal incisional pain s/p CABG and treated with
narcotics, as CEs were normal. Effusions have been felt to be
___ to CHF vs post CABG inflammation. He has had 3 subsequent
taps and develops 3 pillow orthopnea when reaccumulating.
In the ED, initial VS were 98.0 114 100/65 14 98% 4L. Initially
labs were notable WBC 11.7, HCT was 42.9. BUN/CRE was mildly
elevated at 38/1.2 (baseline 1.0). Trop was 0.01. UA was clean.
EKG showed ? with a rate in the 120s. SBPs were stable in the
___. D Dimer was 1000. CTA showed no PE. CXR showed bilateral
pleural effusions with adjacent atelectasis (L>R). Prior to
transfer, VS were 98.1 109 108/67 15 99%. She received metop 75,
ASA 325, CTX 1g, Vanc 1g, and Azithro 500.
At this time, he denies f/c/abd
pain/cough/cp/sob/n/v/constipation/dysuria/uri symptoms. He does
report 2 loose stools today. No brb or melena.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-MI ___
-CABG: CABG ___ (LIMA to LAD, SVG to OM, SVG to RPDA, free
RIMA to diag)
-PACING/ICD: PPM/AICD on 11
3. OTHER PAST MEDICAL HISTORY: N/a
Past TIA
Peptic Ulcer Disease
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION:
Vitals: 98.1 119/89 110 18 98% 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,
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 rash
Neuro: nonfocal
DISCHARGE:
Vitals: 97.6 118/68 76 18 96% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, diminished bs at bases
CV: irregularly irregular, 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 rash
Neuro: nonfocal
Pertinent Results:
ADMISSION:
___ 12:07PM BLOOD WBC-11.7* RBC-5.04 Hgb-13.5* Hct-42.9
MCV-85 MCH-26.9* MCHC-31.6 RDW-16.1* Plt ___
___ 12:07PM BLOOD Neuts-79.4* Lymphs-12.5* Monos-5.8
Eos-1.8 Baso-0.5
___ 05:48AM BLOOD ESR-16*
___ 12:07PM BLOOD Glucose-248* UreaN-38* Creat-1.2 Na-140
K-4.6 Cl-103 HCO3-26 AnGap-16
___ 12:07PM BLOOD cTropnT-<0.01
___ 09:25PM BLOOD CK-MB-5 cTropnT-<0.01
___ 12:07PM BLOOD Calcium-9.2 Phos-4.1 Mg-1.8
___ 12:07PM BLOOD D-Dimer-1601*
___ 05:00AM BLOOD TSH-5.8*
___ 05:00AM BLOOD T4-4.5* T3-57* Free T4-1.1
___ 05:48AM BLOOD CRP-1.7
___ 01:31PM BLOOD Lactate-1.6
DISCHARGE:
___ 06:12AM BLOOD WBC-9.8 RBC-4.97 Hgb-13.2* Hct-42.1
MCV-85 MCH-26.6* MCHC-31.3 RDW-16.3* Plt ___
___ 06:12AM BLOOD ___ PTT-38.5* ___
___ 05:48AM BLOOD ESR-16*
___ 06:12AM BLOOD Glucose-135* UreaN-28* Creat-1.2 Na-139
K-4.3 Cl-101 HCO3-30 AnGap-12
___ 07:53AM BLOOD ALT-20 AST-20 AlkPhos-66 TotBili-0.3
___ 06:12AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.0
EKG:
Atrial flutter with 2:1 block. Intraventricular conduction
delay. Inferior wall myocardial infarction of indeterminate age.
ST-T wave abnormalities.
CXR:
PA and lateral views the chest were obtained. The heart size is
stable. The mediastinal and hilar contours are unremarkable.
There is a
moderate left pleural effusion. There is a small right pleural
effusion. There is no pneumothorax. There is no focal
consolidation concerning for pneumonia.
CTA:
CT of the chest per department PE protocol including coronal,
sagittal and maximum intensity projection oblique images.
FINDINGS: There is no mediastinal, hilar or axillary
lymphadenopathy by CT criteria. Aorta and the great vessels are
unremarkable aside from scattered atherosclerotic
calcifications. There are dense atherosclerotic calcifications
within the coronary arteries and patient is status post CABG and
median sternotomy. The heart is mildly enlarged, but there is
no pericardial effusion.
There are no pulmonary arterial filling defects to the
subsegmental level. The right main pulmonary artery remains
prominent, measuring up to 3.1 cm, stable from the prior exam.
There are bilateral moderate-sized pleural effusions, simple and
layering. There is compressive atelectasis at both lung bases,
although the degree on the left is greater than right. No focal
opacities are worrisome for pneumonia or malignancy.
Limited images of the upper abdomen demonstrate a hiatal hernia.
Otherwise, no gross abnormalities.
Echo:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is at least 15 mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is moderately depressed
(LVEF= 30 %) with global hypokinesis and regional near akinesis
of the basal inferior and infero-lateral segments. There is no
ventricular septal defect. Right ventricular chamber size is
normal. with depressed free wall contractility. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild to moderate
(___) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
overall LVEF has decreased and rhythm is now aflutter.
Brief Hospital Course:
___ with a CAD c/b MI s/p CABG in ___, presenting with an
episode of diaphoresis, lightheadedness while defecating at
cardiac rehabilitation, now with new a flutter
.
ACUTE
# New afib/flutter: variable block on EKG ___. Etiology is
unclear. ___ be related to ongoing pulmonary disease (recurren
effusions). TFTs were checked and demonstrated only mild
hypothyroidism. Pt remained asymtomatic with no chest pain,
dizziness, shortness of breath. Started on heparin gtt on
presentation. Metoprolol uptitrated to 75 QID for improved
rated conrol. Amiodarone was continued per home dosing. Rate
control was adequate with rates in the ___. Pt was then
transitioned to xarelto for anticoagulation with plans to return
to ___ for TEE with cardioversion on ___ followed by 1 mo
of uninterupted anticoagulation. For d/c, metoprolol 75 QID was
transitioned to metoprolol succ 300 daily.
.
# CAD: hx of 3VD s/p CABG in ___. Currently CP free with no
e/o ischemic event by EKG and troponins. Pt was continued on
crestor, metoprolol, irbesartan, and asa 81.
.
# sCHF: EF appears newly depressed with EF of 30% compared to
echo in ___. This is possibly related to a tachycardic
cardiomyopathy given global hypokinesis. He appears euvolemic
at this time. No current orthopnea, pnd, and minimal ___ edema.
Pt was continued on lasix 40 daily, spironolactone 12.5 daily.
Irbesartan was decreased to 150 daily given uptitration of
metoprolol.
.
# HISTORY OF VTACH: Vtach was presumed to be related to ischemia
at OSH due to 3VD that was found necessitating a CABG. Had AICD
placed before discharge due to fact that pt had arrested.
Metoprolol was uptitrated as above and amiodarone was continued
at home dose. No shocks from AICD were required and pt was
asymptomatic. Some episodes self terminated while others
required anti tachycardia pacing. EP was consulted and felt
that he may need ablation if he continues to have frequent runs
of v tach or requires AICD shock
.
CHRONIC
# DMII: Oral medications held in house. Most recent A1C 6.9.
Then transitioned back to metformin once discharged.
.
# HTN: Normotensive on floor in the 120s systolic. He was
continued on home metoprolol and irbesartan.
.
# Recurrent pleural effusions: asymptomatic at this time. Most
recent tap was ___. No pleural fluid studies were performed.
IP outpatient follow-up was arranged.
.
# BPH: continued home tamsulosin 0.4mg Qhs.
TRANSITIONAL
# EP f/u (Dr. ___
# Cardiology f/u (Dr. ___
# IP f/u for pleural fluid analysis (Dr. ___
# TEE with cardioversion on ___
# consider discontinuing anticoagulation 1 mo after TEE with
cardioversion
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO BID:PRN pain
2. Amiodarone 200 mg PO DAILY
hold for hr<60 or sbp<100
3. Aspirin 81 mg PO DAILY
4. Cyanocobalamin 250 mcg PO DAILY
5. Docusate Sodium 100 mg PO BID
hold for loose stools
6. Fish Oil (Omega 3) ___ mg PO BID
7. irbesartan *NF* 300 mg Oral daily
hold for hr<60 or sbp<100
8. Metoprolol Tartrate 75 mg PO TID
9. Multivitamins 1 TAB PO DAILY
10. Polyethylene Glycol 17 g PO DAILY
hold for loose stool
11. Rosuvastatin Calcium 10 mg PO DAILY
12. Senna 1 TAB PO BID:PRN constipation
hold for loose stool
13. Tamsulosin 0.8 mg PO HS
14. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
15. coenzyme Q10 *NF* 120 mg Oral BID
16. glutathione *NF* 250 mg Miscellaneous daily
17. hawthorn *NF* 100 mg Oral daily
18. lecithin *NF* 400 mg Oral BID
19. MetFORMIN (Glucophage) 850 mg PO BID
20. phosphatidyl serine (bulk) *NF* 120 mg Miscellaneous BID
21. resveratrol-quercetin *NF* 100-100 mg Oral BID
Take 2 tabs BID
22. Vitamin D 400 UNIT PO BID
23. Spironolactone 12.5 mg PO DAILY
hold for hr<60 or sbp<100
24. Furosemide 40 mg PO DAILY
hold for hr<60 or sbp<100
Discharge Medications:
1. Acetaminophen 650 mg PO BID:PRN pain
2. Amiodarone 200 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Fish Oil (Omega 3) ___ mg PO BID
5. Furosemide 40 mg PO DAILY
6. irbesartan *NF* 150 mg ORAL DAILY
RX *irbesartan 150 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
7. Multivitamins 1 TAB PO DAILY
8. Polyethylene Glycol 17 g PO DAILY
9. Rosuvastatin Calcium 10 mg PO DAILY
10. Spironolactone 12.5 mg PO DAILY
11. Tamsulosin 0.8 mg PO HS
12. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
13. Rivaroxaban 20 mg PO DAILY
RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
14. coenzyme Q10 *NF* 120 mg Oral BID
15. Cyanocobalamin 250 mcg PO DAILY
16. glutathione *NF* 250 mg Miscellaneous daily
17. hawthorn *NF* 100 mg Oral daily
18. lecithin *NF* 400 mg Oral BID
19. phosphatidyl serine (bulk) *NF* 120 mg Miscellaneous BID
20. resveratrol-quercetin *NF* 100-100 mg Oral BID
21. Senna 1 TAB PO BID:PRN constipation
22. Vitamin D 400 UNIT PO BID
23. Aspirin 81 mg PO DAILY
24. MetFORMIN (Glucophage) 850 mg PO BID
25. Metoprolol Succinate XL 300 mg PO DAILY
RX *metoprolol succinate 100 mg 3 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
New Atrial Flutter
Systolic Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear. Mr ___,
It was a pleasure caring for you during your recent admission to
___. You were admitted with an abnormal heart rhythm known as
Atrial Flutter. Your doses of metoprolol were increased to
improve your heart rate. You remained asymptomatic. You were
started on anticoagulation to prevent a stroke. You will need
to return on ___ for a TEE with cardioversion.
Followup Instructions:
___
|
10691738-DS-8
| 10,691,738 | 21,906,851 |
DS
| 8 |
2187-01-09 00:00:00
|
2187-01-11 19:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bacitracin / Reglan / Accupril / plastic tape
Attending: ___
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o man w/ recent Vtach presented ___) for
work-up that revealed NSTEMI with CAD (3VD) s0 underwent CABG
___ and PPM/AICD on ___, then discharged from ___ on
___ who presented to urgent care today with chest pressure
since last night.
Since CABG has some band-like pressure across the chest. Since
___ afternoon he has been feeling worse with feeling of "bones
crunching against each other at sternotomy site" as well as
orthopnea, PND fatigue, and DOE. Has noted that exhalation is
more difficult and reduced exercise tolerance as he had been
able to walk up one flight of stairs but unable to today due to
fatigue. Was not able to lay flat to sleep due to SOB, had to
spend night in chair last night. Slightly lightheaded with
movement. Felt slightly warm but no fever upon checking
temperature. Also with mild non-productive cough. Denies
abdominal pain, nausea, vomiting, ___ swelling, or frank chest
pain. No rash. No diarrhea. Mildly constipated.
Due to symptoms, PCP's office performed a CXR which showed
bilateral pleural effusions; pt was referred to the ED for
further evaluation.
Of note, on review of records for ___ admission at
___: Had inferior STEMI during this admission
with cath showing 3VD. Underwent a CABG (Dr. ___.
Proceedure went well and was given diuresis post-op. Started on
a beta-blocker post-op. Due to fact that complicated by VT, had
___ Sprint DF4 Model ___ Serial # ___
implanted on ___. Started on metoprolol and amiodarone
while there and his prior plavix was discontinued. Discharged
home with ___ on POD #6.
In the ED, initial vitals were 99.5 68 154/79 18 96%. Cards and
CT surgery saw in the ED - sternal wound is unstable - may be
contributing to SOB. Needs TTE tomorrow morning. On EKG, TWI
more pronounced during CP that resolved with improvement in CP.
Trop of 0.02 is reassuring. Given 325mg ASA and 75mg of
Metoprolol. No Plavix given possible need for OR with CT
surgery. CTA done and negative for a PE. VS on transfer: 98.5 64
141/69 15 96%
On review of systems, he endorses prior TIA, but dednies deep
venous thrombosis, pulmonary embolism, bleeding at the time of
surgery, myalgias, joint pains, hemoptysis, black stools or red
stools. All of the other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
ankle edema, palpitations, syncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-MI ___
-CABG: CABG ___ (LIMA to LAD, SVG to OM, SVG to RPDA, free
RIMA to diag)
-PACING/ICD: PPM/AICD on 11
3. OTHER PAST MEDICAL HISTORY: N/a
Past TIA
Peptic Ulcer Disease
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission:
VS: T=97.9 BP=134/74 HR=66 RR=20 O2 sat=95% on RA, blood sugar
309
GENERAL: Obese white male, NAD, sitting in bed reading
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple, thick neck makes JVP visualization difficult
CARDIAC: normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4. Has sternotomy wound that is c/d/i without swelling,
erythema. Tender to palp especially at middle of the verticle
incision
LUNGS: Trace scattered end-expiratory wheezing, no crackles
ABDOMEN: Distended ___ to habitus, slightly tympanitic to
percussion centrally, slightly firm, NT. No HSM, BS+
EXTREMITIES: No c/c/e. R inside of thick has large bruise
surrounding area of prior vein graft, ___ where graft was
taken is closed, nontender, not erythematous, underlying veing
has cord-like feel
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ ___ 2+
Left: DP 2+ ___ 2+
VS: 98, 107-134/61-81, 54-71, 20, 93% RA weight 93.9 adm weight
95.3 kg
GENERAL: Obese white male, NAD, sitting in bed reading
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple, thick neck makes JVP visualization difficult
CARDIAC: normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4. Has sternotomy wound that is c/d/i without swelling,
erythema. Tender to palp especially at middle of the verticle
incision
LUNGS: decreased sounds at b/l bases otherwise CTAB
ABDOMEN: Distended ___ to habitus, slightly tympanitic to
percussion centrally, slightly firm, NT. No HSM, BS+
EXTREMITIES: 2+ RLE edema, trace LLE edema
PULSES:
Right: DP 2+ ___ 2+
Left: DP 2+ ___ 2+
Pertinent Results:
Admission:
___ 06:15PM URINE HOURS-RANDOM
___ 06:15PM URINE HOURS-RANDOM
___ 06:15PM URINE UHOLD-HOLD
___ 06:15PM URINE GR HOLD-HOLD
___ 06:15PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 06:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-7.0
LEUK-NEG
___ 05:45PM GLUCOSE-191* UREA N-19 CREAT-0.9 SODIUM-136
POTASSIUM-4.6 CHLORIDE-99 TOTAL CO2-28 ANION GAP-14
___ 05:45PM cTropnT-0.02*
___ 05:45PM estGFR-Using this
___ 05:45PM D-DIMER-5443*
___ 05:45PM WBC-14.1*# RBC-3.49*# HGB-9.5*# HCT-29.9*#
MCV-86 MCH-27.3 MCHC-31.9 RDW-16.1*
___ 05:45PM NEUTS-76.2* LYMPHS-15.9* MONOS-4.8 EOS-3.0
BASOS-0.2
___ 05:45PM PLT COUNT-403#
Discharge:
___ 06:08AM BLOOD WBC-11.6* RBC-3.54* Hgb-9.8* Hct-30.5*
MCV-86 MCH-27.6 MCHC-32.0 RDW-16.5* Plt ___
___ 06:08AM BLOOD Glucose-133* UreaN-19 Creat-1.0 Na-136
K-4.4 Cl-97 HCO3-30 AnGap-13
___ 05:45PM BLOOD cTropnT-0.02*
___ 06:11AM BLOOD CK-MB-5 cTropnT-0.01
___ 05:45PM BLOOD D-Dimer-5443*
___ 06:08AM BLOOD Calcium-8.6 Phos-4.4 Mg-2.3
Imaging:
ECG Study Date of ___ 5:56:30 ___
Sinus rhythm. Intraventricular conduction delay. Inferior wall
myocardial
infarction of indeterminate age. Compared to tracing #1 the
findings are
similar.
FINDINGS:
CTA: Contrast opacification of the pulmonary arterial tree is
adequate for exclusion of pulmonary embolism to the subsegmental
level. The aorta is normal caliber throughout its length.
There is no dissection or aneurysm. The right main pulmonary
artery is dilated to 3.3 cm. Mediastinal stranding and surgical
clips are compatible with post CABG changes. Cardiomegaly is
moderate. A pericardial effusion is trace.
The thyroid gland is homogeneous. There is no supraclavicular,
mediastinal, hilar, or axillary adenopathy. Bilateral pleural
effusions are moderate.There is no airspace consolidation, large
nodule or pneumothorax. Bibasilar atelectasis is mild. The
sternotomy has not fused. The widest diastasis is at the
inferior sternal wire where there is 6 mm of separation (3:
37). There are no concerning lytic or sclerotic bone lesions.
IMPRESSION:
1. No pulmonary embolism.
2. Moderate right greater than left nonhemorrhagic pleural
effusions.
Brief Hospital Course:
___ y/o man with recent Vtach presented to OSH for work-up that
revealed 3VD-CAD -> underwent CABG ___ and PPM/AICD on ___,
then discharged from ___ on ___ who presented with
2 days of fatigue and orthopnea and continued pain at sternal
incision site, treated for mild heart failure and post operative
pain.
# Chest Pressure: Patient presented s/p CABG on ___ (LIMA
to LAD, SVG to OM, SVG to RPDA, free RIMA to diag)and PPM/AICD
on ___ with chest pressure that was positional and at the site
of the incision. Differential initially included ACS, post
surgical, pulmonary embolism, gastrointestinal. A CT was done
to rule out pulmonary embolism. H Likely secondary to sternal
wound. EKG without any changes from prior, trop 0.01, 0.02
making ACS unlikely. The pain was most consistent with post
surgical pain in the setting of the patient decreasing his pain
medications. He was seen and evaluated by cardiac surgery who
recommended follow up in two weeks and continued sternal
precautions. The patient was treated with standing tylenol and
PRN oxycodone.
# Acute systolic heart failure: Patient presented with symptoms
concerning for heart failure including orthopnea, PND and
fatigue s/p CABG on ___ and PPM/AICD on ___. TTE on
___ with mod reduced global LV fucntion EF 43%, no sig
valvular disease. A repeat ECHO ___ with preserved EF but
poor image quality. He was lightly diuresed and symptoms
improved. He was discharged on furosemide with follow up with
his cardiologist and cardiac surgery. He was continued on
metoprolol and restarted on irbesartan. Discharge weight 93.9
adm weight 95.3 kg.
# Rhythm s/p Vtach and pacer placement: Vtach was presumed in
setting of ischemia at OSH due to 3VD that was found
necessitating a CABG. Had pacer placed before discharge due to
fact that pt had arrested. Currently in NSR. Continued on
metoprolol 75mg TID and amiodarone 400mg daily.
# Constipation:Patient has been constipated since surgery. Exam
was notable for distension without any tenderness, rebound of
guarding. This is likely secondary to oxycodone. He was put on
docusate, miralax, senna and received one dose of lactulose
after no bowel movement. He then had a large bowel movement and
was discharged on a bowel regimen.
# DMII: Patient put on ISS and lantus while in house and
discharged on home medications.
# HTN: BP well controlled during hospitalization, continued on
home amlodipine 20 mg daily, metoprolol 75 mg TID and restarted
on irbesartan 300 mg daily.
# BPH:
- Tamsulosin 0.4mg Qhs
Transitional Issues:
- Patient started on furosemide and will follow up with
cardiologist.
- Consider discontinuing amiodarone
- Consider changing metoprolol tartrate to succinate for once
daily dosing
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 10 Units Bedtime
2. MetFORMIN (Glucophage) 850 mg PO BID
3. glimepiride *NF* 2 mg Oral daily
4. Rosuvastatin Calcium 10 mg PO DAILY
5. Amlodipine 10 mg PO DAILY
6. Amiodarone 400 mg PO DAILY
7. Metoprolol Tartrate 75 mg PO TID
8. Aspirin 81 mg PO DAILY
9. Tamsulosin 0.8 mg PO HS
10. OxycoDONE (Immediate Release) 5 mg PO Q3H:PRN pain
11. Acetaminophen Dose is Unknown PO Frequency is Unknown
12. Cyanocobalamin Dose is Unknown PO Frequency is Unknown
13. Fish Oil (Omega 3) ___ mg PO DAILY
14. coenzyme Q10 *NF* 120 mg Oral BID
15. Multivitamins 1 TAB PO DAILY
16. glutathione *NF* 250 mg Miscellaneous daily
17. resveratrol-quercetin *NF* 100-100 mg Oral BID
Take 2 tabs BID
18. selenium *NF* 200 mcg Oral daily
19. lecithin *NF* 400 mg Oral BID
20. hawthorn *NF* 100 mg Oral daily
21. phosphatidyl serine (bulk) *NF* 120 mg Miscellaneous BID
22. irbesartan *NF* 300 mg Oral daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Amiodarone 400 mg PO DAILY
3. Amlodipine 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Glargine 10 Units Bedtime
6. Metoprolol Tartrate 75 mg PO TID
7. Multivitamins 1 TAB PO DAILY
8. OxycoDONE (Immediate Release) 5 mg PO Q3H:PRN pain
9. Rosuvastatin Calcium 10 mg PO DAILY
10. Tamsulosin 0.8 mg PO HS
11. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
12. 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
13. irbesartan *NF* 300 mg Oral daily
14. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 packet by mouth once a
day Disp #*30 Packet Refills:*0
15. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*30 Tablet Refills:*0
16. coenzyme Q10 *NF* 120 mg Oral BID
17. Fish Oil (Omega 3) ___ mg PO DAILY
18. glimepiride *NF* 2 mg ORAL DAILY
19. glutathione *NF* 250 mg Miscellaneous daily
20. hawthorn *NF* 100 mg Oral daily
21. lecithin *NF* 400 mg Oral BID
22. MetFORMIN (Glucophage) 850 mg PO BID
23. phosphatidyl serine (bulk) *NF* 120 mg Miscellaneous BID
24. resveratrol-quercetin *NF* 100-100 mg Oral BID
Take 2 tabs BID
25. selenium *NF* 200 mcg Oral daily
26. Cyanocobalamin 250 mcg PO DAILY
27. Milk of Magnesia 30 mL PO PRN constipation Duration: 1 Doses
RX *magnesium hydroxide [Milk of Magnesia] 400 mg/5 mL 30 mL by
mouth once a day Disp #*1 Container Refills:*0
28. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: acute systolic heart failure s/p CABG
Secondary: hypertension, coronary artery disease, hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
with chest discomfort. There was no evidence of any damage to
your heart. A CT scan showed normal post CABG findings. You were
seen by cardiac surgery who felt that your incision was **
stable**. You also had orthopnea and fatigue. A CT scan showed
fluid in your lungs and you were given Lasix to remove fluid.
Medication changes:
Irbesartan 300 mg daily restarted
START Lasix 40 mg PO daily
START Senna 1 tab twice a day for constipation
START Colace 100 mg twice per day for constipation
START Milk of Magnesia 30ml as needed for constipation
START polyethylene glycol 17 g daily for constipation
START ferrous sulfate 325 mg daily
Followup Instructions:
___
|
10691749-DS-2
| 10,691,749 | 21,647,141 |
DS
| 2 |
2184-02-15 00:00:00
|
2184-02-18 08:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Seizure x 2
Major Surgical or Invasive Procedure:
Nil
History of Present Illness:
The patient is a ___ year old woman presenting with two
episodes concerning for seizure. Her main medical history is
that
she had a concussion at age ___ and binge drinks alcohol. At ___,
she was out running and woke up on the side of the road; she had
a headache but otherwise did not know what happened to her. She
thought she might have tripped and fallen. She did not have any
long term sequelae from this injury. She has been feeling well
recently but for several years has consumed considerable amounts
of alcohol: she binge drinks on ___ and ___ with
friends, an uncountable number. She denies any tremors,
hallucinations, or seizures after these episodes, and she does
not drink to the point of passing out. However, her friend at
the
bedside does say she "can drink everyone else under the table."
On ___, she was out running and looked at her watch around
11:00 or 11:30 AM. The next thing she could remember was lying
in
bed around 12:30 ___ in a different set of clothes. She could not
remember anything that occurred in the previous hour or so, but
she felt that her right forehead hurt a bit as if she had struck
it. She had scrapes on her knees as if she had fallen. She later
thought she had "burned" her tongue on coffee on the left side.
She looked at her phone and saw a text from a friend; she did
not
recognize the name at first. She also looked at a picture with
some friends in it, but she could not recognize who they were by
name for about two minutes. She came to the ___ ED to be
evaluated for this. Basic studies and a noncontrast head CT were
fortunately unrevealing for acute abnormalities. She was set up
for a Neurology Urgent Care appointment. She went home and felt
okay for the rest of the day and the next few days. She usually
sleeps 8 to 9 hours per night, but last night she stayed up to 2
AM (sleeping about 6 hours) because she was watching the ___ basketball game. This morning, she felt a bit lightheaded
but this improved after drinking coffee. She walked to her
appointment this morning but felt more lightheaded. While
walking, she suddenly lost consciousness and reportedly had a
witnessed generalized convulsive episode lasting ___ minutes. No
other eye witness information is provided. She sustained a
laceration to the right side of the head. She was then brought
to
our Emergency Department for further care.
With regards to any underlying predisposition for seizures, the
patient:
- Endorses one prior time lapse (___) and one prior LOC
episode (age ___, concussion). But no behavioral/speech arrests.
- Endorses a prior major head injury (concussion, with loss of
consciousness, at age ___ while running).
- Denies any prior febrile seizures, meningitis or encephalitis.
- Denies any personal history of seizures or learning disorders.
- Denies any substance abuse.
- Denies any family history of seizures.
- Denies any significant family history of learning disorders or
developmental disorders.
- With regards to temporal lobe auras, the patient denies
olfactory hallucinations, gustatory hallucinations, micropsia,
macropsia, frequent ___ or ___, dream-like state,
sudden unprovoked fear, or epigastric rising sensation.
On review of systems, the patient endorses: mild headache, loss
of consciousness.
On review of systems, the patient denies the following:
- Neurologic: confusion, difficulty producing speech, difficulty
understanding speech, vision loss, diplopia, vertigo,
dysarthria,
dysphagia, focal limb weakness, sensory loss, gait imbalance.
- Constitutional: fever, rigors, night sweats, unintentional
weight loss.
- Cardiovascular: chest pain, palpitations, lightheadedness.
- Gastrointestinal: nausea, emesis, diarrhea, constipation.
- Genitourinary: dysuria, urinary urgency, urinary incontinence.
- Ear, Nose, Throat: tinnitus, hearing loss, rhinorrhea,
odynophagia.
- Hematologic: bleeding, easy bruising.
- Musculoskeletal: arthralgia, myalgia.
- Psychiatric: anxiety, depression.
- Respiratory: dyspnea, cough, hematemesis.
- Skin: rash, new skin lesions.
Past Medical History:
Neurologic - Concussion (age ___ while running, lost
consciousness)
Social History:
___
Family History:
No known neurologic diseases including no
seizures, no learning disorders. ("Everyone in my family is a
genius!" which is to say that they're all professionals,
___, ___, etc.)
Physical Exam:
Physical Examination:
VS T: 98.3 HR: 78 BP: 115/72 RR: 18 SaO2: 98% RA
- General/Constitutional: Lying in bed comfortably,
well-appearing young, Caucasian woman.
- Eyes: Round, regular pupils. No conjunctival icterus, no
injection.
- Ear, Nose, Throat: Left lateral tongue bite. No external
auditory canal lesions.
- Neck: No meningismus. No carotid, vertebral, or subclavian
bruits appreciated. No lymphadenopathy.
- Musculoskeletal: Range of motion with neck rotation full
bilaterally. No focal spinal tenderness.
- Skin: Right vertex laceration (approximately ___ inches). No
rashes. No concerning lesions appreciated.
- Cardiovascular: Regular rate. Regular rhythm. No murmurs,
rubs,
or gallops appreciated. Normal distal pulses.
- Respiratory: Lungs clear to auscultation bilaterally. No
crackles. No wheezes.
- Gastrointestinal: Soft. Nontender. Nondistended.
- Psychiatric: Mood congruent with affect. Intact insight.
Neurologic Examination:
- Mental Status - Awake, alert. Oriented to name, birth place,
current location, year. Attention to examiner easily attained
and
maintained. Recalls a coherent and detailed history. Speech is
fluent with full sentences. Follows midline and appendicular
commands. Intact repetition. Intact high frequency and low
frequency naming. No paraphasias. Normal prosody. No dysarthria.
No ideomotor apraxia. No hemineglect.
- Cranial Nerves - [II] PERRL 3->2 brisk. VF full to number
counting. Funduscopy shows crisp disc margins, no papilledema.
[III, IV, VI] EOMI, no nystagmus. [V] V1-V3 without deficits to
light touch bilaterally. [VII] No facial movement asymmetry.
[VIII] Hearing intact to finger rub bilaterally. [IX, X] Palate
elevation symmetric. [XI] SCM/Trapezius strength ___
bilaterally.
[XII] Tongue midline.
- Motor - Normal bulk and tone. No pronation, no drift. No
tremor, asterixis, or myoclonus. No hemihypoplasia at the hands.
=[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[___]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1] [L5]
L 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5
- Sensory - No deficits to cold temperature or proprioception
bilaterally.
- Reflexes
=[Bic] [Tri] [___] [Quad] [Gastroc]
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. Intact cadence and accuracy with rapid alternating
movements (finger tap).
- Gait - Normal initiation. Stable stance with narrow base.
Romberg sign is absent. Normal stride length. Normal arm swing.
No sway with standard gait. No sway with turns.
Pertinent Results:
___ 11:25AM BLOOD WBC-4.9 RBC-4.46 Hgb-13.7 Hct-43.3 MCV-97
MCH-30.7 MCHC-31.6 RDW-13.3 Plt ___
___ 11:25AM BLOOD Neuts-49.2* Lymphs-42.4* Monos-5.6
Eos-0.9 Baso-1.9
___ 11:25AM BLOOD ___ PTT-26.6 ___
___ 11:25AM BLOOD Glucose-82 UreaN-13 Creat-0.8 Na-136
K-6.4* Cl-100 HCO3-20* AnGap-22*
___ 11:25AM BLOOD ALT-37 AST-86* AlkPhos-39 TotBili-0.4
___ 11:25AM BLOOD Albumin-5.1 Calcium-9.8 Phos-3.3 Mg-2.1
___ 11:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:35PM BLOOD K-4.1
___ 02:20PM URINE UCG-NEGATIVE
___ 02:20PM URINE RBC-1 WBC-2 Bacteri-MOD Yeast-NONE Epi-40
___ 02:20PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 02:20PM URINE Color-Straw Appear-Hazy Sp ___
___ 2:20 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
MRI: Small focus of signal abnormality in the left frontal white
matter adjacent to
the corpus callosum. This is of nonspecific nature and does not
appear to be
of neoplastic origin. It is unclear whether this is related to
reported remote
trauma. No migration abnormalities are seen. No evidence of
mesial temporal
sclerosis. MRI was repeated with contrast and this focus of
signal abnormality did NOT enhance with gadolinium.
EEG (final report pending), reviewed with Dr. ___:
identifies normal background with few ___ epochs of generalized
epileptiform discharges, compatible with a generalized epilepsy
Brief Hospital Course:
___ was admitted to the general neurology service. We obtained
a history of a previous "concussion", which was something of a
vaguely defined syncopal episode that occurred when she was
running associated with some head trauma, but it was not clear
whether the head trauma precipitated the loss of consciousness.
She had presented to our emergency room earlier in the week
following a period of lapsed time following which she woke up in
a completely new environment and was transiently disoriented. As
above, she presented to the ED with a convulsive event that
occurred while on the street and was apparently witnessed by
bystanders and EMS brought her to our ED. While admitted, she
received an MRI which identified a small focus of T2 hyper
intensity in the left anterior frontal lobe which did not
enhance. The diagnostic possibilities are numerous including a
scar from a prior concussion, cortical dysplasia, previous
inflammation, nonspecific ___ change, etc. Her EEG identified
generalized epileptiform discharges, consistent with a
generalized epilepsy.
She was briefly started on oxcarbazepine prophylactic therapy
until the EEG returned, and so she was switched to the more
broad spectrum agent, levetiracetam, at a dose of 750mg BID and
with instructions to increase to 1000mg BID in one week. She was
given instructions regarding driving restrictions in the state
of MA following a seizure, as well as other general seizure
warnings. She was counseled extensively on the importance of
abstaining from binge drinking and drinking in moderation. Her
step father and mother, as well as her friends were all
understanding of the gravity of the situation and we had a
chance to answer all of their questions.
She will follow up with Drs. ___ in the Neurology
clinics of ___.
Medications on Admission:
Nil
Discharge Medications:
1. LeVETiracetam 750 mg PO BID
RX *levetiracetam [Keppra] 750 mg 1 tablet(s) by mouth twice
daily Disp #*16 Tablet Refills:*0
RX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth twice
daily Disp #*60 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS: Seizures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neurologic Status: No neurologic deficits.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized because you had two SEIZURES. This occurs
when there is abnormal electrical activity in the brain. When
the risk of recurrence is high, we ask that patients take a
medication daily to reduce the risk of having seizures. Seizures
have several common triggers including missing doses of
antiseizure medications, infections, sleep deprivation or a
variable sleep schedule, excessive alcohol consumption, and some
other medications (certain antibiotics). You had an EEG and an
MRI. Your routine extended EEG identified generalized
epileptiform discharges, consistent with a "generalized
epilepsy", and your MRI identified a small area of increased
signal in the left frontal lobe. The significance of this
finding is uncertain, and will need to be followed up in the
future.
It is important to avoid activities where you might come to
severe harm if you were to lose consciousness. These include but
are not limited to climbing up ladders, roof work, swimming
alone, etc.
By ___ Law, you cannot legally drive for six
months after your last episode of loss of consciousness even if
you are on anticonvulsant medications.
We ask that you start a medication called KEPPRA or
LEVETIRACETAM to help prevent seizures.
- Start at 750mg twice daily
- Increase to 1000mg twice daily in a week
Do not hesitate to contact us with questions or concerns. We
will arrange to have you come back and see us in clinic in the
next ___ weeks. You will receive a phone ___ with the date/time
of your appointment. It is also pertinent that you follow up
with your primary care physician within the next week.
Followup Instructions:
___
|
10691828-DS-10
| 10,691,828 | 28,157,656 |
DS
| 10 |
2170-08-26 00:00:00
|
2170-08-26 13:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ esophageal cancer metastatic to bone s/p one cycle of
palliative ramucirumab who presented to ___ ED with pain and
failure to thrive. Patient had stage IIA (T3N0) esophageal
adenocarcinoma at initial diagnosis, s/p concurrent weekly
___ and RT but then had biopsy-proven bony metastatic
disease, with progression despite 2 cycles CapOx/trastuzumab,
now s/p C1 palliative ramucirumab,
Patient was in USOH when he had an episode of hyperventilation
with muscle twitching. She called the Fire Department which
brought him to ___. Wife has noticed a
progressive decline in the last week in his ADL. He was able to
dress himself last week. Wife states no fevers at home. 99. She
also reports that there has been increasing amount of pain not
controlled by his usually managment. Labs at ___ ED notable for
9.6 wbc hgb 8.6 plt 177 na 130 k 4.6 bun 26 cre 0.7 asl 236 alt
137 ak phos 1072 trop <0.01 and inr 1.4. Ct head was negative
per report but no disc, portable cxr unremarkable. He was
transferred to ___ ED for further management.
- In the ED, initial VS were 3 97.6 103 128/79 24 99% ra.
- Exam was notable for being alert, oriented to person and date
though somewhat confused as to place and circumstance. Pt denied
pain or discomfort, no s/sx of resp distress, able to tolerate
some water and POs, no desaturation, coughing, or choking.
- Labs were notable for na 132, cr 0.6, phos 2.6, alb 2.5,
ast/alt 232/126, ap 908, inr 1.3.
- Imaging was notable for CXR that showed no acute process.
- Patient was given 500cc IVF. ED got verbal signout that
patient got zosyn but no record in OSH records
- Patient was admitted to ___ for iv pain control and
management of progressive decline.
- VS prior to ED pain (denies) 104 120/97 23 98% Nasal Cannula.
On presentation to the OMED floor, patient was VSS. He was
complaining of ___ pain but was also very drowsy and sleeping
through most of the hisotry. he described pain to be most in his
hip and while he was comfortable at rest, winced when i palpated
his RLL in the abdomen. No fevers chills nasiea, vomitting
diarrhea, dyspnea. The patient reports not having taken
metahdone since last night. Not using lidoacine or fentanyl
patches at present.
Past Medical History:
PAST ONCOLOGIC HISTORY:
In ___, the patient developed dyspepsia, hiccups and then
progressive dysphagia. He underwent
EGD on ___ performed by Dr. ___, which showed
an inflammatory, firm and friable 0.9 cm stricture measuring 3
cm long from 36 cm to the gastroesophageal junction; there was
erythema at the gastric antrum; the duodenum appeared normal;
biopsy of the lesion at the gastroesophageal junction was
positive for adenocarcinoma, at least moderately differentiated;
biopsy of the gastric antrum was negative and biopsy of the
duodenum was negative for cancer. On ___, Dr. ___ performed an EUS and noted a fungating mass of malignant
appearance at the gastroesophageal junction in the lower one-
third of the esophagus with partial obstruction; the adult
gastroscope would not traverse; EUS was performed with an EBUS
scope and showed a 3-4 cm long lesion measuring 1.8 cm in depth
at the lower one-third of the esophagus and the gastroesophageal
junction with invasion beyond the muscularis compatible with a
T3 lesion; there was a 0.8 x 0.6 cm celiac lymph node, which was
very suspicious but a clear path for biopsy could not be
obtained; there was a 0.4 x 0.7 cm lymph node in the
paraesophageal mediastinum adjacent to the tumor, which also
could not be biopsied but was very suspicious. PET-CT was
performed on ___ which showed increased FDG avidity in
the distal esophagus at the known carcinoma with an SUV of 11.5;
there were no other abnormal foci in the chest. There was a 1.3
cm FDG avid lesion at the lower pole of the right kidney with an
SUV of 8.1 and further imaging was recommended; there were no
liver metastases; the official report does not describe bone
metastases, but on a review of the PET-CT with Dr. ___
at the thoracic oncology conference on ___, Dr. ___ that uptake in the left upper humerus and several
other bony areas was indeterminate, but somewhat suspicious and
recommended followup.
Mr. ___ was treated with concurrent chemotherapy and
radiation therapy to the esophagus and lymph nodes to a dose of
41.4 Gy in 23 fractions, completed on ___ the
chemotherapy was weekly carboplatin and Taxol. Mr. ___
generally tolerated the treatment reasonably well. He had a
followup PET-CT performed on ___, which was compared
to a prior examination from ___, which showed that the
gastroesophageal junction mass was less FDG avid with SUV
decreased to 6.7 compared with 11.5 prior to treatment;
unfortunately, there was interval progression of numerous bony
metastases including the left humeral head, the bilateral
acetabula, the sacrum and the bilateral ischial tuberosity;
there were new bony lesions involving the L5 vertebral body, the
bilateral iliac bones, the right acetabulum, the left second,
fourth and sixth ribs laterally, the right fifth rib laterally
and the right seventh rib posteriorly. PSA on ___
had decreased to 7.3 compared with 8.7 and CEA increased to 5.7
compared with a prior
value of 5.2. Mr. ___ underwent a ___ biopsy of the
left humeral head lesion on ___ and pathology showed
metastatic adenocarcinoma with CDX2 positive, CK7 positive, CK20
positive; TTF-1, PSA, and PSAP were negative and the lesion was
felt compatible with gastrointestinal origin. Mr. ___ is
felt to have bone metastases from the esophageal cancer.
Mr. ___ started on chemotherapy with oxaliplatin,
capecitabine, and Herceptin on ___. He had chest
pain and underwent cardiac catheterization on ___
which showed no angiographically significant coronary artery
disease. PET-CT on ___, showed a focus of uptake
in the clivus with an SUV of 6.2; there was a 0.9 cm left lower
lobe lung nodule with an SUV of 2.9; there was uptake in the
gastroesophageal junction, which had not changed and showed an
SUV of 6.5; there was no mediastinal adenopathy; there were two
liver lesions compatible with metastases, one measuring 1.3 cm
with an SUV of 6.1 and a second measuring 1.2 cm with an SUV of
5.4; there are extensive osseous metastases, which had increased
compared with ___ a right scapular lesion had an
SUV of 4 and thoracic and lumbar spine and rib lesions were FDG
avid; a lesion in the right iliac wing had an SUV of 10 and a
lesion in the bilateral superior acetabula were FDG-avid; a
right lateral femoral condyle lesion had an SUV of 4.4 and a
lesion posterior to the right femur had an SUV of 7.3. Because
of Mr. ___ very significant right knee pain, which had
actually caused interruption of a prior PET-CT on ___, we treated Mr. ___ with palliative radiation therapy to
the right distal femur lesion and also to an FDG avid
symptomatic lesion in the
left proximal humerus; both sites were treated to a dose of 20
Gy
given in five fractions, completed on ___.
- c1d1 ___ Ramicurimab palliative IV Days 1 and 15.
___ and ___
Social History:
___
Family History:
His father died at age ___ of prostate cancer. He has one
brother who is alive and fairly well at age ___. Otherwise,
there is no known family history of any malignancies.
Physical Exam:
ADMISSION:
General: elderly emaciated gentleman, sleeping, RASS -1
VITAL SIGNS: 97.5 146/80 112 20 97% RA ___
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG tahcycardic
PULM: CTAB
ABD: BS+, soft, tender in RLL, no masses or hepatosplenomegaly
LIMBS: 2+ edema to mid shins, no clubbing, tremors, or
asterixis; no inguinal adenopathy
SKIN: No rashes or skin breakdown
NEURO: Cranial nerves II-XII are within normal limits excluding
visual acuity which was not assessed, no nystagmus; strength is
___ of the proximal and distal upper and lower extremities. Gait
deferred
DISCHARGE:
VS: 98.2 ___ 18 96 RA
GEN: elderly male, awake, rass +1
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG tahcycardic
PULM: CTAB
ABD: BS+, soft, tender in RLL, no masses or hepatosplenomegaly
LIMBS: 2+ edema to mid shins, no clubbing, tremors, or
asterixis; no inguinal adenopathy
SKIN: No rashes or skin breakdown
NEURO: Cranial nerves II-XII are within normal limits excluding
visual acuity which was not assessed, no nystagmus; strength is
___ of the proximal and distal upper and lower extremities. Gait
normal but slow requriing assistance. AOX3.
Pertinent Results:
ADMISSION:
___ 05:28AM BLOOD WBC-8.5 RBC-2.34* Hgb-6.5*# Hct-20.4*#
MCV-87 MCH-27.8 MCHC-31.9 RDW-18.3* Plt ___
___ 01:00PM BLOOD ___ PTT-40.8* ___
___ 05:28AM BLOOD Ret Aut-3.7*
___ 01:00PM BLOOD Glucose-93 UreaN-25* Creat-0.6 Na-132*
K-4.5 Cl-99 HCO3-24 AnGap-14
___ 01:00PM BLOOD ALT-136* AST-232* AlkPhos-908*
TotBili-0.7
___ 01:00PM BLOOD Albumin-2.5* Calcium-7.4* Phos-2.6*
Mg-2.3
___ 05:28AM BLOOD Hapto-228*
___ 01:30PM URINE Color-Yellow Appear-Clear Sp ___
___ 01:30PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-8* pH-6.5 Leuks-TR
___ 01:30PM URINE RBC-0 WBC-7* Bacteri-NONE Yeast-NONE
Epi-0
DISCHARGE:
___ 05:15AM BLOOD WBC-9.7 RBC-2.73* Hgb-7.6* Hct-23.8*
MCV-87 MCH-27.9 MCHC-32.0 RDW-18.6* Plt ___
___ 05:15AM BLOOD Glucose-108* UreaN-26* Creat-0.5 Na-133
K-4.3 Cl-101 HCO3-24 AnGap-12
___ 05:15AM BLOOD Calcium-7.3* Phos-2.1* Mg-2.3
CXR PA LAT ___: No acute cardiopulmonary process.
ECG ___: Sinus tachycardia. Left axis deviation. Right
bundle-branch block with left anterior fascicular block. There
are Q waves in the inferior leads consistent with myocardial
infarction. Non-specific ST-T wave changes. Compared to the
previous tracing of ___ ventricular ectopy is no longer
present.
Brief Hospital Course:
___ w/ esophageal cancer metastatic to bone s/p one cycle of
palliative ramucirumab who presented to ___ ED with pain and
failure to thrive. Patient oscillating between pain and
sedation; metahdone was reduced to 7.5mg tid with good effect.
Was continued on PO dilaudid. hct dropped to 20 likely ___ low
production, no evidence of bleeding and got one unti prbc.
Discharged to home with hospice.
# Pain: patient has had chronic pain for some time that is
difficult to manage. The patient is a poor historian who varies
his reporting substantially. The patient oscillates between too
much pain and too much sedation. Recently was started on po
methadone and was also using dilaudid po at home though it makes
him sleepy. In the ___ ED, patient denied pain. Sedation
improved with donwtitration of metahdone.
Dc-ed at metahdone at 7.5mg tid (may go down further to 5 tid)
and po dilaudid
# Anemia: pt's hct dropped to 20 from 27 on ___, likely
unmasked with fluid resusciation. Retic index 0.9% indicates low
production, with normal haptoglobin siggesting against
destruction. Given 1 unit prbc and responded appropriately. No
evidence of hemolysis on labs.
# Failure to Thrive: Mr. ___ has been off of tube feeds and
is s/p J-tube removal. Is having progressive difficulty with
ADLs at home. Poor nutrition is a component which is being
driven by progressive disease. Has significant edema from low
albumin. Had a goals of care discussion with family who are
interested in home with hsopice. We continue ritalin, nutrition
reccommended scandi drink and ensure tid, multivit w/ minerals.
# Esophageal Cancer: Patient currently getting palliative
treatment with ramucirumab (C1D1 ___ with plan for second
dose on ___. plan was to treat for ___ cycls and assess
response with imaging however plan changed to pursue no further
cehmo per outpatient hem onc docs.
# AFIB: stable; was in rvr in OSH, but stable in NSR in ___
ED. We continued home ___ 81 and digoxin for now
# BPH: stable. We continued home tamsulosin for now
# Constipation: stable. Had BM on ___. We continued home
senna, colase miralax. Can give ducolax enema if needed
PAIN: Po dilaudid and metahdone for now
BOWEL REGIMEN: senna/colase/miralax
DVT PROPHYLAXIS: got systemic anticoagulation with ___
150mg qd
ACCESS: ___ powerport
CODE STATUS: DNR/DNI discharging to home hospice
CONTACT INFORMATION:
Name of health care proxy: ___
Relationship: Wife
Phone number: ___
Cell phone: ___
TRANSITIONAL ISSUES:
- MAY REDUCE METHADONE TO 5MG TID IF SEDATION PERSISTS
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. ___ Etexilate 150 mg PO DAILY
3. Digoxin 0.125 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Ondansetron 8 mg PO Q8H:PRN nausea
6. Prochlorperazine ___ mg PO Q6H:PRN nausea
7. Tamsulosin 0.4 mg PO HS
8. Docusate Sodium 100 mg PO BID
9. Senna 8.6 mg PO BID:PRN constipation
10. Acetaminophen ___ mg PO Q8H:PRN pain
11. Lorazepam 0.5 mg PO QHS:PRN insomnia
12. Polyethylene Glycol 17 g PO BID:PRN constipation
13. HYDROmorphone (Dilaudid) ___ mg PO Q2H:PRN pain
14. Methadone 10 mg PO TID
15. MethylPHENIDATE (Ritalin) 2.5 mg PO BID
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
3. ___ Etexilate 150 mg PO DAILY
4. Digoxin 0.125 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. HYDROmorphone (Dilaudid) ___ mg PO Q2H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth q2 Disp #*40
Tablet Refills:*0
7. Lorazepam 0.5 mg PO QHS:PRN insomnia
RX *lorazepam 0.5 mg 1 tablet by mouth at bedtime Disp #*10
Tablet Refills:*0
8. Methadone 7.5 mg PO TID
RX *methadone 5 mg 1.5 tablet by mouth q8 Disp #*35 Tablet
Refills:*0
9. MethylPHENIDATE (Ritalin) 2.5 mg PO BID
RX *methylphenidate 5 mg 0.5 (One half) tablet(s) by mouth twice
a day Disp #*20 Tablet Refills:*0
10. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*10
Capsule Refills:*0
11. Ondansetron 8 mg PO Q8H:PRN nausea
RX *ondansetron 8 mg 1 tablet(s) by mouth q8 Disp #*30 Tablet
Refills:*0
12. Polyethylene Glycol 17 g PO BID:PRN constipation
RX *polyethylene glycol 3350 17 gram/dose 17 grams by mouth q12
Refills:*0
13. Prochlorperazine ___ mg PO Q6H:PRN nausea
14. Senna 8.6 mg PO BID:PRN constipation
15. Tamsulosin 0.4 mg PO HS
16. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Esophageal Cancer
Failure to Thrive
Pain
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with worsening pain and sedation. We made
changes to your pain medications which improved both. You were
discharged to home with hospice in a stable condition.
Followup Instructions:
___
|
10692094-DS-11
| 10,692,094 | 24,259,055 |
DS
| 11 |
2122-08-23 00:00:00
|
2122-08-23 12:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
right head laceration repaired ___
History of Present Illness:
This patient is a ___ year old female who complains of fall
with laceration to her head and left shoulder pain.
Past Medical History:
Stage IV CKD
Mechanical mitral and tricuspid valves
Atrial Fib
DM
HTN
CHF
Neuropathy
Social History:
___
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAMINATION: upon admisson
Constitutional: Moderate discomfort
HEENT: 2 x 4 cm V-shaped laceration with the use of blood
400
Neck without midline tenderness
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, Nontender
Extr/Back: Tenderness over the chest wall and right
shoulder
Skin: Warm and dry, No rash
Neuro: Speech fluent
Psych: Normal mentation
DISCHARGE EXAM:
VITALS: 98.2 PO 129 / 56 L Lying 88 18 97 Ra
GENERAL: interactive, sitting in
chair, in NAD.
HEENT: Large repaired scalp laceration on R forehead improving.
Bilateral orbital ecchymoses. PERRLA, EOMI. Sclera anicteric and
without injection. Oropharynx clear of erythema and
exudates.
CARDIAC: RRR. Audible mechanical and faint heart sounds. No MRG.
LUNGS: CTAB, no increased work of breathing.
ABDOMEN: soft, NT/ND +BS
EXTREMITIES: WWP. No c/c/e. DP and ___ palpable.
NEUROLOGIC: AOx3. CN II-XII grossly intact. ___ strength in ___.
Pertinent Results:
___ 11:55AM BLOOD WBC-7.1 RBC-2.49* Hgb-7.9* Hct-23.7*
MCV-95 MCH-31.7 MCHC-33.3 RDW-16.5* RDWSD-57.1* Plt ___
___ 05:46AM BLOOD WBC-6.7 RBC-2.23* Hgb-7.2* Hct-21.8*
MCV-98 MCH-32.3* MCHC-33.0 RDW-16.6* RDWSD-60.0* Plt ___
___ 09:20PM BLOOD WBC-7.8 RBC-2.05* Hgb-6.6* Hct-19.8*
MCV-97 MCH-32.2* MCHC-33.3 RDW-17.5* RDWSD-61.6* Plt ___
___ 04:58PM BLOOD WBC-7.8 RBC-2.23* Hgb-7.2* Hct-21.5*
MCV-96 MCH-32.3* MCHC-33.5 RDW-17.9* RDWSD-62.9* Plt ___
___ 11:00AM BLOOD WBC-8.2 RBC-2.37* Hgb-7.5* Hct-23.1*
MCV-98 MCH-31.6 MCHC-32.5 RDW-18.3* RDWSD-64.3* Plt ___
___ 11:29PM BLOOD WBC-8.1 RBC-2.37* Hgb-7.7* Hct-22.6*
MCV-95 MCH-32.5* MCHC-34.1 RDW-17.6* RDWSD-60.1* Plt ___
___ 12:20PM BLOOD WBC-6.6 RBC-2.18* Hgb-7.3* Hct-22.2*
MCV-102* MCH-33.5* MCHC-32.9 RDW-13.6 RDWSD-50.5* Plt ___
___ 04:05PM BLOOD Neuts-87.1* Lymphs-7.3* Monos-4.3*
Eos-0.4* Baso-0.2 Im ___ AbsNeut-9.02* AbsLymp-0.76*
AbsMono-0.44 AbsEos-0.04 AbsBaso-0.02
___ 11:55AM BLOOD Plt ___
___ 05:46AM BLOOD ___ PTT-42.8* ___
___ 05:46AM BLOOD Glucose-89 UreaN-76* Creat-3.6* Na-135
K-3.9 Cl-96 HCO3-21* AnGap-18
___ 11:00AM BLOOD Glucose-122* UreaN-73* Creat-3.2* Na-137
K-3.4 Cl-97 HCO3-23 AnGap-17
___ 12:20PM BLOOD UreaN-73* Creat-2.9*
___ 05:46AM BLOOD Calcium-7.8* Phos-4.7* Mg-2.0
___ 12:21PM BLOOD pO2-197* pCO2-44 pH-7.40 calTCO2-28 Base
XS-2 Comment-GREEN TOP
___ 12:21PM BLOOD Glucose-223* Lactate-0.9 Na-136 K-3.0*
Cl-99
___ 12:21PM BLOOD freeCa-1.15
___: CXR:
No comparison. The lung volumes are low. Moderate
cardiomegaly. Status post sternotomy and valvular replacement.
Minimal fluid overload but no overt pulmonary edema. Old healed
fracture of the fourth left-sided rib but no evidence of newly
or displaced rib fractures. No pneumonia, no pneumothorax, no
pleural effusions.
___: CT head:
1. Moderately motion limited examination.
2. No definite intracranial hemorrhage or acute fracture.
3. Right frontal subgaleal hematoma and scalp laceration.
___: CT abd/pelvis:
1. Acute comminuted angulated right proximal humeral shaft
fracture with
substantial surrounding hematoma.
2. Concern for acute impacted left proximal humerus fracture
with small
surrounding hematoma.
3. Non-displaced left-sided rib fractures possibly acute
involving the fourth rib, and probably sub-acute involving the
fifth through ninth ribs.
4. No pneumothorax. No other fracture identified.
5. Right upper lobe peripheral opacity may reflect contusion or
infection.
6. No evidence of intra-abdominopelvic traumatic injury.
7. Multilevel degenerative changes in the spine with severe
central canal
stenosis at L2-L3 and moderate central narrowing at L1-L2 and
L3-L4.
8. Findings may suggest pulmonary hypertension. Ascending aortic
enlargement measuring 43 mm. No evidence of mediastinal
hematoma.
9. 22 mm soft tissue nodularity adjacent to the right thyroid
lobe may
represent a thyroid nodule or possibly enlarged lymph
node/parathryoid gland. Non-emergent thyroid ultrasound
recommended.
10. Diverticulosis. Cholelithiasis.
___: CT c-spine:
1. Moderately motion limited examination.
2. Minimal anterolisthesis of C2 on C3 and C5 on C6 is most
likely
degenerative. If persistent clinical concern for cervical spine
injury,
consider repeat CT examination when the patient is better able
to tolerated with less motion.
3. No fracture in the cervical spine within limitations of the
examination.
4. Comminuted right proximal humeral shaft fracture.
5. Multilevel degenerative changes with severe spinal canal and
left neural foraminal narrowing at C4-C5.
6. 22 mm soft tissue nodularity adjacent to the right lobe of
the thyroid may represent a thyroid nodule or lymph node.
Non-emergent thyroid ultrasound recommended
RECOMMENDATION(S): Non-emergent thyroid ultrasound.
___: Right forearm
Extensive vascular soft tissue calcifications. The cortical
structures are intact. There is no convincing evidence for the
presence of a fracture.
___: right hand:
1. Tiny ossific density adjacent to the radial styloid may be
chronic/
degenerative but a tiny fracture fragment is difficult to
exclude.
2. No other definite acute fracture. If snuffbox tenderness,
consider repeat radiographs in ___ days.
___: right shoulder:
No comparison. 5 projections of the right shoulder and the
right humerus are provided. The humeral head is not dislocated,
however, there is a displaced and complicated complete fracture
of the humeral shaft, with at least 1 loose bony fragment and
substantial shortening of the regional anatomical distance.
The limited assessment of the elbow shows no coexisting
fractures.
___: left shoulder:
Likely sub-acute impacted transverse left humeral neck fracture
with probable avulsion component of the greater tuberosity.
___: right humerus:
There is persistent visualization of a comminuted spiral
fracture of the
proximal humeral diaphysis. A butterfly fragment measuring 9.7
cm
cranio-caudal remains displaced anteriorly along the humeral
diaphysis. The dominant fracture fragment is displaced
anteriorly by approximately 1 cm. No significant callus
formation is appreciated. No additional fractures are
seen.
DISCHARGE LABS
___ 06:30AM BLOOD WBC-5.8 RBC-2.73* Hgb-8.8* Hct-27.0*
MCV-99* MCH-32.2* MCHC-32.6 RDW-18.0* RDWSD-62.4* Plt ___
___ 06:30AM BLOOD Plt ___
___ 06:30AM BLOOD ___ PTT-39.9* ___
___ 06:30AM BLOOD Glucose-107* UreaN-65* Creat-2.6* Na-138
K-3.9 Cl-99 HCO3-PND
___ 06:30AM BLOOD Calcium-9.0 Phos-3.2 Mg-1.9
___ 06:30AM BLOOD Glucose-107* UreaN-65* Creat-2.6* Na-138
K-3.9 Cl-99 HCO3-23 AnGap-16
Brief Hospital Course:
Ms. ___ is a ___ yo right-handed F w/ h/o CHF (LVEF 35%),
valvular disease s/p MVR and TVR in ___, A fib on warfarin, CKD
stage IV s/p L AV fistula, and DM who suffered a ground level
fall on ___ with resultant left ___ rib fractures, scalp
laceration (repaired by ACS at bedside), and right displaced
closed spiral fracture of her proximal humerus and impacted
transverse left humeral neck fracture transferred from trauma
surgery due to complications of labile INRs, ___, and anemia.
ACTIVE ISSUES:
==============
# Valvular cardiomyopathy
# Mechanical mitral and tricuspid valves
# Sub/supratherapeutic INR
MVR and TVR in ___. Given mechanical valves, INR goal 2.5-3.5.
Initially subtherapeutic INR in setting of reversal s/p fall.
Bridged with heparin gtt initially with subsequent
supratherapeutic INRs. Dosed warfarin daily based on INR.
# Acute on chronic macrocytic anemia
Bleeding secondary to trauma as well as chronic component likely
___ CKD. On home Epoetin ___ ___ unit/mL SC every other week,
given on ___. Continued on home iron, folic acid, and thiamine
supplementation. Received 6u pRBC during hospitalization with
goal for Hg >8. Discharge Hgb 8.8.
# ___
# Stage IV CKD ___ diabetic nephropathy, s/p L AV fistula
Admitted with Cr 2.9, peak of 3.7, downtrended to 2.6 on
discharge. Baseline Cr
2.5-3.0. Likely pre-renal given poor PO intake, fluid losses,
recent diuretic changes. No evidence of overt volume overload on
exam to suggest cardiorenal etiology. Urine lytes suggesting
prerenal process with Na <20. Dose reduced home Torsemide as
below.
# Fall
# Humeral shaft fracture
# Scalp laceration
# Rib fractures, left ___ ribs
Scalp laceration repaired by ACS at bedside. Suture removal in
14 days from ___. Closed/nonoperative management of
humeral shaft fracture recommended by orthopedics. NCHCT
negative and denies LOC. Etiology of syncope likely overdiuresis
leading to orthostatic hypotension vs. vasovagal episode.
Orthstatics inpatient negative though checked after adequate
resuscitation. Pain control with Tylenol, lidocaine patches, and
dilaudid PO PRN. Follow-up with Dr. ___ on discharge with
repeat plain films.
# Acute on chronic congestive heart failure:
Last known LVEF 35% from ___ TTE at OSH. Weight was 173 lbs
on admission to ___ ___. Continues to be euvolemic to dry
on exam. Reduced home Torsemide dose to 50 mg BID given ___,
possible orthostasis. Continued home hydralazine, imdur, and
carvedilol.
#Lytic calvarium lesions: Incidentally found on ___. Possibly
indicative of metastasis from breast cancer vs. myeloma. Prior
SPEP from ___ at ___ negative.
Oncologist made aware of these findings, will work-up
outpatient.
CHRONIC ISSUES:
===============
# A-fib: Continue home carvedilol as above, A/C as above.
#HTN: Continue home hydral, imdur, carvedilol.
# HLD: Continued home atorvastatin 80mg PO QD
# DM: Last HgbA1c 6.7% at OSH (___). Sugars low 100s due to
low PO intake. On Lantus 16 units at bedtime at home, which was
held inpatient and on discharge. On ISS while in hospital.
# Hypothyroidism: S/p partial thyroidectomy. Continued
levothyroxine 175mcg PO QD.
# Unspecified mood disorder: Continued home fluoxetine 20mg PO
daily.
TRANSITIONAL ISSUES
===================
Incidental Findings:
- 22 mm soft tissue nodularity adjacent to the right lobe of the
thyroid may represent a thyroid nodule or lymph node.
Nonemergent thyroid ultrasound recommended.
- Several lytic calvarial lesions measuring up to 15 mm in the
right posterior frontal bone. Correlate with malignancy history
or myeloma.
- Ascending aortic enlargement measuring 43 mm.
- Held home lantus on discharge as patient had poor PO intake
and sugars inpatient were well controlled. Initiate lantus when
PO intake adequate, consider decreasing dose as last Hgb A1c
6.7%.
- Suture removal in 2 weeks from placement as per surgery
recommendations (___).
- Dose reduced home Torsemide to 50 mg BID as above.
- F/u in ___ clinic in 1 week with repeat humerus plain
films.
- Oncology follow-up for lytic lesions as above.
- Last given home epogen ___ on ___.
- Please use dilaudid for pain control only if needed, wean off
during rehab stay.
INR Monitoring:
- INR has been supratherapeutic in setting of poor PO intake.
Please check INR daily and dose warfarin accordingly. Goal INR
2.5-3.5 given mechanical valves. If INR <2.5, please start
lovenox or heparin gtt for bridging until INR therapeutic. Next
INR check ___. Please dose warfarin based on INR. Daily
dosage requirement is likely 2.5 mg.
Medications on Admission:
Active Inpatient Medication list as of ___ at 1517:
Medications - Standing
Influenza Vaccine Quadrivalent 0.5 mL IM NOW X1
Sodium Chloride 0.9% Flush ___ mL IV Q8H and PRN, line flush
Insulin SC
Carvedilol 12.5 mg PO/NG BID
Ascorbic Acid ___ mg PO/NG BID
Atorvastatin 80 mg PO/NG QPM
Calcitriol 0.25 mcg PO DAILY
Docusate Sodium 100 mg PO/NG BID
FLUoxetine 20 mg PO/NG DAILY
FoLIC Acid 1 mg PO/NG DAILY
Levothyroxine Sodium 175 mcg PO/NG DAILY
Multivitamins 1 TAB PO DAILY
Thiamine 100 mg PO/NG DAILY
Lidocaine 5% Patch 1 PTCH TD QAM
Acetaminophen 1000 mg PO Q8H
HydrALAZINE 75 mg PO/NG TID
___ MD to order daily dose PO DAILY16
Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
Torsemide 100 mg PO BID
Ferrous Sulfate 325 mg PO BID
Potassium Chloride 20 mEq PO DAILY
Medications - PRN
Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
Glucose Gel 15 g PO PRN hypoglycemia protocol
LORazepam 0.25 mg IV Q4H:PRN nausea
Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, shortness of
breath
TraMADol 50 mg PO Q4H:PRN pain
Senna 8.6 mg PO/NG BID:PRN constipation
Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN cough
Discharge Medications:
1. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Severe
RX *hydromorphone 2 mg ___ tablet(s) by mouth Q4H:PRN Disp #*7
Tablet Refills:*0
2. Lidocaine 5% Patch 1 PTCH TD QAM
3. Polyethylene Glycol 17 g PO BID
4. Senna 8.6 mg PO BID:PRN constipation
5. Acetaminophen 1000 mg PO Q8H
6. Thera-Tabs (therapeutic multivitamin) 1 tab oral DAILY
7. Torsemide 50 mg PO BID
8. ___ MD to order daily dose PO DAILY16
9. Albuterol Inhaler 2 PUFF IH Q6H:PRN for wheezing
10. Ascorbic Acid ___ mg PO DAILY
11. Atorvastatin 80 mg PO DAILY
12. Calcitriol 0.25 mcg PO DAILY
13. calcium carbonate-vitamin D3 600 mg(1,500mg) -200 unit oral
QHS
14. Carvedilol 12.5 mg PO BID with meals
15. ___ (docusate sodium) 100 mg oral BID
16. Epoetin ___ ___ unit/mL SC EVERY OTHER WEEK
17. Ferrous Sulfate 325 mg PO BID
18. FLUoxetine 20 mg PO DAILY
19. FoLIC Acid 1 mg PO DAILY
20. HydrALAZINE 75 mg PO Q8H
21. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
22. Klor-Con 10 (potassium chloride) 20 mEq oral DAILY
23. levothyroxine 175 mcg oral DAILY
24. Thiamine 100 mg PO DAILY
25. HELD- Lantus (insulin glargine) 16 units subcutaneous
Bedtime This medication was held. Do not restart Lantus until
cleared by a physician.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
S/p mechanical fall
Bilateral proximal humerus fractures with hematomas
Left-sided rib fractures
Scalp laceration
Acute on chronic normocytic anemia
Acute on chronic kidney disease
Chronic congestive heart failure with reduced ejection fraction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ after a fall. You had a laceration on
your scalp that was sutured. You also had fracture of both your
right and left arms and your ribs. You were seen by our surgeons
that did not recommend surgery. We treated your pain. Your
warfarin was initially held after the fall and then restarted
once you were stable. We also reduced the dose of your home
diuretic and gave you blood tranfusions as well as your home
injections of Epogen to help with your anemia. It is now safe
for you to be discharged. It was a pleasure caring for you.
Wishing you the best,
Your ___ Team
Followup Instructions:
___
|
10692230-DS-20
| 10,692,230 | 24,373,486 |
DS
| 20 |
2111-09-18 00:00:00
|
2111-09-18 17:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lipitor
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Cardiac stress test ___
History of Present Illness:
___ year old man with PMH CHF, CABG ___, Atrial fibrillation,
multiple episodes of pneumonia, multiple CVA residual left sided
weakness, lives in ___ for residual left sided weakness,
presents with acute on subacute shortness of breath, wheezing.
Over the past few weeks he has had some pharyngitis and sore
throat. Wife and daughter had similar symptoms. There was some
concern at SNF, and he had CXR earlier this week that was
unrevealing. Last night, wife saw patient, stated he was in
usual state of health. Overnight, he acutely developed trouble
breathing and was taken to the ___. Patient endorses
intermittent fevers and chills over the past few days. Had
intermittent chest pain and congestion in ___ chest. No
productive cough. Denied abdominal pain, diarrhea, constipation.
In the ED, initial vitals: T 99.8, HR ___, RR 18, 94%
RA.
- Labs significant for wbc 17.4, H/H 16.2/46.9, plt 195; Na 140,
K 3.6, Cl 104, Bicarb 23, BUN 23, Cr 1.4, glucose 102. INR 2.2,
lactate 3.1, trop <0.01, BNP 671.
- ABG with pH 7.44, CO2 34, pO2 104, Bicarb 24
- UA with 1 wbc, <1 epi
- CXR with mild central pulmonary vascular congestion with mild
associated interstitial pulmonary edema.
- Given duonebs, Cefepime 2g, 1L NS, 1000mg acetaminophen, 1g
Vanc
- Developed worsening SOB and placed on nonrebreather, weaned
down tot 6L NC
- Febrile to 102.4, improved to 101.9.
- Vitals prior to transfer: T 101.9, HR 107, BP 125/75, RR 28,
97% Nasal Cannula.
On arrival to the MICU, Vitals 101.2, HR 105, BP 133/50, 29, 97
6L NC. Patient lying flat in bed, comfortably, wearing oxygen.
No shortness of breath currently.
Review of systems:
(+) Per HPI
(-) Denies headache, congestion. Denies chest pain or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
CAD s/p PCI and CABG ___
Atrial fibrillation on warfarin
Hx of CVA- L sided weakness
CHF
Incontinence
Constipation
Recurrent pneumonia
Hip fracture
Glaucoma
Aspiration pneumonitis
Social History:
___
Family History:
Mother with hx of CAD, CABG. Father deceased from lung cancer,
CAD.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 101.2, HR 105, BP 133/50, 29, 97 6L
GENERAL: Alert, oriented x2, diaphoretic, no acute distress,
wearing nasal canula
HEENT: PERRL, EOMI, Sclera anicteric, dry MM, oropharynx clear
NECK: supple
LUNGS: Ronchorous anteriorly, wheezes anteriorly, no crackles
CV: irregular 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
NEURO: At baseline, face symmetric, ___ strength in upper and
lower L extremities. ___ strength on R upper and lower
extremities. Light touch sensation intact b/l in upper and lower
extremities.
DISCHARGE EXAM:
Vitals: 97.7 141-181/92-105 ___ 18 96%/RA
I/Os: ___ ___
Weight: 119 <- 123.8 <- 125.2 <- 126.6
GENERAL: Alert, no acute distress
HEENT: NCAT
NECK: supple
LUNGS: CTAB AL
CV: exam limited by body habitus
ABD: somewhat firm but non-tender, non-distended, no rebound
tenderness or guarding
EXT: Warm, trace dependent edema, left > right ___ (chronic)
SKIN: warm, well perfused, no rash
GU: Foley in place draining clear yellow urine
NEURO: A&O x 3 (slow). Currently grossly normal
Pertinent Results:
ADMISSION LABS
==================
___ 04:00AM BLOOD WBC-17.4* RBC-5.32 Hgb-16.2 Hct-46.9
MCV-88 MCH-30.5 MCHC-34.5 RDW-14.6 RDWSD-46.3 Plt ___
___ 04:00AM BLOOD Neuts-88.3* Lymphs-5.0* Monos-5.6
Eos-0.3* Baso-0.3 Im ___ AbsNeut-15.32* AbsLymp-0.87*
AbsMono-0.98* AbsEos-0.06 AbsBaso-0.05
___ 04:00AM BLOOD ___ PTT-35.7 ___
___ 04:00AM BLOOD Glucose-102* UreaN-23* Creat-1.4* Na-140
K-3.6 Cl-104 HCO3-23 AnGap-17
___ 04:00AM BLOOD proBNP-671*
___ 04:00AM BLOOD cTropnT-<0.01
___ 09:29AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.7
___ 04:27AM BLOOD Type-ART pO2-104 pCO2-34* pH-7.44
calTCO2-24 Base XS-0 Intubat-NOT INTUBA
___ 03:53AM BLOOD Lactate-3.1*
___ 10:02AM BLOOD Lactate-2.9*
___ 04:27AM BLOOD O2 Sat-96
___ 04:48AM URINE Color-Yellow Appear-Clear Sp ___
___ 04:48AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 04:48AM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1
___ 04:48AM URINE Mucous-RARE
___ 09:15AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
DISCHARGE LABS
===================
___ 05:40AM BLOOD WBC-6.6 RBC-4.55* Hgb-13.7 Hct-40.9
MCV-90 MCH-30.1 MCHC-33.5 RDW-15.3 RDWSD-49.4* Plt ___
___ 06:40AM BLOOD ___ PTT-36.6* ___
___ 05:40AM BLOOD Glucose-87 UreaN-19 Creat-1.2 Na-141
K-3.6 Cl-104 HCO3-24 AnGap-17
___ 06:20AM BLOOD CK(CPK)-148
___ 04:00AM BLOOD proBNP-671*
___ 09:50PM BLOOD CK-MB-4 cTropnT-<0.01
___ 05:40AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.0
___ 04:27AM BLOOD Type-ART pO2-104 pCO2-34* pH-7.44
calTCO2-24 Base XS-0 Intubat-NOT INTUBA
___ 07:50AM BLOOD Lactate-1.5
IMAGING
===================
___ Cardiac perfusion scan:
FINDINGS: Left ventricular cavity size is 113 ml. There is mild
fixed inferolateral wall defect with hypokinesis. No
reversibility is seen. The calculated left ventricular ejection
fraction is 44% post wrist.
IMPRESSION:
1. Mild fixed inferolateral wall defect with hypokinesis.
2. Dilated left ventricle.
3. Low ejection fraction of 44% post-stress.
___ ECHO:
The left atrial volume index is moderately increased. The right
atrium is moderately dilated. There is mild symmetric left
ventricular hypertrophy. 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 moderately depressed (LVEF = 35 %). The
right ventricular free wall thickness is normal. Right
ventricular chamber size is normal with moderate global free
wall hypokinesis. The ascending aorta is mildly dilated. The
aortic arch is mildly dilated. There are focal calcifications in
the aortic arch. The number of aortic valve leaflets cannot be
determined. The aortic valve leaflets are mildly thickened (?#).
There is no aortic valve stenosis. The mitral valve leaflets are
mildly thickened. The left ventricular inflow pattern suggests a
restrictive filling abnormality, with elevated left atrial
pressure. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
___ L foot Xray:
IMPRESSION:
There is extensive arthropathy in the left foot. There is
patchy osteopenia and these findings combine make observation of
subtle findings difficult. There are no definite fractures.
Vascular calcifications are present. Calcaneal spurs are
present. If symptoms persist, I would recommend repeat
evaluation to search for an occult fracture.
___ UNILAT LOWER EXT VEINS LEFT
COMPARISON: None.
FINDINGS: There is normal compressibility, flow, and
augmentation of the left common femoral, femoral, and popliteal
veins. The calf veins were not clearly visualized. There is
normal respiratory variation in the common femoral veins
bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
Calf veins not clearly seen. No evidence of deep venous
thrombosis in the visualized left lower extremity veins.
CHEST (PORTABLE AP) Study Date of ___
FINDINGS: Mild central pulmonary vascular congestion with mild
associated interstitial pulmonary edema is present. There is no
pleural effusion, pneumothorax, or focal consolidation. The
aorta is tortuous. The cardiomediastinal silhouette is
otherwise unremarkable. 6 median sternotomy wires are noted
without fracture of the superior most wire.
IMPRESSION: Mild central pulmonary vascular congestion with
mild associated interstitial pulmonary edema.
Brief Hospital Course:
___ year old man who lives in a SNF with ___ CAD s/p PCI and CABG
___, Atrial fibrillation on coumadin, multiple episodes of
recurrent pneumonia, multiple CVAs with residual left sided
weakness, presented with fever and shortness of breath.
#Aspiration pneumonitis: Patient presented with SIRS (tachypnea,
leukocytosis, fever) and new oxygen requirement. Reports on
admission were significant for a presumed history of diastolic
CHF, although no ECHO in ___ system. Patient has a history of
recurrent pneumonia, including 3 previous admissions for
pneumonia in the last 6 months. CXR concerning for vascular
congestion and interstitial edema. Lactate 3.1 in the ED, given
1L NS, and had worsening oxygen requirement. Flu swab was
negative although he was MRSA screen positive. He received
vanc/cefepime in the ED. Sputum culture obtained but cancelled
for contamination. Lower extremity dopplers negative for DVT.
Per speech and swallow evaluation, patient has no evidence of
aspiration but postprandial reflux cannot be ruled out.
Differential includes viral PNA, aspiration PNA, or volume
overload. He completed a five-day course of levofloxacin 750mg
daily & flagyl (day 1 = ___ for atypical & anaerobic coverage
(through ___, which was given due to his history of recurrent
PNA and stroke. He was also diuresed with IV then PO Lasix. He
was treated with ranitidine for possible reflux.
# CHF: Patient has reported prior history of diastolic CHF but
no formal ECHO in ___ system. Overloaded on exam, suggesting
acute exacerbation. ECHO ___ showed LVEF = 35%. He was diuresed
with IV Lasix and then was switched to Lasix 40mg PO BID. His
spironolactone was held while inpatient. His home metoprolol was
continued.
# HTN: hypertensive to 180s intermittently in setting of held
nifedipine and spironolactone. He was diuresed with Lasix. He
was restarted on losartan and nifedipine was switched to
amlodipine. He was continued on metoprolol at higher dose. Home
isosorbide mononitrate ER 30mg daily was continued. Given
multiple medications, outpatient workup of refractory HTN should
be considered. Amlodipine should be given staggered from
simvastatin; baseline CK 148.
# Atrial fibrillation: in atrial fibrillation on Coumadin. INR
was initially therapeutic but uptrended so decreased Coumadin
from 5.5 mg PO 4X/WEEK (___), 4 mg PO 3X/WEEK (___)
to Warfarin 2mg qday. Patient was tachycardic in setting of
standing duonebs, nifedipine was held. Home metoprolol of 25mg
XL was increased to 50mg.
# Chest pain: Patient intermittently complained of chest pain.
On admission, EKG had some T wave inversions (but baseline is
unknown), Troponins negative x2. Pain is at rest, self limited,
no associated SOB, nausea, sweating, of vitals instability.
Patient described pain as pressure and may have had some
coughing afterwards, denies orthopnea but also describes PND
like symptoms. Nifedipine initially held for low blood pressures
then was switched to amlodipine for hypertension to 180s.
Cardiac perfusion scan showed mild fixed inferolateral wall
defect with hypokinesis. SBP on discharge was 150s.
# CAD s/p CABG: continued on ASA 81mg daily and Simvastatin 10
mg PO QPM.
# Left foot pain: Pt complained of severe L foot pain ___. No
evidence of infection, compartment syndrome, has painful PROM
only with pressure on plantar area otherwise WNL, afebrile, no
leukocytosis, no focal tenderness, suspect plantar fascitits vs
DTI vs fracture. Resolved ___.
# Incontinence: Has foley at ___. His oxybutynin was changed to
2.5mg BID while inpatient. His foley was continued.
# Anxiety/Insomnia: held Lorazepam 2 mg PO QHS:PRN anxiety due
to respiratory distress. He was given TraZODone 25 mg PO QHS:PRN
insomnia
# Depression: home Paroxetine 40 mg PO DAILY was held while
inpatient
# Constipation: continued Docusate Sodium 100 mg PO BID,
Polyethylene Glycol 17 g PO DAILY:PRN constipation, magnesium
hydroxide 473 oral DAILY:PRN constipation, Bisacodyl 10 mg PO
DAILY:PRN constipation
#Goals of care: Patient is now full code per wife. He has also
expressed wish for fewer hospitalizations. ___ benefit from
palliative care referral to manage chronic quality of life
problems
___ paperwork should be adjusted to reflect this.
===============================
TRANSITIONAL ISSUES:
- Please clarify code status. Patient was full code on this
admission, also expressed wish for fewer hospitalizations. ___
benefit from palliative care referral to manage chronic quality
of life problems
- Discontinued nifedipine
- Started amlodipine
- Continue to titrate antihypertensives
- Amlodipine should be given staggered from simvastatin;
baseline CK 148
- Changed Lasix dose to 40 BID
- Restart Spironolactone 25 mg PO DAILY as outpatient
- Recheck electrolytes in 1 week (___)
- Metoprolol was increased to 50mg qday
- Coumadin was changed to 2mg daily for supratherapeutic INR
- Trend INR and adjust dose daily until stabilized, next draw on
___
- Consider work-up for refractory hypertension
- Consider restarting ranitidine if concern for reflux
- weight patient daily. If has 3 pounds or more weight gain in
24 hours, please give extra one time dose of PO Lasix 40mg and
call cardiologist for further instructions.
- if gaining between ___ pounds daily, increase PO Lasix to 60mg
BID
- check Chem 10 and Creatinine on ___, fax results to PCP ___
___ (Dr. ___.
# Communication: Wife ___ ___
# Code: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 5.5 mg PO 4X/WEEK (___)
2. Warfarin 4 mg PO 3X/WEEK (___)
3. Aspirin 81 mg PO DAILY
4. Cyanocobalamin 500 mcg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Furosemide 60 mg PO QAM
7. Furosemide 40 mg PO QPM
8. I-Vite (vit A,C & E-lutein-minerals) 1,000 unit-200 mg-60
unit-2 mg oral DAILY
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. Lorazepam 2 mg PO QHS:PRN anxiety
11. Losartan Potassium 100 mg PO DAILY
12. Metoprolol Succinate XL 25 mg PO DAILY
13. NIFEdipine CR 90 mg PO DAILY
14. Oxybutynin 5 mg PO DAILY
15. Paroxetine 40 mg PO DAILY
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
17. Simvastatin 10 mg PO QPM
18. Spironolactone 25 mg PO DAILY
19. TraZODone 25 mg PO QHS:PRN insomnia
20. Acetaminophen 650 mg PO Q4H:PRN headache
21. benzocaine-menthol ___ mg mucous membrane Q4H:PRN sore
throat
22. Bisacodyl 10 mg PO DAILY:PRN constipation
23. Calcium Carbonate 1000 mg PO QID:PRN heartburn
24. Guaifenesin 5 mL PO Q4H:PRN cough
25. magnesium hydroxide 473 oral DAILY:PRN constipation
26. petrolatum, white-water 1 pkg topical as directed dry skin
27. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN shortness of
breath
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN headache
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN shortness of
breath
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PO DAILY:PRN constipation
5. Calcium Carbonate 1000 mg PO QID:PRN heartburn
6. Cyanocobalamin 500 mcg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Furosemide 40 mg PO BID
RX *furosemide 40 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
9. Guaifenesin 5 mL PO Q4H:PRN cough
10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
11. Losartan Potassium 100 mg PO DAILY
12. Metoprolol Succinate XL 50 mg PO DAILY
13. Oxybutynin 5 mg PO DAILY
14. Simvastatin 10 mg PO QPM
15. TraZODone 25 mg PO QHS:PRN insomnia
16. Warfarin 2 mg PO DAILY16
17. benzocaine-menthol ___ mg mucous membrane Q4H:PRN sore
throat
18. I-Vite (vit A,C & E-lutein-minerals) 1,000 unit-200 mg-60
unit-2 mg oral DAILY
19. Lorazepam 2 mg PO QHS:PRN anxiety
20. magnesium hydroxide 473 oral DAILY:PRN constipation
21. Paroxetine 40 mg PO DAILY
22. petrolatum, white-water 1 pkg topical as directed dry skin
23. Polyethylene Glycol 17 g PO DAILY:PRN constipation
24. Outpatient Lab Work
427.31 Atrial fibrillation
INR on ___
CMP on ___
Please fax results to PCP
25. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Aspiration pneumonitis
CHF with EF 35%
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were seen at ___ due to difficulty breathing. We think
that your difficulty breathing was due to some food going down
the wrong pipe as well as some volume overload from your heart
failure. You were treated with a five-day course of antibiotics
and Lasix to get the water off your lungs and your breathing
improved.
You also had some high blood pressures so we started you on
amlodipine instead of your nifedipine.
You also had a stress test for your intermittent chest pain
which did not show any new damage to your heart.
There was also some discrepancy in your wishes in case of a
life-threatening or life-ending event. At this hospitalization,
you indicated that you would like to have chest compressions in
the event of your heart stopping and a breathing tube if you
cannot breath on your own. You have also requested to have fewer
hospitalizations. Please discuss these wishes with your family
and primary care provider and update the paperwork (MOLST) at
your facility accordingly.
Please continue to take your medications as prescribed.
We wish you all the best,
Your ___ team
Followup Instructions:
___
|
10692373-DS-18
| 10,692,373 | 21,841,549 |
DS
| 18 |
2179-06-06 00:00:00
|
2179-06-08 02:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Atrial fibrillation with conduction system disease.
Major Surgical or Invasive Procedure:
___: pacemaker placement
History of Present Illness:
___ w/ history of hypertension and recent presumed TIA presents
from home with abnormal findings on Holter monitor.
Patient was admitted to ___ a few weeks ago for
sudden onset of numbness and weakness of the left arm and slight
numbness lateral to the left side of her mouth, and possibly
facial asymmetry. Symptoms resolved in 30 mins. She was
evaluated with MRI that was negative for infarct. Carotid
ultrasound was negative for any significant stenosis. She was
discharged on asa. She was also discharged with Holter monitor.
Holter monitor auto-triggered while she was sleeping last night
___ to ___ and noted 6 second sinus pause, 3.5 sinus pause,
and 7 beat run of monomorphic VT. In addition, she had few
episodes of a fib. She was told by her PCP to go to ED for
possible pacemaker placement. Patient reports sleeping and being
asymptomatic throughout all these episodes. She denies CP,
palpitations, SOB, dizziness.
In the ED she was in a fib with rates in ___, well appearing.
She did have 1 sinus pause for 4 seconds which was associated
with "pressure sensation across her forehead". This sensation
resolved in a few seconds. She denied any CP or palpitations at
that time.
In the ED initial vitals were: 98.3, 63, 109/83, 18, 100% RA
EKG:
Labs/studies notable for: Trop <0.01
Patient was given: Started on heparin gtt for Afib
Vitals on transfer: 61, sinus rhythm 129/76, 17, 97% RA
On arrival to the CCU: She denies any chest pain, shortness of
breath, lightheadedness, fainting spells, or palpitations.
She denies recurrence of TIA symptoms and denies any dizziness,
light headedness, changes in vision, weakness, changes in
sensation, or difficulty speaking. She reports that after her
TIA episode a few weeks ago she has some residual parasthesia in
her L palm, but otherwise no residual neurological symptoms.
Past Medical History:
1. CARDIAC RISK FACTORS
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- Coronaries: unknown
- Pump: EF 60%
- Rhythm: paroxysmal a fib
3. OTHER PAST MEDICAL HISTORY
Scoliosis
Lumbar disc disease
Osteopenia
Thyroid nodules
Social History:
___
Family History:
Family hx of colon cancer in father. Mother died in her sleep at
___ yo of unknown causes. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
==============================
VS: T 36.5 HR 61 BP 129/76 RR 17 O2 SAT 97%
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. No JVP.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs,
or gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISHCARGE PHYSCIAL EXAMINATION
==============================
VS: T 97.5 HR 63 BP 101/60 RR 18 O2 SAT 97%
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. No JVP.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs,
or gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
ADMISSION LABS
==============
___ 06:17AM BLOOD WBC-6.2 RBC-4.19 Hgb-12.5 Hct-37.7 MCV-90
MCH-29.8 MCHC-33.2 RDW-14.3 RDWSD-47.5* Plt ___
___ 09:00PM BLOOD ___ PTT-129.9* ___
___ 02:19PM BLOOD Glucose-108* UreaN-11 Creat-0.7 Na-136
K-6.9* Cl-97 HCO3-26 AnGap-13
___ 02:19PM BLOOD cTropnT-<0.01
___ 02:19PM BLOOD Calcium-9.6 Phos-3.5 Mg-2.0
___ 02:19PM BLOOD TSH-1.2
___ 03:35PM BLOOD K-4.6
DISCHARGE LABS
==============
___ 06:17AM BLOOD WBC-6.2 RBC-4.19 Hgb-12.5 Hct-37.7 MCV-90
MCH-29.8 MCHC-33.2 RDW-14.3 RDWSD-47.5* Plt ___
___ 06:17AM BLOOD Glucose-105* UreaN-12 Creat-0.6 Na-142
K-3.9 Cl-104 HCO3-28 AnGap-10
___ 06:17AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.8
IMAGING
=======
EP Report ___
___ yo WF with PAF, sinus node dysfunction, conversion pauses
documented on telemetry, and multiple pre-syncopal events
presents for a ___ implant.
A dual chamber MRI compatible ___ ___ Advisa) implanted
via left cephalic vein without complications. Ventricular lead
in His bundle area with non-selective HB capture with excellent
threshold. Very tortuous venous anatomy and large RA.
Brief Hospital Course:
BRIEF HOSPITAL COURSE
=====================
___ w/ history of hypertension and recent presumed TIA who
presents from home with abnormal findings on Holter (sinus pause
and Afib). On admission, patient was hemodynamically stable but
experience symptomatic pauses lasting up to 6 seconds. The
patient was evaluated by EP and a dual chamber ___ PPM was
placed on ___ without complication.
# CORONARIES: unknown
# PUMP: estimated ventricular ejection fraction in the range of
60%
# RHYTHM: Paroxysmal a fib/flutter
#Paroxysmal a fib/flutter
#Sinus pause
Rhythm abnormalities were noted on holter event monitor that
patient started due to TIA 3 weeks ago. She was asymptomatic
initially with holter monitor revealing pauses and with a
fib/flutter. In the ED she had another 4 second pause, this time
accompanied by a feeling of pressure across her forehead, which
resolved in a few seconds. She was started on heparin gtt for
h/o TIA and new a fib/flutter. She was admitted to CCU for
monitoring pre pacemaker placement. She remained hemodynamically
stable and received a dual chamber MRI compatible pacemaker on
___ ___ Advisa) implanted via left cephalic vein without
complications. Aspirin was continued. Vancomycin was given ___
procedure and patient was discharged on Keflex to take until
___ to decrease the risk of infection post procedure.
#HTN - patient was on Lisinopril 2.5mg daily and HCTZ 25mg daily
at home. BP was 120 systolic on arrival. No edema on exam, no Hx
of weight changed recently. Lisinopril was continued and HCTZ
was held prior to pacemaker procedure. Blood pressure has been
stable during this admission.
#TIA - we continued home aspirin and simvastatin. she was kept
on heparin drip prior to her pacemaker procedure. Apixaban was
started upon discharge.
TRANSITIONAL ISSUES
===================
- Weight at discharge: 68.7 kg
- Creatinine at discharge: 0.6
MEDS
+ New: Apixaban 5 mg PO/NG BID, Keflex
+ Changed: None
+ Discontinued: HCTZ was held as patient was not hypertensive
- Patient had a ___ dual chamber pacer placed on ___
- Patient needs to continue taking Keflex until ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Simvastatin 40 mg PO QPM
3. Hydrochlorothiazide 25 mg PO DAILY
4. Lisinopril 2.5 mg PO DAILY
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*3
2. Cephalexin 500 mg PO TID
RX *cephalexin 500 mg 1 tablet(s) by mouth Three times a day
Disp #*6 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Lisinopril 2.5 mg PO DAILY
5. Simvastatin 40 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
=================
Tachy-Brady syndrome
Symptomatic Bradycardia
Secondary Diagnosis
===================
Hypertension
Paroxysmal Atrial Fibrillation/ Atrial flutter
Transient ischemic attack
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
WHY WAS I HERE?
You were admitted to the hospital because you had worrisome
heart rhythm on your holter monitor.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL
- While you were in the hospital you had a pacemaker placed to
keep your heart at a normal rhythm.
- You were started on a new medication to prevent clots in your
blood (Apixaban 5 mg by mouth twice a day)
WHAT SHOULD I DO WHEN I GET HOME?
- Please take all your medications as prescribed
- Please continue to monitor your weight and call your doctor if
you notice an increase of more than 3lbs in your weght
- Follow up with your Primary Care Doctor
- Follow up with the Device clinic on ___ at 10:20am
It was a pleasure taking care of you!
Your ___ Care Team
Followup Instructions:
___
|
10692417-DS-10
| 10,692,417 | 21,810,921 |
DS
| 10 |
2161-01-22 00:00:00
|
2161-01-22 16:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
R hip pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year-old female with a past medical history of
invasive ductal breast cancer, initially Stage IV
(T3N2M1-adrenal
gland suspicious lesion on CT), ER+/PR+ Her2neu negative, now
with metastastic disease who presents to the ED with R hip pain.
She has had various pains on and off over the past few months
that generally resolve. This pain started 2 days ago and is the
worst pain she's had. It is ___ at its worst. She has been
taking tylenol which brings it down to ___. She is able to
ambulate with a limp. She does not have much pain anywhere else.
She denies any numbness or weakness in arms or legs. She has no
back pain. She reports some chills last night but no fevers. She
has been having some nausea and vomiting and not eating much the
last few days.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, night sweats, denies headache, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, or weakness. Denies diarrhea,
constipation, abdominal pain. Denies dysuria. Denies rashes or
skin changes. All other ROS negative
Past Medical History:
ONCOLOGIC HISTORY:
-___: ___-one month history of a pruritic right
breast mass. Exam revealed an irregularly shaped, protruding 7cm
mass, purplish in color at approximately 2 o'clock. Clinical
T3N2
tumor
-___: Diagnostic MMG and ultrasound at ___
revealed an irregular high density oval 6 cm mass at 12 o'clock
and enlarged right axillary lymph nodes. There were no
suspicious
masses or calcifications in the left breast. Ultrasound of the
right breast revealed a 4.7 x 4.4 x 3.4 cm mass at 12 o'clock, 6
cm from the nipple, corresponding to the mammographic mass. A
right axillary lymph node measured 1.8 x 1.5 x 0.9 cm with loss
of echogenic hilum.
**PATH ___ CONSULT REVIEW: Breast, right at 12 o'clock, core
needle biopsy (___):
-->Invasive ductal carcinoma, grade 2, measuring up to 0.9 cm in
this limited sample, see note.
-->The tumor cells are positive for ER (50%, medium to strong),
positive for PR (30%, medium to strong), and negative for HER2
(0) by Immunohistochemistry.
-___: CT Torso:
*large lobulated mass in the right breast with overlying skin
thickening. The mass lesion measures approximately 5.5 by 5.5
cm
diameter and has internal calcification. The mass approaches
the
chest wall but there does appear to be of fat plane between it
and the pectoralis muscles.
*right axillary lymph node that measures approximately 2.0 x 1.5
cm diameter. This has an oval configuration and low attenuation
center and is consistent with a metastatic node.
*multiple pulmonary nodules in nodular pleural thickening. The
largest pulmonary nodule in the left lower lobe approximately 3
mm.
*Multiple smaller nodules are seen elsewhere in the lungs.
*Right adrenal mass that measures approximately 2.4 x 1.8 cm
diameter. This is of increased attenuation and is highly
suspicious for metastatic deposit.
*3 cm diameter mass in the uterus which likely represents a
fibroid.
-___: Bone scan negative for metastatic disease.
-NEOADJUVANT CHEMOTHERAPY: 8 cycles of dose-dense
cyclophosphamide, adriamycin and paclitaxel with minimal
clinical
response.
-___: Dr. ___ performed a right lumpectomy
and right axillary lymph node dissection at ___. SIGNIFICANT RESIDUAL TUMOR
***PATH ___ CONSULT REVIEW: The breast specimen measured 9 x 8
x 5 cm
-->Breast, right, excision: Invasive ductal carcinoma, grade 3,
measuring up to 4 cm (by report) with invasion into dermis and
changes consistent with treatment effects. Lymphatic vascular
invasion is present. Ductal carcinoma in situ, high nuclear
grade, solid pattern. Biopsy site changes.
-->Lymph nodes, right axillary dissection (___): One lymph node with metastatic carcinoma with
extracapsular extension and changes consistent with treatment
effects. Largest dimension of metastasis = 0.9 cm.
-->Margins negative for malignancy.
-Adjuvant radiation therapy at ___ and started
adjuvant tamoxifen
-___: Annual MMG negative for malignancy.
-___: Annual MMG negative for malignancy.
-___: Difficulty concentrating and was unable
to perform her typical functions as a ___.
-___: ___ for CNS sxs
-___: CT head-4.0 x 3.0 x 4.4 cm mass with cystic component
within the left frontal lobe with surrounding vasogenic edema
and
mass effect on the left frontal horn and minimal midline shift
to
the right. There was also vasogenic edema of the right frontal
lobe, with inferior extension and mass effect on the right
frontal horn.
-___: MRI of the brain- 5.1 x 3.6 x 4.2 left frontal lobe
mass with a large cystic component and surrounding vasogrnic
edema. There was a right frontal 2.3 x 2.2 x 2.6cm lesion with a
cystic component and peripheral enhancement. The lesion involved
the surface of the brain. A third right periatrial lesion was
also noted.
-___: CT Torso: Stable 2mm LUL nodule and a stable right
adrenal mass. The right adrenal gland contains an enhancing
lesion measuring 2.3 x 1.8 cm in cross section (previously: 2.2
x 1.8 cm on ___. Stable 3.8 cm uterine mass is most
consistent with a fibroid (previously: 3.8 cm on ___: Transferred to ___ for further care.
MRI of the brain with large cystic left frontal mass, a smaller
more solid and cystic right frontal mass, and a 9 x 7 mm right
periatrial lesion.
-___: Dr. ___ a ___ craniotomy for
resection of the right frontal lesion. He noted "the metastasis
was found to be arising from the dura at the ___ orbital
rim and supraorbital roof" and he performed a wide excision of
the surrounding dura. He also noted that "the surrounding
meningeal tissue was carefully coagulated, though a small
remnant
is likely at the most inferior-posterior margin of the dura."
-___: Dr. ___ a ___ craniotomy for
resection of the left frontal cystic lesion. Of note, the
localization MRI on ___ noted an additional 7mm left
parietal lesion in additional to the previously noted right
periatrial and left cystic lesion. The pathology from both
resections is pending. Dr. ___ that the ___
lesion in particular was very densely adhered to the underlying
meninges.
-___: MRI of the brain demonstrated resection of the
right frontal lesion and left frontal lesion, with
marsupializaiton of the left frontal cystic metastases. The
right
periatrial lesion was noted; however the previously noted left
parietal lesion was not demonstrated.
-___: 15 fractions of whole brain radiotherapy at ___.
-___: MRI Brain There is enlargement of the anterior
component of the left frontal cystic lesion compared with her
MRI
on ___. The other lesions appeared stable.
-___ to ___: 3 CK sessions 2400 cGy out of 2400 cGy
planned to residual anterior component of the left frontal
cystic
lesion
-___: Infection at site of surgery requiring
wound revision on ___. Intra-operative cultures
grew MSSA and diphtheroids. She was discharged on an extended
course of PO cephalexin and completed therapy on ___.
-___: Sutures removed; small separation in the middle part
of the incision
-___: Wound check revealed 1-2cm defect along the surgical
site.
-___: MRI Brain- Rim enhancing of surgical resection
cavities in the left frontal lobe has slightly decreased in
size. Surrounding parenchymal FLAIR hyperintensity is
unchanged, although there is decreased sulcal FLAIR
hyperintensity in this region. Small extra-axial fluid
collection
overlying the right frontal resection site
has slightly decreased in size. A 5 mm rim enhancing lesion
within the right temporal lobe is unchanged from
the most recent prior examination, but has decreased in size
over
time.
-___: OR for debridement-Intraoperative cultures negative.
She underwent repeat debridement on of the left frontal mass
(?infection). Given MSSA and presumed scalp bone
infection, decision made to treat with nafcillin 2gm q4H. She
was also empirically on ciprofloxacin 500mg BID per ID
-___: MRI Brain Left frontoparietal postsurgical changes
with 3.8 cm extra-axial fluid collection contiguous with an
intraparenchymal rim enhancing lesion within the
left frontal convexity decreased in size now measuring 2.6 cm.
Right frontal postsurgical changes with stable underlying
extra-axial collection and increasing FLAIR hyperintensity.
Slightly less prominent 5 mm rim enhancing lesion anterior to
the
right ventricular trigone with mildly decreased surrounding
FLAIR
hyperintensity.
-___: Completed 6 weeks of parenteral therapy for MSSA
-___: MRI Brain Postoperative changes without findings to
indicate intracranial abscess.
-___: MRI Brain Stable appearance of the left frontal
postoperative cavity. Multiple rounded enhancing lesions in
bilateral cerebellar hemispheres, right greater than left
concerning for progression of metastatic disease. The largest
lesion measures approximately 6 mm in the right
hemisphere. There is edema surrounding these lesions.
-___ TO ___: SUMMARY OF RADIATION THERAPY:
Treatment Site: Whole brain C2. Field Arrangement: Opposed
laterals.Beam Energy: ___ Dose Per Fraction: 200 cGy.
Number of Fractions: 10. Total Time: 14 days. Total Dose:
___
cGy.
-___: CT TORSO
*Lymphadenopathy, severe at the right hilus, mild in the
mediastinum, consistent with metastatic breast carcinoma.
*2 punctate pulmonary nodules chronicity and significance
indeterminate.
*Numerous hepatic metastases. Hypodense lesion in the
pancreatic
head likely represents a metastatic focus.
*Heterogenous lesion in the right adrenal gland likely
represents
a metastatic focus.
*Lytic lesions in the left iliac bone, right acetabulum, and
lumbar spine
-___: MRI Brain
*The rim enhancing resection cavity within the left frontal lobe
is unchanged in size; however, surrounding FLAIR signal
abnormality has increased. This may be secondary to
posttreatment
changes versus tumor recurrence/ progression.
*Multiple infra tentorial enhancing lesions have slightly
diminished in size as has the associated FLAIR signal
abnormality.
*Two subcentimeter right temporal lobe lesions are slightly more
conspicuous than on the prior examination. Other subcentimeter
supratentorial lesions are unchanged. No new lesion is
identified.
-___: Bone Scan
*Multiple focal areas of tracer uptake concerning for metastatic
disease including in the right proximal femur, left iliac bone,
right acetabulum, cervical, thoracic and lumbar spine and right
rib and left ribs.
PMH:
-Breast cancer (see above)
-s/p C-section X ___
-s/p appendectomy in ___
Gyn History:
-G4P2 (two miscarriages): First birth at age ___
-Menses at age ___
-Menopause at age ___
-No OCP or hormonal use
Social History:
___
Family History:
NC
Physical Exam:
Physical Examination:
VS: 98.1 112/62 84 18 98%RA
GEN: Alert, oriented to name, place and situation. no acute
signs of distress.
HEENT: NCAT, Pupils equal and reactive, sclerae non-icteric,
MMM.
Neck: Supple
CV: normal S1S2, reg rate and rhythm, no murmurs, rubs or
gallops.
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, non-tender, non-distended, no hepatosplenomegaly
EXTR: No lower leg edema. tenderness to palpation over R hip
DERM: No active rash
Neuro: muscle strength grossly full and symmetric in all major
muscle groups
PSYCH: Appropriate and calm.
Pertinent Results:
==================================
Labs
==================================
___ 06:30AM BLOOD WBC-9.6 RBC-4.32 Hgb-12.1 Hct-38.3 MCV-89
MCH-28.1 MCHC-31.7 RDW-13.1 Plt ___
___ 06:30AM BLOOD Neuts-74.0* Lymphs-14.7* Monos-10.1
Eos-0.8 Baso-0.4
___ 06:30AM BLOOD Glucose-117* UreaN-9 Creat-0.6 Na-134
K-5.4* Cl-96 HCO3-26 AnGap-17
___ 06:30AM BLOOD ALT-30 AST-69* CK(CPK)-126 AlkPhos-145*
TotBili-0.3
___ 06:30AM BLOOD Lipase-47
___ 06:30AM BLOOD Albumin-3.7
==================================
Radiology
==================================
FEMUR (AP & LAT) RIGHTStudy Date of ___ 6:20 AM
Final Report
INDICATION: History of metastatic breast cancer with right leg
pain. Please
evaluate.
COMPARISONS: CT abdomen and pelvis from ___.
TECHNIQUE: Right hip, two views; right knee, two views.
FINDINGS: There is no evidence of fracture or dislocation.
Lucencies seen
along the acetabulum and right proximal femur are consistent
with the
patient's known metastatic lesions as seen on the prior CT and
bone scan from
___. No soft tissue calcification or radiopaque
foreign body is
identified. There is no evidence of a joint effusion.
IMPRESSION:
1. No evidence of fracture or dislocation.
2. Subtle lucencies along the right proximal femur and
acetabulum are likely
secondary to the patient's known metastatic disease as
characterized by the
recent CT and bone scan from ___.
CHEST (PA & LAT)Study Date of ___ 6:20 AM
Final Report
INDICATION: History of metastatic breast cancer. Please
evaluate for
pneumonia.
COMPARISONS: Chest radiographs dated back to ___.
TECHNIQUE: PA and lateral radiographs of the chest.
FINDINGS: The heart size is normal. Fullness of the right
hilum is secondary
to patient's known lymphadenopathy as characterized by the CT
scan from ___. The left hilar and mediastinal contours are otherwise
unremarkable.
No focal consolidations concerning for pneumonia are identified.
There is no
pleural effusion or pneumothorax.
IMPRESSION:
Fullness of the right hilum is consistent with patient's known
lymphadenopathy
as characterized by recent CT from ___. No focal
consolidations
concerning for pneumonia identified.
Brief Hospital Course:
# R hip pain: xray in ED shows no fracture but known lytic
lesions. She was controlled on a small amount of pain
medications. At the time of discharge she was started on Tyelnol
___ mg tid and oxycodone 2.5-5mg prn for pain. She worked with
physical therapy and will be discharged with a walker and
recommendation for home physical therapy program.
# nausea/vomiting: The was occurring on admission. She had no
further episodes while in the hospital and felt well.If
persistent symptoms may need to have repeat brain MRI to
evaluate CNS disease as outpatient.
# Metastatic breast cancer: plan to start new chemo regimen
___.
Medications on Admission:
1. anastrozole 1 mg oral DAILY
2. Midodrine 5 mg PO BID
3. LeVETiracetam 500 mg PO BID
4. Famotidine 20 mg PO BID
Discharge Medications:
1. anastrozole 1 mg oral DAILY
2. Famotidine 20 mg PO BID
3. LeVETiracetam 500 mg PO BID
4. Midodrine 5 mg PO BID
5. Acetaminophen 650 mg PO TID
Please take this medication three times a day
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth three times a day Disp #*60 Tablet Refills:*0
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
7. OxycoDONE (Immediate Release) 2.5-5 mg PO Q6H:PRN Pain
RX *oxycodone 5 mg ___ capsule(s) by mouth four times a day
prn Disp #*12 Capsule Refills:*0
8. walker 1 miscellaneous daily
9. Senna 8.6 mg PO BID constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*30 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Metastatic Breast Cancer
Discharge Condition:
Uncontrolled Pain.
Discharge Instructions:
Ms. ___,
You were seen in the hospital for increased pain in your right
leg. You were not found to have a fracture. Imaging completed
showed the known metastatic disease you have in your bones. We
treated with you with pain medications and your pain improved.
You should take Tylenol ___ mg three times a day and oxycodone
2.5 mg as needed for pain.
Please keep your appointment for ___.
Followup Instructions:
___
|
10692417-DS-12
| 10,692,417 | 26,822,323 |
DS
| 12 |
2161-02-23 00:00:00
|
2161-02-23 15:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
=============================================================
OMED ADMISSION NOTE
___
1040
=============================================================
PCP: ___
Neuro-onc: ___
CC: confusion
Major ___ or Invasive Procedure:
lumbar puncture
History of Present Illness:
___ with stage 4 breast cancer (metastases to brain and bone,
ER+, PR+, HER2-) with recent diagnosis of seizure disorder
started on keppra who presents with altered mental status.
The patient can provide limited history due to confusion. The
daughter and HCP was contacted and provided much of the
information in this note.
She was apparently doing well immediately after hospitalization.
She was able to have some conversations and feed herself. 3 days
prior to presentation she began having worsening word finding
difficulties and confusion. She was not able to feed herself.
She did not recognize her daughter. She had very limited PO
intake and a few episodes of emesis (nonbloody, bilious).
There were no fevers, headache, neck pain, sinus pain, chest
pain, shortness of breath, cough, abdominal pain, diarrhea,
constipation, dysuria or other symptoms noted. The patient notes
a non-descript pain but cannot localize. She denies other
symptoms. Of note, she has not taken benzos. Her last dose of
oxycodone was yesterday (2.5mg).
Due to the confusion, she presented to the hospital. In the ED,
initial VS were 100.1 73 113/66 16 99% RA. Labs were notable for
WBC 13.1, hct 34.1, Cr 1.1, BUN 21. CT head showed evidence of
known metastatic disease similar to recent MRI from ___,
without hemorrhage or midline shift. She was admitted for
further work-up of AMS.
On arrival to the floor, denies all symptoms. She cannot tell me
why she was admitted. She tells me her name but is unable to
tell me other information about herself.
REVIEW OF SYSTEMS:
Denies fever, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
She denies other symptoms.
Past Medical History:
-___: ___-one month history of a pruritic right
breast mass. Exam revealed an irregularly shaped, protruding 7cm
mass, purplish in color at approximately 2 o'clock. Clinical
T3N2 tumor
-___: Diagnostic MMG and ultrasound at ___ revealed
an irregular high density oval 6 cm mass at 12 o'clock and
enlarged right axillary lymph nodes. There were no suspicious
masses or calcifications in the left breast. Ultrasound of the
right breast revealed a 4.7 x 4.4 x 3.4 cm mass at 12 o'clock, 6
cm from the nipple, corresponding to the mammographic mass. A
right axillary lymph node measured 1.8 x 1.5 x 0.9 cm with loss
of echogenic hilum.
**PATH ___ CONSULT REVIEW: Breast, right at 12 o'clock, core
needle biopsy (___): -->Invasive ductal
carcinoma, grade 2, measuring up to 0.9 cm in this limited
sample, see note. -->The tumor cells are positive for ER (50%,
medium to strong), positive for PR (30%, medium to strong), and
negative for HER2 (0) by Immunohistochemistry.
-___: CT Torso:
*large lobulated mass in the right breast with overlying skin
thickening. The mass lesion measures approximately 5.5 by 5.5
cmdiameter and has internal calcification. The mass approaches
thechest wall but there does appear to be of fat plane between
it and the pectoralis muscles. *right axillary lymph node that
measures approximately 2.0 x 1.5 cm diameter. This has an oval
configuration and low attenuation center and is consistent with
a metastatic node. *multiple pulmonary nodules in nodular
pleural thickening. The largest pulmonary nodule in the left
lower lobe approximately 3 mm.
*Multiple smaller nodules are seen elsewhere in the lungs.
*Right adrenal mass that measures approximately 2.4 x 1.8 cm
diameter. This is of increased attenuation and is highly
suspicious for metastatic deposit. *3 cm diameter mass in the
uterus which likely represents a fibroid.
-___: Bone scan negative for metastatic disease.
-NEOADJUVANT CHEMOTHERAPY: 8 cycles of dose-dense
cyclophosphamide, adriamycin and paclitaxel with minimal
clinical response.
-___: Dr. ___ performed a right lumpectomy and
right axillary lymph node dissection at ___.
SIGNIFICANT RESIDUAL TUMOR
***PATH ___ CONSULT REVIEW: The breast specimen measured 9 x 8
x 5 cm -->Breast, right, excision: Invasive ductal carcinoma,
grade 3, measuring up to 4 cm (by report) with invasion into
dermis and changes consistent with treatment effects. Lymphatic
vascular invasion is present. Ductal carcinoma in situ, high
nuclear grade, solid pattern. Biopsy site changes.
-->Lymph nodes, right axillary dissection ___
___: One lymph node with metastatic carcinoma with
extracapsular extension and changes consistent with treatment
effects. Largest dimension of metastasis = 0.9 cm. -->Margins
negative for malignancy.
-Adjuvant radiation therapy at ___ and started
adjuvant tamoxifen
-___: Annual MMG negative for malignancy.
-___: Annual MMG negative for malignancy.
-___: Difficulty concentrating and was unable to perform her
typical functions as a ___.
-___: ___ for CNS sxs
-___: Transferred to ___ for further care. MRI of the
brain with large cystic left frontal mass, a smaller more solid
and cystic right frontal mass, and a 9 x 7 mm right periatrial
lesion.
-___: Dr. ___ a ___ craniotomy for
resection of the right frontal lesion. He noted "the metastasis
was found to be arising from the dura at the ___ orbital
rim and supraorbital roof" and he performed a wide excision of
the surrounding dura. He also noted that "the surrounding
meningeal tissue was carefully coagulated, though a small
remnant is likely at the most inferior-posterior margin of the
dura."
-___: Dr. ___ a ___ craniotomy for
resection of the left frontal cystic lesion. Of note, the
localization MRI on ___ noted an additional 7mm left
parietal lesion in additional to the previously noted right
periatrial and left cystic lesion. The pathology from both
resections is pending. Dr. ___ that the ___
lesion in particular was very densely adhered to the underlying
meninges.
-___: 15 fractions of whole brain radiotherapy at ___
___.
-___ to ___: 3 CK sessions 2400 cGy out of 2400 cGy
-___: Infection at site of surgery
-___: OR for debridement
-___: Completed 6 weeks of parenteral therapy for ___
-___ TO ___: Whole brain radiation
PAST MEDICAL AND SURGICAL HISTORY:
-s/p C-section X ___
-s/p appendectomy in teens
Social History:
___
Family History:
History of prostate cancer.
Physical Exam:
Admission exam:
General: No apparent distress, chronically ill appearing female
Vitals: 98.1, 110/64, 16
Pain: unable to locate or quantify
HEENT: chronic skull deformity, no lesions, rash or trauma
apparent. No OP lesions. Pupils slightly small but responsive
and equal bilaterally. Dry MM.
Cardiac: rr, nl rate, no murmurs
Lungs: CTAB
Abd: soft, nontender, nondistended, bowel sounds
Ext: wwp, moves extremities
Neuro: word finding difficulties, limited participation in the
motor and sensory exam, no neck stiffness or pain, no
photophobia.
Psych: pleasant, but confused. AOx1.
Discharge exam:
98.5 105/70 93 17 97%RA
General: alert, less confused than previous, thin, oriented to
person and place
HEENT: MM slightly dry, no OP lesions, no cervical,
supraclavicular, or axillary adenopathy
Scar over the left scalp is well-healed. EOMI, PERRLA.
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: nontender, nondistended
LIMBS: No edema, clubbing, tremors, or asterixis.
SKIN: No rashes or skin breakdown
NEURO: moving limbs but unable to cooperate with exam
Pertinent Results:
==================================
Labs
==================================
___ 02:00AM BLOOD WBC-13.1* RBC-3.90* Hgb-11.2* Hct-34.3*
MCV-88 MCH-28.7 MCHC-32.7 RDW-13.9 Plt ___
___ 06:19AM BLOOD WBC-6.5 RBC-3.58* Hgb-10.1* Hct-31.4*
MCV-88 MCH-28.1 MCHC-32.1 RDW-13.8 Plt ___
___ 10:30AM BLOOD ___ PTT-28.2 ___
___ 02:00AM BLOOD Glucose-127* UreaN-21* Creat-1.1 Na-137
K-4.1 Cl-99 HCO3-25 AnGap-17
___ 06:19AM BLOOD Glucose-108* UreaN-12 Creat-0.5 Na-138
K-4.3 Cl-101 HCO3-28 AnGap-13
___ 01:30PM BLOOD ALT-35 AST-65* AlkPhos-230* TotBili-0.4
___ 07:20AM BLOOD ALT-68* AST-96* AlkPhos-335* TotBili-0.3
___ 01:30PM BLOOD Albumin-3.5 Calcium-11.1* Phos-3.9 Mg-1.7
___ 06:19AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.3
___ 07:00AM BLOOD Cortsol-10.0
___ 08:23AM BLOOD Type-ART pH-7.46*
___ 02:21AM BLOOD Lactate-1.2
___ 08:23AM BLOOD freeCa-1.27
==================================
Radiology
==================================
CHEST (PA & LAT)Study Date of ___ 12:28 AM
FINDINGS: AP upright and lateral views of the chest were
obtained. Heart is
normal size and cardiomediastinal contour is unremarkable.
Persistent
prominence of the right hilum is unchanged and could represent
lymphadenopathy
in that region. Lungs are notable for mild plate-like
retrocardiac
atelectasis, otherwise clear. There is no pleural effusion. No
pneumothorax.
Thoracolumbar scoliosis noted.
IMPRESSION: No substantial change from prior.
CT HEAD W/O CONTRASTStudy Date of ___ 12:35 AM
FINDINGS: The patient is status post left frontal craniectomy,
unchanged.
Post-surgical changes in the left frontal lobe and multiple
known metastatic
lesions in the brain are better evaluated on recent MRI from
___.
There is no evidence of hemorrhage. Ventricles and sulci are
normal in size
and configuration. There is no shift of normally midline
structures.
Gray-white matter differentiation is preserved. Basal cisterns
are patent.
Partially imaged paranasal sinuses, mastoid air cells and middle
ear cavities
are clear. Changes of prior right frontal craniotomy and
cranioplasty are
noted.
IMPRESSION:
1. Metastatic disease, better evaluated on recent MRI from ___.
2. No evidence of hemorrhage or midline shift.\
MRI spine ___
FINDINGS:
Cervical spine: The vertebrae are normal in stature and
alignment. There are
numerous osseous metastases throughout the cervical spine, as
seen on bone
scan from ___. There is no pathologic fracture. There
is no epidural
extension of tumor. There is no abnormal enhancement of the
spinal cord.
At C4-5, there is a broad-based central disk herniation causing
mild spinal
canal stenosis and flattening of the spinal cord. There is no
cord signal
abnormality. At C5-6, there is a disc bulge and left greater
than right
uncovertebral hypertrophy causing mild spinal canal, moderate
left, and mild
right foraminal stenosis.
Thoracic spine: The vertebrae are normal in stature and
alignment. There are
numerous osseous metastases throughout the thoracic spine, as
seen on bone
scan from ___. There is no pathologic fracture. There
is no epidural
extension of tumor. There is no abnormal enhancement of the
spinal cord. The
conus is normal in appearance and position, terminating at
T12-L1.
There is degenerative disc disease at T11-12 with disc space
narrowing,
posterior osteophytic ridging and a mild disc bulge. There is
associated mild
focal kyphosis. At T12-L1, there is a disc bulge without
significant spinal
canal stenosis.
Lumbar spine: The vertebrae are normal in stature and alignment.
There are
numerous osseous metastases throughout the lumbar spine, as seen
on bone scan
from ___. There is mild chronic concavity of the
superior endplate of
L3. There is no acute fracture. There is a 0.9 cm intrathecal
enhancing mass
within the cauda equina, most likely due to a drop metastasis
(series 15 image
8). There is no significant spinal canal or foraminal stenosis.
There are additional osseous metastases throughout the sternum,
ribs, and
pelvis. There are numerous liver metastases. There are
atelectatic changes of
the lower lobes. There is subcarinal lymphadenopathy/mass
identified. There
is right posteromedial lung parenchymal mass lesion identified.
There is
possible involvement of the right posterior sixth rib. There is
enlarged right
adrenal gland identified. Multiple signal changes within the
liver could be
due to metastatic disease. Correlation with abdominal and chest
CT
recommended.
IMPRESSION:
1. Numerous osseous metastases throughout the cervical,
thoracic, and lumbar
spine. No pathologic fracture. No epidural extension of tumor or
cord
compression.
2. Intrathecal focus of enhancement at L2-3 level likely due to
drop
metastasis.
3.. Diffuse metastases throughout the entire visualized
skeleton and liver.
4. Cervical spondylosis with degenerative foraminal stenosis at
C5-6, left
greater than right.
==================================
Pathology
==================================
___ cytology ___
negative for malignant cells
==================================
Procedures
==================================
EEG, multiple recordings, no definite epileptiform activity
last EEG ___
IMPRESSION: This is an abnormal continuous ICU EEG monitoring
study because
of intermittent focal slowing over the right hemisphere. This
finding is
indicative of focal cerebral dysfunction in the right
hemisphere, maximal in
the temporal region. There is continuous increased amplitude and
accentuation
of faster frequencies in the left parasagittal region consistent
with breach
artifact. There is mild diffuse background slowing and slow
alpha rhythm,
indicative of mild diffuse cerebral dysfunction, which is
non-specific as to
etiology. No epileptiform discharges or electrographic seizures
are present.
Compared to the prior day's recording, there are no significant
changes.
Brief Hospital Course:
___ y/o F with metastatic breast CA s/p
resection with subsequent seizure disorder presents with
recurrence of confusion similar to prior episodes. After
discussion with family and outpatient attendings, daughter
decided she would like to take her home with hospice care.
# Encephalopathy/seizure disorder - Had been improving though
mental status not completely back to baseline, but then pt had a
likely
witnessed seizure on ___. signs/symptoms of her seizure
included staring into space, unresponsiveness for a few minutes.
Several EEG recordings show various abnormalities consistent
with encephalopathy, but no definitive
epileptiform discharges. Restarted keppra ___ and increased
lacosamide to 150mg IV BID. No further fever or signs of
infection; LP not suggestive of meningitis. CT head ___ showed
no midline shift or hemorrhage and metastatic disease similar to
prior MRI in ___. She had an LP to evaluate for leptomeningeal
disease which shows no malignant cells.
Mental status continues to wax and wane. On the day of
discharge she is much more alert, nodding yes/no or asking
questions. She does have some word finding difficulty but
indicates that she understands what we are saying. She will
continue on her seizure meds at home.
# urinary retention - pt has been retaining urine intermittently
requiring 2 straight caths and foley was placed ___ be
related to oxycodone use. UA unremarkable repeatedly. No
diarrhea or fecal incontinence. However, in setting of known
lumbar and thoracic bony disease and upgoing babinski on the
left, had MRI spine ___. no evidence of cord compression. We
have left the Foley in for now, as she is deconditioned and
unable to make it to the commode. We did offer the option of
removing Foley and using diapers, and the small risk of
infection with indwelling Foley. For convenience in the hospice
setting, will leave Foley in. She is on less narcotics now, and
if pt/family would like, a decatheterization trial at home would
be appropriate.
# Weakness - right sided - could be ___ brain involvement of
metastatic disease or post-ictal ___ paralysis
in setting of recent and possibly ongoing seizure activity and
poor underlying substrate. MRI spine did not show any cord
compression
# Decreased PO intake - Likely due to loss of appetite in
setting
of metastatic disease, including hepatic mets. Cortisol level
WNL
though known adrenal met. S/p IVF ___ and pamidronate for mild
hypercalcemia. encourage PO intake when alert and safe to
swallow. recommend Ensure supplements with meals.
# fever - resolved. Had low grade temp after LP ___. LP
suggests
no meningitis. blood cultures remained negative. UA unremarkable
(small number gram positives, unlikely clinically meaningful)
# Pain - pt reports right hip pain, persistent abdominal pain,
and intermittent headaches. Pain ___ diffuse metastatic disease.
received XRT to right acetabular met. gave pamidronate ___ to
assist with bony pain in setting of
hypercalcemia. Her pain also improves with tylenol and
ibuprofen. While here she was getting oxycodone as well. At one
point up to ___ at a time, but in the past this has made her
very confused so we reduced her doses to 2.5mg. She has been
more alert off of the oxycodone.
# Hypercalcemia - improving after pamidronate ___
# Goals of care - Daughter is planning to take her home with
hospice after palliative XRT to hip. Unless her mental status
improves reliably, which we do not expect, there is no plan to
give further chemotherapy. If her overall performance status
does improve, they will call Dr. ___ office to set up an
appointment
# Transaminitis - known hepatic mets, slightly worsened on labs
___ likely reflects worsening disease
# Constipation - standing bowel regimen, suppositories prn
# Hypotension - ongoing issue for which patient has been on
midodrine. Note pt is now off dexamethasone
# Breast cancer - stage 4, mets to brain, adrenal, liver, likely
pancreas, and bone (hip and spine), ER/PR + HER2-. s/p R
craniotomy for resection of right and left frontal lesion
___,
s/p WBXRT ___. she will continue anastrazole. There is no
plan to give chemotherapy due to deconditioning and overall poor
performance status. She will go home on hospice care.
# ___ - improved s/p IVF
# Dispo:
[x] Discharge documentation reviewed, pt is stable for
discharge.
[x] Time spent on discharge activity was greater than 30min.
[ ] Time spent on discharge activity was less than 30min.
____________________________________
___, MD, pager ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. Famotidine 20 mg PO BID
4. LeVETiracetam 1500 mg PO BID
5. Midodrine 5 mg PO TID
6. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
7. anastrozole 1 mg PO DAILY
8. Ibuprofen 400 mg PO TID
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
RX *acetaminophen 325 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*50 Tablet Refills:*0
2. anastrozole 1 mg PO DAILY
RX *anastrozole 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*2
4. Famotidine 20 mg PO BID
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*2
5. Midodrine 5 mg PO TID
RX *midodrine 5 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*2
6. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg/5 mL 2.5 mg by mouth every four (4) hours
Refills:*0
7. Bisacodyl ___AILY:PRN constipation
RX *bisacodyl 10 mg 1 suppository(s) rectally daily Disp #*50
Suppository Refills:*0
8. LeVETiracetam ___ mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*120 Tablet Refills:*2
9. LACOSamide 150 mg PO BID
RX *lacosamide [Vimpat] 150 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*2
10. Ensure
Ensure supplements TID with meals. Dispense 90, 3 refills
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
metastatic breast cancer
seizures
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert but unable to verbalize
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted for confusion. We
found that you were having seizures and started you on seizure
medicines. You continue to have confusion which we think is
related to progression of breast cancer in your brain. We do not
think that further treatment directed at the cancer will help
improve your quality of life, so we have decided at this point
to focus only on treatments that will help you feel better. You
will be discharged home with hospice care. As always, we are
available if you need us.
Followup Instructions:
___
|
10692509-DS-9
| 10,692,509 | 27,432,568 |
DS
| 9 |
2169-07-09 00:00:00
|
2169-07-14 19:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
episode of aphasia, left leg
weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year-old ___ speaking man with
mild dementia, history of HTN, HLD, chronic gait instability
former smoker who presents with new episode of nonfluent aphasia
and left leg weakness.
The history is obtained through the patient's son-in-law and a
bedside ___ interpreter. The patient was in his usual state
of health in the past few days. At baseline he has mild dementia
requiring the help of home health aides and visiting nurses, but
he walks daily with a walker and is engaged and conversant in
___ with family. Symptoms began this morning at 9AM when
his
long-time nursing aide came to make breakfast and he did not
recognize who she was. He recalled having difficulty finding
words when speaking to her. Later in the afternoon at 2PM a
second home aide who speaks ___ found that his speech was
confused and nonsensical, which is very atypical for him. When
he got up to walk, he felt lightheaded and noted left leg
weakness but did not fall. The whole episode last for about ___
hours per the patient. He recalls being aware "that his speech
sounded garbled", but he could do nothing about it. There was
no
HA, vision change, facial droop or paresthesias. His PCP was
alerted who recommended transfer to the ED
Of note, the patient had a prior episode 3 months ago that was
similar in presentation. Family recalls a 5 hour episode of
word-finding difficulty, confused speech and gait instability.
He
did not seek medical attention. He has not been on an aspirin
per OMR documentation.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
Per PCP ___:
Hypertension
CAD
Peripheral vertigo
Insomnia
Ataxic gait
___
Dementia
Social History:
___
Family History:
No history of CAD, diabetes as far as he knows.
Physical Exam:
Physical Exam:
Vitals: T:98.3 69 118/53 18 97%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x self, month, year, date ___.
Able to relate history through the translator. Per ___
interpreter speech was clear, coherent, nondysarthic. He is
mildly inattentive, ___ forward with ___ mistakes. Intact
repetition and comprehension. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
follow both midline and appendicular commands. There was no
evidence of neglect.
-Cranial Nerves:
II: PERRL 3 to 2mm and brisk. VFF to confrontation by finger
movement
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. There were 2 beats of asterixis initially, but was
not reproducible on repeat attempts later
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 0 0
R 1 1 1 0 0
Plantar response was flexor bilaterally.
-Coordination: Slight bilateral intention tremor, no
dysdiadochokinesia noted. No dysmetria on FNF or HKS
bilaterally.
-Gait: There was no walker available to test gait. He was very
unsteady on attempted rise to standing position.
Pertinent Results:
admit labs:
___ 05:20PM BLOOD WBC-5.5 RBC-3.39* Hgb-10.4* Hct-33.0*
MCV-97# MCH-30.8 MCHC-31.6 RDW-14.4 Plt ___
___ 05:20PM BLOOD Neuts-49.8* ___ Monos-14.4*
Eos-0.5 Baso-0.3
___ 05:20PM BLOOD ___ PTT-30.0 ___
___ 05:20PM BLOOD Glucose-146* UreaN-22* Creat-1.7* Na-142
K-4.6 Cl-109* HCO3-22 AnGap-16
___ 05:20PM BLOOD cTropnT-<0.01
___ 05:20PM BLOOD ALT-6 AST-14 AlkPhos-84 TotBili-0.3
___ 05:20PM BLOOD Albumin-3.8 Calcium-8.9 Phos-3.7 Mg-2.0
STROKE LABS
___ 06:20AM BLOOD Triglyc-132 HDL-34 CHOL/HD-3.5 LDLcalc-58
___ 06:20AM BLOOD %HbA1c-5.5 eAG-111
STUDIES
___ NCHCT:
No acute intracranial process.
___ MRI/MRA:
1. No evidence of acute intracranial hemorrhage, mass effect, or
acute
ischemia.
2. No evidence of hemodynamically significant stenosis within
the head or
neck.
Brief Hospital Course:
___ is a ___ year-old ___ speaking man with
history of HTN, HLD, former smoker who presented with new
episode of aphasia and left leg weakness. He was admitted to the
stroke service for mgmt. Neurological exam quickly returned to
___. CT/MRI/MRA were all negative for acute process. Initial
labs were significant for ___ which was likely prerenal from
hypovolemia - this was thought likely to be a large contributer
to his presentation. TIA is still on the Ddx given his multiple
risk factors. LDL 58 and HBA1c 5.5. The patient was started on
asa 81.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Meclizine 12.5 mg PO TID
2. Cyanocobalamin 1000 mcg PO BID
3. Ferrex ___ (polysaccharide iron complex) 150 mg iron oral BID
4. Avodart (dutasteride) 0.5 mg oral daily
5. Senna 8.6 mg PO BID
6. Bisacodyl 5 mg PO BID
7. Bisacodyl 10 mg PR HS:PRN constipation
8. Docusate Sodium 100 mg PO BID
9. Voltaren (diclofenac sodium) 1 % topical BID
10. Omeprazole 40 mg PO DAILY
11. Ranitidine 150 mg PO DAILY
12. Rosuvastatin Calcium 10 mg PO DAILY
13. Lactulose 30 mL PO Q6H:PRN constipation
14. Ibuprofen 400 mg PO BID
15. Lidocaine Jelly 2% 1 Appl TP BID
16. Gabapentin 300 mg PO DAILY
17. Calcium Carbonate 500 mg PO BID
18. Exelon (rivastigmine;<br>rivastigmine tartrate) 4.6 mg/24 hr
transdermal daily
19. Nitroglycerin SL 0.3 mg SL PRN chest pain
20. Donepezil 5 mg PO HS
21. Memantine 5 mg PO DAILY
22. Nitroglycerin Patch 0.2 mg/hr TD Q24H
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Lactulose 30 mL PO Q6H:PRN constipation
3. Meclizine 12.5 mg PO TID
4. Memantine 5 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Senna 8.6 mg PO BID
7. Aspirin 81 mg PO DAILY
8. Avodart (dutasteride) 0.5 mg oral daily
9. Bisacodyl 5 mg PO BID
10. Bisacodyl 10 mg PR HS:PRN constipation
11. Calcium Carbonate 500 mg PO BID
12. Cyanocobalamin 1000 mcg PO BID
13. Donepezil 5 mg PO HS
14. Exelon (rivastigmine;<br>rivastigmine tartrate) 4.6 mg/24 hr
transdermal daily
15. Ferrex ___ (polysaccharide iron complex) 150 mg iron oral
BID
16. Gabapentin 300 mg PO DAILY
17. Ibuprofen 400 mg PO BID
18. Lidocaine Jelly 2% 1 Appl TP BID
19. Nitroglycerin Patch 0.2 mg/hr TD Q24H
20. Nitroglycerin SL 0.3 mg SL PRN chest pain
21. Ranitidine 150 mg PO DAILY
22. Rosuvastatin Calcium 10 mg PO DAILY
23. Voltaren (diclofenac sodium) 1 % topical BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: transient ischemic attack
Secondary Diagnosis: hypertension, coronary artery disease,
acute kidney injury
Discharge Condition:
Mental Status: Confused - sometimes. (some confusion at night).
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because of your symptoms of
trouble with speaking and leg weakness. This may have been due
to a TIA (transient ischemic attack). Your MRI did not show any
stroke. Your blood pressure was low when you came in as well
which may have comtibuted to your symptoms.
Please START a baby aspirin.
Continue all your other medications.
Followup Instructions:
___
|
10692526-DS-5
| 10,692,526 | 21,761,757 |
DS
| 5 |
2140-06-26 00:00:00
|
2140-06-26 21:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
ibuprofen / Vioxx / monosodium glutamate
Attending: ___
Chief Complaint:
transient monocular vision loss
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ old right-handed woman with a past
medical history of migraine, epilepsy and asthma who presents
with painless, transient left-sided monocular vision loss and
left facial paresthesias.
Patient reports that at 4pm today, she went into her basement
and
noticed that her vision "got dark on one side." She looked at
her
hand and noticed that she was able to see her hand in her right
field of vision but not her left. She covered the left eye and
was able to see normally, but she covered her right eye and only
saw black. There was no curtain coming down, only black. She
then
saw "bolts of lightening" in black and white in the "blind eye."
At the same time, she had left cheek paresthesias, like the
"sensation of coming out of novacaine." The loss of vision
occured for 6 minutes total. The paresthesias lasted for 3 hours
and then resolved. During the episode, she was able to climb the
stairs out of the basement, call her neighbor and describe her
symptoms. She denies any other neurologic symptoms such as
headache, dysarthria, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty. Denied difficulties producing or
comprehending speech. Denies focal weakness. No bowel or
bladder
incontinence or retention. Denied difficulty with gait.
She presented to ___ where she underwent head CT which was
unremarkable. Neurology was not available over the weekend so
patient was transferred for neurology evaluation.
Of note, patient has a history of migraines, which she describes
as starting with hypersensitivity over the vertex/scalp, then
bifrontal, throbbing headche with photophobia and rare nausea.
She denies a history of aura. Her last migraine was a few months
ago.
She also reports a history of epilepsy, well controlled on
Dilantin (brand name only). She reports her seizures are "grand
mal." Her last seizure was ___ years ago in the setting of a
concussion. Before that, it was ___ years prior.
Additionally, she underwent an MRI at ___ last month for a
different type of headache which began in ___, shortly
after
she fell and hit the back of her head. She reports these
headaches are due to "tight neck muscles" and has been getting
Pt
fro them with improvement. The headaches are present first thing
in the morning and then improve over the course of the day. The
MRI showed an acute left cerebellar stroke. She was not started
on an antiplatelet and etiology of the stroke is unclear as
records from that hospital stay are not currently available for
review.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Patient denies scalp tenderness, jaw claudication or shoulder or
hip pain or weakness.
Past Medical History:
Migraines without aura
Epilepsy
Asthma
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION EXAM:
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted
in
oropharynx
Neck: Supple. No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation. Visual acuity
___ in the right and ___ in the left. Fundoscopic exam
revealed no papilledema, exudates, or hemorrhages.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 5 5 ___ 5 5 5 5 5 5
R 5 5 ___ 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, proprioception
throughout. No extinction to DSS. Romberg absent.
-DTRs:
___ 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: Good initiation. Narrow-based, normal stride and arm
swing.
=====================
DISCHARGE EXAM:
No change in exam during admission. Discharge exam same as
admission exam.
Pertinent Results:
___ 05:30AM BLOOD WBC-3.4* RBC-4.20 Hgb-13.0 Hct-39.5
MCV-94 MCH-31.0 MCHC-32.9 RDW-12.5 RDWSD-42.6 Plt ___
___ 05:30AM BLOOD ___
___ 05:30AM BLOOD Glucose-89 UreaN-15 Creat-0.7 Na-144
K-4.3 Cl-105 HCO3-27 AnGap-___ 10:37PM BLOOD ALT-19 AST-25 AlkPhos-78 TotBili-0.3
___ 10:37PM BLOOD cTropnT-<0.01
___ 06:15AM BLOOD %HbA1c-4.9 eAG-94
___ 06:15AM BLOOD Triglyc-33 HDL-98 CHOL/HD-1.5 LDLcalc-42
___ 06:15AM BLOOD TSH-2.0
___ 10:37PM BLOOD CRP-3.6
========
DIAGNOSTIC STUDIES:
Echo ___: Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. Mildly
dilated ascending aorta. No definite cardiac source of embolism
identified.
MRI w/wo contrast ___:
No evidence for an acute infarction or intracranial hemorrhage.
Developmental venous anomaly is identified in the left
cerebellar hemisphere.
CTA Head and Neck ___:
No significant abnormalities on CT of the head without contrast.
No
significant abnormalities on CT angiography of the head and
neck.
CT Head (___): no radiology read from ___. No
abnormalities noted on review.
Brief Hospital Course:
___ old right-handed woman with a past medical history of
migraine, epilepsy and asthma, and L cerebellar lesion who
presents with acute painless, transient left-sided monocular
vision loss 6 minutes and 3 hours of left facial paresthesias.
# TIA: Patient symptoms resolved by time of presentation, and
was diagnosed with a TIA. CT head at ___ was unremarkable,
as was CTA. MRI was done with and without contrast to evaluate
for acute stroke as well as to evaluate prior diffusion
restriction in cerebellum noted from patient's MRI in ___. No acute stroke was found. Patient has a developmental
venous abnormality in the cerebellum, and adjacent remote
stroke. Echocardiogram TTE was done and was unremarkable. A ___
of hearts cardiac monitor was set up for discharge to look for
atrial fibrillation. Overall there is concern for cardioembolic
stroke risk given prior stroke and current TIA symptoms. Patient
was recommended to start on aspirin 81mg for stroke prevention.
Patient LDL was 48, so statin was not initiated at this time.
# ocular migraine: On the differential for transient visual
symptoms. It was explained to patient that we cannot be sure
based on a single presentation of her visual symptoms.
# History of seizures: Patient was kept on home Dilantin, no
seizures during admission.
===================
Transitional Issues:
- Patient discharged with ___ of ___ monitor, to be followed
up by neurology
- Patient to follow up with neurologist Dr. ___ in ___
months
===========
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day
2? (x) Yes - () No
4. LDL documented? (x) Yes (LDL = 48) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (x) No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? () Yes - (x) No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Phenytoin Sodium Extended 300 mg PO DAILY
2. Loratadine 10 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Spiriva Respimat (tiotropium bromide) 2.5 mcg/actuation
inhalation DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*5
2. Loratadine 10 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Phenytoin Sodium Extended 300 mg PO DAILY
5. Spiriva Respimat (tiotropium bromide) 2.5 mcg/actuation
inhalation DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Transient Ischemic Attack
Developmental Venous Abnormality
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were hospitalized due to symptoms of <> resulting from a
TRANSIENT ISCHEMIC ATTACK (TIA), a condition where a blood
vessel providing oxygen and nutrients to the brain is
temporarily blocked by a clot, without permanent damage to the
brain. The brain is the part of your body that controls and
directs all the other parts of your body, so damage to the brain
from being deprived of its blood supply can result in a variety
of symptoms. We found that there is an abnormal vein
(developmental venous abnormality) and a previous stroke next to
that area.
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:
migraines
We are changing your medications as follows:
Please start to take aspirin to prevent future stroke.
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10692526-DS-6
| 10,692,526 | 23,246,833 |
DS
| 6 |
2140-08-03 00:00:00
|
2140-08-22 14:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
ibuprofen / Vioxx / monosodium glutamate / codeine
Attending: ___.
Chief Complaint:
Fall, Facial pain/bleeding
Major Surgical or Invasive Procedure:
___:
1. Open reduction and internal fixation of left ___ Fort
fracture.
2. Close reduction of septal deviation.
History of Present Illness:
___ with history of epilepsy on Dilantin who presents after a
fall from standing in the setting of seizure activity, +HS,
+LOC, does not recall the event. She suffered contusions on her
face and reports pain on her face, left shoulder and left
thumb/wrist.
Her last seizure prior to the current episode was ___ years ago in
the setting of a concussion. Before that, it was ___ years prior.
Past Medical History:
Migraines without aura
Epilepsy
Asthma
Social History:
___
Family History:
Unknown
Physical Exam:
T 99.3 HR 114 BP 128/67 RR 16 SatO2 95% RA
GCS 15
NAD
Bil periorbital/nose/lip edema
RRR
CTA bil
No tenderness of the chest wall
Abdomen soft, non tender
Extremities: tenderness and ecchymosis of L thumb. Tenderness to
palpation of the left clavicle/shoulder.
Motor and sensory intact
Pertinent Results:
___ 04:50AM BLOOD WBC-7.3 RBC-3.66* Hgb-11.2 Hct-34.8
MCV-95 MCH-30.6 MCHC-32.2 RDW-12.9 RDWSD-44.9 Plt ___
___ 03:05PM BLOOD WBC-5.0 RBC-4.22 Hgb-13.1 Hct-40.1 MCV-95
MCH-31.0 MCHC-32.7 RDW-12.8 RDWSD-44.2 Plt ___
___ 04:50AM BLOOD ___ PTT-24.1* ___
___ 08:28PM BLOOD ___ PTT-22.1* ___
___ 04:50AM BLOOD Glucose-100 UreaN-13 Creat-0.7 Na-144
K-3.7 Cl-107 HCO3-28 AnGap-9*
___ 03:05PM BLOOD Glucose-151* UreaN-19 Creat-0.8 Na-144
K-4.1 Cl-103 HCO3-23 AnGap-18
___ 04:50AM BLOOD Albumin-3.7 Calcium-8.2* Phos-3.1 Mg-2.1
___ 09:15AM BLOOD Phenyto-9.4*
___ 04:50AM BLOOD Phenyto-11.7
___ 03:05PM BLOOD Phenyto-9.0*
___ 05:38AM BLOOD Lactate-1.0
___ 08:20PM BLOOD Lactate-0.8
___ 03:08PM BLOOD Lactate-5.0*
Brief Hospital Course:
The patient presented to the Emergency Department on ___
after a fall, she suffered pain in the face, left shoulder and
thumb. Given findings, the patient was taken to the radiology
for trauma characterization. The following findings were
obtained.
___
Relatively high position of the humeral head respect to the
glenoid fossa, but
no evidence of acute fracture.
___
In comparison with the earlier study of this date, the AC joint
remains within
normal limits. There is relatively high position of the humeral
head with
respect the glenoid fossa. However, no evidence radiographic
impingement or
abnormal calcification.
___ Hand Xray:
Suspect mild subluxation at the left thumb MCP joint. Please
correlate
clinically. No fracture.
___ CXR:
No acute cardiopulmonary process. No displaced rib fracture.
___ CT C-Spine:
1. No acute fracture or malalignment of the cervical spine.
2. Facial bone fractures and opacification of the paranasal
sinuses are better
assessed on concurrent sinus CT.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet
of full liquids, ambulating, voiding without assistance, and
pain was well controlled. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Loratadine 10 mg PO DAILY
3. omeprazole 20 mg oral DAILY
4. Phenytoin Sodium Extended 300 mg PO DAILY
5. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Cephalexin 500 mg PO Q6H
End ___
RX *cephalexin 500 mg 1 tablet(s) by mouth every six (6) hours
Disp #*20 Tablet Refills:*0
3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
RX *chlorhexidine gluconate 0.12 % gently swish and spit 15 mL
twice a day Disp #*473 Milliliter Milliliter Refills:*1
4. Docusate Sodium 100 mg PO BID
5. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*10 Tablet Refills:*0
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
7. Aspirin 81 mg PO DAILY
8. Loratadine 10 mg PO DAILY
9. omeprazole 20 mg oral DAILY
10. Phenytoin Sodium Extended 300 mg PO DAILY
11. Tiotropium Bromide 1 CAP IH DAILY
12. Zomig (ZOLMitriptan) 5 mg oral ASDIR
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
bilateral ___ ___ fracture
Left orbital floor fracture
Bilateral nasal bone fracture
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 Acute Care Surgery Service on ___
after sustaining a fall that was probably caused by a seizure.
You fractured multiple bones in your face. You were taken to the
operating room with the facial surgeons who repaired the bones.
Please continue to follow sinus precautions listed below. You
should continue to follow a full liquid diet until cleared by
your oral/facial surgeon. Your nasal splint will be removed for
the surgeon in follow up. Please follow up with your outpatient
dentist for monitoring and definitive treatment of splinted
teeth. Your primary dentist may refer you to a restorative
dentist.
The inpatient Neurology team was consulted and recommended
continuing your home dose anti-seizure medications and follow up
with Dr. ___. Your Dilantin blood levels were checked and in
good range. Please do not drive, operate heavy machinery, or
engage in high risk activities for the next 6 months given your
recent episode of impaired awareness.
You had xrays taken of your left hand, shoulder, clavicle that
showed no fractures.
You are now doing better tolerating a full liquid diet and pain
is better controlled on oral medications. You are now ready to
be discharged to 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.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
===============================
Sinus Precautions:
Because of the close relationship between the upper back teeth
and the sinus, a communication between the sinus and the mouth
sometimes results from surgery. This condition has occurred in
your case, which often heals slowly and with difficulty. Certain
precautions will assist healing and we ask that you faithfully
follow these instructions:
1. Take the prescribed medications as directed.
2. Do not forcefully spit
3. Do not smoke
4. Do not use straws
5. Do not forcefully blow your nose for at least 2 weeks, even
though your sinus may feel stuffy or there may be some nasal
drainage.
6. Try not to sneeze; it will cause undesired sinus pressure. If
you must sneeze, keep your mouth open.
7. Eat only liquids, always trying to chew on the opposite side
of your mouth.
8. Do not rinse vigorously for several days. GENTLE salt water
swishes may be used. Slight bleeding from the nose is not
uncommon for several days after the surgery. Please keep our
office advised of any changes in your condition, especially if
drainage or pain increases. It is important that you keep all
future appointments until this condition has resolved.
Followup Instructions:
___
|
10692551-DS-10
| 10,692,551 | 29,221,198 |
DS
| 10 |
2168-05-21 00:00:00
|
2168-05-21 16:02:00
|
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 distal radius fracture
Major Surgical or Invasive Procedure:
ORIF left distal radius fracture
History of Present Illness:
Patient presents after being transferred from OSH for distal
radius fracture after a motorcycle crash. He denies any
additional trauma, no head pain, no neck pain, no loss of
consciousness. Was wearing a helmet.
.
Pain in L wrist, initially had paresthesias which have resolved,
denies elbow or shoulder pain. Is R hand dominant. Denies
weakness. No back pain. No leg pain, numbness or tingling.
.
Previous history includes a scaphoid fracture of the L scaphoid
due to be fixed in ___ with Dr ___, has also had L tib/fib
orif previously.
Past Medical History:
nc
Social History:
___
Family History:
nc
Physical Exam:
___, ___: in splint, SILT m/r/u, motor grossly intact to all digits
Pertinent Results:
___ 06:35PM BLOOD Glucose-87 UreaN-15 Creat-0.9 Na-141
K-3.7 Cl-107 HCO3-24 AnGap-14
___ 06:50AM BLOOD Glucose-99 UreaN-8 Creat-1.0 Na-138 K-4.1
Cl-100 HCO3-26 AnGap-16
___ 06:35PM BLOOD Plt ___
___ 06:50AM BLOOD Plt ___
___ 06:35PM BLOOD WBC-15.0*# RBC-4.45*# Hgb-12.9*#
Hct-39.4*# MCV-89# MCH-29.0 MCHC-32.7 RDW-13.4 Plt ___
___ 06:50AM BLOOD WBC-13.6* RBC-4.44* Hgb-13.0* Hct-39.4*
MCV-89 MCH-29.3 MCHC-33.0 RDW-13.3 Plt ___
Brief Hospital Course:
The patient was admitted to the Orthopaedic Trauma Service for
repair of a left distal radius fracture. The patient was taken
to the OR and underwent an uncomplicated ORIF left distal radius
fracture. The patient tolerated the procedure without
complications and was transferred to the PACU in stable
condition. Please see operative report for details. Post
operatively pain was controlled with a PCA with a transition to
PO pain meds once tolerating POs. The patient tolerated diet
advancement without difficulty and made steady progress with ___.
Weight bearing status: non-weight bearing left upper extremity.
The patient received ___ antibiotics as well as
lovenox for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. All questions were answered prior to discharge
and the patient expressed readiness for discharge.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
standing dose
2. Docusate Sodium 100 mg PO BID
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four to six
(___) hours Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
left distal radius fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Wound Care: Please leave the splint on until your follow-up
appointment. 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.
******WEIGHT-BEARING*******
non-weight bearing left upper extremity
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on ___.
Followup Instructions:
___
|
10692563-DS-12
| 10,692,563 | 27,428,169 |
DS
| 12 |
2192-11-14 00:00:00
|
2192-11-14 17:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Fish Containing Products
Attending: ___.
Chief Complaint:
20 pound weight gain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with NASH cirrhosis currently
on the liver transplant list (hx of HE, portal hypertension s/p
TIPS, SBP, bleeding varices banding, hepatic hydrothorax,
non-occlusive PVT, and HCC s/p microwave ablation) who is
presenting 3 weeks after his last discharge with a 20 pound
weight gain.
Since leaving the hospital, started gaining weight about 1 week
ago. Meds have been changed from ___ 50 to 100 (over 1 week
ago) with no effect, then torsemide was changed from 80mg to
100mg daily (yesterday evening). This morning was the first time
he took the 100mg dose of torsemide and he has noticed a
dramatic
increase in the urine output which has. Has been following 2g Na
diet and 2L fluid restriction despite increase in weight. Other
than legs getting more swollen hasn't had any other symptoms
such
as orthopnea, chest pains, shortness of breath, worsening of
cough.
Of note, he had a mechanical fall and has lumbar tenderness (CT
scan at ___ negative for fracture recently).
In the ED, initial vitals were 97.8 109 142/80 16 95% RA. Exam
was notable for jaundice. Labs all stable compared to earlier in
the month. Imaging notable for RUQ U/S with no ascites or
thrombosis, CXR with stable loculated effusion, hip x ray
pending
read. Patient was given Magnesium.
Past Medical History:
- Atrial fibrillation (on warfarin)
- NASH cirrhosis c/b previous GIB, esophageal varices s/p
banding, non-occlusive SMV thrombus, ascites, portal HTN,
recurrent
pleural effusions
- Asthma
- HTN
- HLD
- GERD
- Sleep apnea
- Heart failure with preserved EF
Social History:
___
Family History:
No h/o premature ASCVD. Mother with ___, brother with ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: 99.3 120/74 97 18 99 Ra
Weight 232 pounds (214 on ___
Gen: well appearing, recounts medical history well, no distress
CV: irregularly irregular, II/VI systolic murmur at ___
Chest: crackles at bilateral bases
Abd: soft, non tender
Ext: warm, pitting edema to knees bilaterally
Neuro: no asterixis, alert and oriented x 3
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 906)
Temp: 98.3 (Tm 98.3), BP: 109/69 (102-126/63-75), HR: 91
(87-98), RR: 18`, O2 sat: 98% (97-100), O2 delivery: RA, Wt:
221.0 lb/100.25 kg
Gen: well appearing, recounts medical history well, no distress
HEENT: MMM, no JVD
CV: irregularly irregular, II/VI systolic murmur at ___
Chest: decreased breath sounds on RLL, left side without
crackles. no accessory muscle ue.
Abd: soft, non tender, non-distended. Palpable hard notch
located
medial to known hernia and R of mid-line just inferior to lower
ribs. No tenderness to palpation.
Ext: warm, 1+ pitting edema to mid-shins bilaterally
Neuro: no asterixis, alert and oriented x 3
Pertinent Results:
ADMISSION LABS:
================
___ 09:10AM BLOOD WBC-5.1 RBC-3.01* Hgb-8.9* Hct-28.8*
MCV-96 MCH-29.6 MCHC-30.9* RDW-15.3 RDWSD-53.5* Plt Ct-84*
___ 10:00PM BLOOD Neuts-75.9* Lymphs-7.7* Monos-11.7
Eos-3.4 Baso-0.8 Im ___ AbsNeut-4.76 AbsLymp-0.48*
AbsMono-0.73 AbsEos-0.21 AbsBaso-0.05
___ 09:10AM BLOOD ___
___ 09:10AM BLOOD UreaN-9 Creat-0.8 Na-135 K-3.4* Cl-99
HCO3-22 AnGap-14
___ 09:10AM BLOOD ALT-17 AST-41* AlkPhos-209* TotBili-4.2*
___ 09:10AM BLOOD Albumin-3.5
___ 09:10AM BLOOD AFP-2.0
MICROBIOLOGY:
==============
None
IMAGING:
========
___ DOPP ABD/PE
1. Patent TIPS.
2. Cirrhosis. A 1.7 cm hypoechoic lesion may correlate with
the segment VIII ablation site seen on outside MRI from ___. No ascites. Stable splenomegaly.
___ (PA & LAT)
1. Persistent and unchanged appearance of the right lower
hemithorax loculated effusion since ___ chest
radiograph. No pulmonary edema.
2. Right lower lobe opacities are also similar to prior and may
represent chronic atelectasis or scarring however infection
cannot be excluded.
___ (UNILAT 2 VIEW) W/P
There is no acute fracture or dislocation. Mild degenerative
changes at the bilateral hip joints are demonstrated. There is
no suspicious lytic or sclerotic lesion. There is no soft
tissue calcification or radio-opaque foreign body.
___ (PORTABLE AP)
Comparison to ___. Minimal decrease in extent of
the known
loculated right pleural effusion. Minimal right basilar
atelectasis. Borderline size of the cardiac silhouette. No
pulmonary edema. No pneumonia. No pneumothorax.
Brief Hospital Course:
Patient Summary for Admission:
Mr. ___ is a ___ year old man with NASH cirrhosis currently
on the liver transplant list (hx of HE, portal hypertension s/p
TIPS, SBP, bleeding varices banding, hepatic hydrothorax,
non-occlusive PVT, and ___ s/p microwave ablation) who is
presenting 3 weeks after his last discharge when he was
established on torsemide 80mg. Though since that discharge, he
has had a 20 pound weight gain while on torsemide while
maintaining strict diet.
ACUTE ISSUES:
=============
#Decompensated cirrhosis
#Volume overload
___
Hx of hydrothorax s/p TIPS, varices s/p banding, SBP, HE. LFTs
on admission stable as compared to previous admission indicating
no acute liver pathology. He was started on 100mg torsemide ___
with good urine output, net -5.7L over first two days. On third
day (___) he was noted to have an increased Cr (0.8->1.1) and
so diuretics were held and albumin 25% 25g given was given over
the following two days. Most likely pre-renal due to diuretic
adverse effect as Urine Na was >60. He has history of diuretic
induced ___. Diuretics were held at that time, and Cr
downtrended to 0.9 over the following 48 hours with albumin
resuscitation. He was discharged on torsemide 40mg QD and
spironolactone 50mg QD instructed to call the ___
if his weight went up more 3 pounds.
#Chronic AF
Reportedly off AC given history of GIB. Rate controlled with
Diltiazem Extended-Release 120 mg PO DAILY and Digoxin 0.125 mg
PO DAILY.
#Hiccups
___ RFA procedure last hospitalization, started on baclofen and
chlorpromazine at that time. Continued during admission, he did
not complain of significant hiccups.
#Chronic cough
#OSA
Continued home Cepacol, Albuterol Inhaler, Fluticasone
Propionate, Fluticasone-Salmeterol Diskus (250/50); GuaiFENesin.
He continued to have coughing but said it was baseline. CXR
during a
===========================
TRANSITIONAL ISSUES:
Hepatology:
#Diuresis
[ ] Follow up with patient's diuresis. Torsemide was decreased
to 40mg because he is sensitive to diuresis induced ___. Please
re-evaluate diuresis regimen and Spironolactone was maintained
at 50mg daily.
[ ] Patient was informed to call if any weight gain greater than
3 pounds and Transplant coordinators will direct outpatient
uptitration.
[ ] Please continue with weekly labs, next draw ___ and sent
to Dr. ___
[ ] He will require outpatient evaluation by Dr. ___
the next ___ weeks, patient to be contacted by Transplant Clinic
regarding scheduling.
PCP:
___ AF:
[ ] Of note, patient has been off of anticoagulation in the
setting of varices
[ ] Continue Digoxin, further evaluation by outpatient
Cardiologist.
- New Meds: None
- Stopped/Held Meds: None
- Changed Meds: Torsemide 80mg was changed to 40mg daily
- Post-Discharge Follow-up Labs Needed: None
- Incidental Findings: None
- Discharge weight: 99.97 kg (220.39 lb)
- Discharge Creatine: 0.9
Code Status: Full Code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
2. Baclofen 5 mg PO TID
3. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H:PRN Sore throat
4. ChlorproMAZINE 25 mg PO Q6H:PRN hiccups
5. Ciprofloxacin HCl 500 mg PO DAILY
6. Digoxin 0.125 mg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. Diltiazem Extended-Release 120 mg PO DAILY
9. Fluticasone Propionate NASAL 2 SPRY NU BID:PRN
congestion/allergies
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
11. Lactulose 30 mL PO TID
12. Midodrine 5 mg PO TID
13. Multivitamins 1 TAB PO DAILY
14. Pantoprazole 40 mg PO Q24H
15. Rifaximin 550 mg PO BID
16. Ursodiol 500 mg PO BID
17. Vitamin D ___ UNIT PO 1X/WEEK (SA)
18. Torsemide 100 mg PO DAILY
19. GuaiFENesin ___ mL PO Q6H:PRN cough
20. Spironolactone 50 mg PO DAILY
Discharge Medications:
1. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
3. Baclofen 5 mg PO TID
4. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H:PRN Sore throat
5. ChlorproMAZINE 25 mg PO Q6H:PRN hiccups
6. Ciprofloxacin HCl 500 mg PO DAILY
7. Digoxin 0.125 mg PO DAILY
8. Diltiazem Extended-Release 120 mg PO DAILY
9. Ferrous Sulfate 325 mg PO DAILY
10. Fluticasone Propionate NASAL 2 SPRY NU BID:PRN
congestion/allergies
11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
12. GuaiFENesin ___ mL PO Q6H:PRN cough
13. Lactulose 30 mL PO TID
14. Midodrine 5 mg PO TID
15. Multivitamins 1 TAB PO DAILY
16. Pantoprazole 40 mg PO Q24H
17. Rifaximin 550 mg PO BID
18. Spironolactone 50 mg PO DAILY
RX *spironolactone 50 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
19. Ursodiol 500 mg PO BID
20. Vitamin D ___ UNIT PO 1X/WEEK (SA)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
===================
Decompensated Cirrhosis
SECONDARY DIAGNOSIS:
=====================
Acute Kidney Injury
Atrial Fibrillation
Hiccups
Chronic cough
Obstructive Sleep Apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___ were admitted to the hospital to monitor your kidney
function and electrolyte while being diuresed.
WHAT HAPPENED WHILE ___ WERE IN THE HOSPITAL?
___ were admitted to the hospital because ___ inappropriately
gained 20 pounds on your home diuretic regimen
WHAT HAPPENED WHILE ___ WERE IN THE HOSPITAL?
- We increased the torsemide from 80mg to 100mg. While doing
so, we monitored your kidney, electrolyte levels and fluid
in/outs.
- On the third day we held your diuresis due to abnormal labs
which then normalized
- ___ improved and were ready to leave the hospital.
WHAT DO ___ NEED TO DO WHEN ___ LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Keep your follow up appointments with your doctors and
continue your weekly labs
- Weigh yourself every morning, call the ___
(___) if your weight goes up more than 3 lbs to ask
regarding diuretic dosing
- Please stick to a low salt diet and closely monitor your
fluid intake and weight
- If ___ 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 ___ the
best!
- Your ___ Care Team
Followup Instructions:
___
|
10692563-DS-14
| 10,692,563 | 23,594,287 |
DS
| 14 |
2193-02-17 00:00:00
|
2193-02-17 15:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Fish Containing Products
Attending: ___
Chief Complaint:
Edema
Major Surgical or Invasive Procedure:
Right lower extremity thoracentesis
History of Present Illness:
Mr. ___ is a ___ year old man with NASH cirrhosis currently
on the liver transplant list (hx of HE, portal hypertension s/p
TIPS, SBP, variceal bleeding s/p banding, hepatic hydrothorax,
non-occlusive PVT, and HCC s/p microwave ablation) who presents
with weight gain, and leg swelling.
Of note, patient was recently admitted to ___ from ___
to
___ for volume overload, leg swelling, and fatigue.
During
that admission he was diuresed and eventually had hyponatremia
thought to be due to doverdiuresis as weight decreased to 228
lbs
from dry weight of 234lbs. He was discharged on torsemide 40mg
daily and spironolactone 50mg daily. After discharge, patient's
case was presented at liver tumor conference on ___ with
plans for RFA of 1.4cm lesion in segment ___ of liver c/f HCC.
Since discharge, patient notes gradually worsening lower
extremity edema. He denies dyspnea with exertion, chest pain,
PND, or orthopnea. No change in diet or recent infections.
Past Medical History:
- Atrial fibrillation (on warfarin)
- NASH cirrhosis c/b previous GIB, esophageal varices s/p
banding, non-occlusive SMV thrombus, ascites, portal HTN,
recurrent
pleural effusions
- Asthma
- HTN
- HLD
- GERD
- Sleep apnea
- Heart failure with preserved EF
Social History:
___
Family History:
No h/o premature ASCVD. Mother with ___, brother with ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
___ Temp: 98.3 PO BP: 103/66 R Sitting HR: 106 RR: 18
O2 sat: 95% O2 delivery: Ra
General: Sitting comfortably in bed.
HEENT: MMM, PERRL, EOMI, neck supple
Neck: JVP 10cm
CV: RRR. No murmurs, rubs, gallops.
Lungs: CTAB. No wheezes, rales, rhonchi.
Abdomen: Distended, nontender. No fluid wave. No rebound or
guarding
Ext: 2+ pitting edema bilaterally to thighs. No stasis
dermatitis
changes. Extremities warm and well-perfused. Pulses 2+.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation. No asterixis.
DISCHARGE PHYSICAL EXAM:
=======================
___ 0748 Temp: 98.7 PO BP: 109/69 L Lying HR: 87 RR: 18 O2
sat: 97% O2 delivery: Ra
___ Total Output: 2295ml Urine Amt: 2295ml
___ Total Output: 2295ml Urine Amt: 2295ml
HEENT: no scleral icterus, MMM
CV: irregularly irregular rhythm, nl s1/s2, no mgr
LUNGS: nl WOB, CTAB, no wheezing or crackles
ABD: NABS, soft, nontender, nondistended, no rebound/guarding
EXT: trace lower extremity edema b/l improved from prior
NEURO: A/Ox3, moves all extremities, no asterixis
SKIN: warm, dry, no rash or other lesions, no jaundice
Pertinent Results:
ADMISSION LABS:
====================================================
___ 05:02PM BLOOD WBC-4.6 RBC-3.22* Hgb-8.7* Hct-27.3*
MCV-85 MCH-27.0 MCHC-31.9* RDW-17.4* RDWSD-54.2* Plt Ct-98*
___ 05:02PM BLOOD ___ PTT-36.2 ___
___ 05:02PM BLOOD Glucose-73 UreaN-7 Creat-0.7 Na-136 K-3.6
Cl-98 HCO3-28 AnGap-10
___ 05:02PM BLOOD ALT-16 AST-38 AlkPhos-162* TotBili-5.1*
DirBili-1.4* IndBili-3.7
___ 05:02PM BLOOD Lipase-22
___ 05:02PM BLOOD cTropnT-<0.01
___ 05:02PM BLOOD proBNP-237*
___ 05:02PM BLOOD Albumin-2.9* Calcium-8.2* Phos-2.5*
Mg-1.6
___ 05:02PM BLOOD Digoxin-<0.4*
DISCHARGE LABS:
====================================================
___ 07:30AM BLOOD WBC-4.8 RBC-3.24* Hgb-8.9* Hct-27.9*
MCV-86 MCH-27.5 MCHC-31.9* RDW-18.6* RDWSD-58.0* Plt ___
___ 08:42AM BLOOD Neuts-76.0* Lymphs-7.0* Monos-13.3*
Eos-2.8 Baso-0.5 Im ___ AbsNeut-5.89 AbsLymp-0.54*
AbsMono-1.03* AbsEos-0.22 AbsBaso-0.04
___ 07:30AM BLOOD Plt ___
___ 07:30AM BLOOD Glucose-91 UreaN-10 Creat-0.8 Na-135
K-3.8 Cl-97 HCO3-28 AnGap-10
___ 07:30AM BLOOD ALT-7 AST-21 LD(LDH)-161 AlkPhos-134*
TotBili-4.7*
___ 07:30AM BLOOD Albumin-4.0 Calcium-8.8 Phos-3.4 Mg-1.8
OTHER PERTINENT LABS:
====================================================
paracentesis fluid path pending
MICROBIOLOGY:
====================================================
___ urine cx CONTAMINATED
___ blood cx
___ 8:47 am PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
IMAGING:
====================================================
___ ABDOMINAL ULTRASOUND WITH DOPPLER
FINDINGS:
The liver appears diffusely coarsened and nodular consistent
with known
cirrhosis. Known liver lesions are not well assessed on this
exam. There is no ascites. There is stable splenomegaly, with
the spleen measuring 16.5 cm. There is no intrahepatic biliary
dilation. Gallbladder is surgically absent. Right pleural
effusion is noted.
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: 32 cm/sec, previously 36 cm/sec
Proximal TIPS: 81 cm/sec, previously 110cm/sec
Mid TIPS: 122 cm/sec, previously 162 cm/sec
Distal TIPS: 128 cm/sec, previously 137 cm/sec
The left and right portal veins are not well assessed.
Appropriate flow is seen in the hepatic veins and IVC.
PANCREAS: The pancreas is not well visualized, largely obscured
by overlying bowel gas.
IMPRESSION:
1. Patent TIPS. Portal vasculature is not well assessed.
2. Cirrhosis with splenomegaly. Known liver lesions are not
well assessed. No ascites seen.
3. Incidentally noted right pleural effusion.
___ CHEST X-RAY (PA & LAT)
FINDINGS:
Loculated right pleural effusion is re-demonstrated, similar to
prior, with associated overlying atelectasis. Mild left base
atelectasis is seen without definite focal consolidation. No
evidence of pneumothorax is seen. Cardiac and mediastinal
silhouettes are stable. No overt pulmonary edema is seen.
IMPRESSION:
Re-demonstrated loculated right pleural effusion, similar in
appearance. No overt pulmonary edema.
___ CXR
IMPRESSION:
1. Interval placement of a pigtail catheter at the right lung
base, with
interval decrease of the previously moderate pleural effusion.
There remains a small right hydropneumothorax.
2. Residual mild atelectasis of the right middle lower lobes.
3. Unchanged mild pulmonary edema.
OTHER DIAGNOSTIC STUDIES:
====================================================
paracentesis fluid path pending
Brief Hospital Course:
SUMMARY:
======================================================
Mr. ___ is a ___ year old man with ___ cirrhosis currently
on the liver transplant list (hx of HE, portal hypertension s/p
TIPS, SBP, variceal bleeding s/p banding, hepatic hydrothorax,
non-occlusive PVT, and HCC s/p microwave ablation) who presents
with weight gain, and leg swelling concerning for volume
overload.
ACUTE ISSUES:
======================================================
#Volume overload
___ edema
Baseline weight is supposedly 234 lb. On admission, the patient
weighed 240 lbs and endorsed worsened ___ edema over the course
of days. On recent admission his torsemide dose was halved at
discharge (80mg to 40mg), thus it was felt that his fluid
retention was in the setting of insufficient diuresis. He denied
any medication noncompliance or dietary indiscretion. On
admission his spironolactone was continued but his torsemide was
held and he was given IV lasix instead. He required a short
period of Lasix gtt and soon after was diuresed to lowest weight
of 227 lbs. He also received albumin for intravascular repletion
during diuresis. He was maintained on a 2g sodium restricted
diet. He was discharged him on torsemide 60mg once daily.
#Hypervolemic hyponatremia
The patient developed intermittent mild hyponatremia (lowest
132) throughout his admission that was felt to be likely due to
third-spacing in addition to diuresis with intravascular
depletion. He was given albumin with improvement.
# NASH Cirrhosis
MELD-Na 21, Childs Class C on admission, previously
decompensated by HE, portal HTN, SBP, variceal bleeding s/p
banding and TIPS, hepatic hydrothorax, and HCC in segment ___ s/p
ablation. His volume was managed as above. He was continued on
his home ciprofloxacin for SBP prophylaxis. He was continued on
his home lactulose and rifaximin for HE. He remained A/Ox3 with
only occasional mild asterixis throughout his admission.
Nutrition was consulted and he received supplementation with
meals. He was continued on his home midodrine and ursodiol. Of
note, he had recent imaging in ___ concerning for recurrent
HCC but has yet to undergo treatment.
#Fever
On ___ the patient spiked a fever to 100.5. Infectious
work-up was completed including CXR, blood, and urine cultures.
These were all negative. He did not have ascites and thus
diagnostic paracentesis was not able to be performed. He has a R
chronic loculated pleural effusion and there was concern that
this space was infected. Thus, chest tube was temporarily placed
and 150cc of fluid was removed. Analysis of pleural fluid
showed: TNCs 443, RBCs ___, 8% polys, 89% lymphs, 3% macros,
total protein 2.2, LDH 142, cholesterol 25, pH 7.33. Although
LDH pleural:serum ratio was >0.6, it was felt that overall his
fluid was transudative, and the LDH may have been falsely
elevated by diuresis. Ultimately, it was felt that his fever may
have been spurious, or in the setting of a chronic inflammatory
state.
#Chest pain
On ___ the patient started noticing some substernal chest
pressure, pleuritic in nature, without radiation or associated
symptoms. This started in the setting of receiving some bad
news. ECG was unchanged, and trop/CK-MB were negative x2. He
received SL nitro x1 which did not improve his symptoms. He then
received Ativan and oxycodone with partial relief. During this
time he also had drainage of his R pleural effusion, as above,
which also appeared to be associated with improved symptoms. The
pain completely dissipated prior to discharge and did not recur.
Of note, last TTE in ___ had normal EF with normal systolic
function. Last cath ___ without CAD. Last stress test ___
with possible anginal symptoms, no ST changes, no evidence of
perfusion defect.
CHRONIC ISSUES:
======================================================
# Chronic atrial fibrillation
At home, the patient is on digoxin, diltiazem, and full-dose
ASA. He is not on other anticoagulation due to history of GI
bleeding. He was continued on his home medications throughout
his hospitalization. His rate remained stable and he did not go
into RVR.
#R pleural effusion, loculated
Loculated R pleural effusion, earliest seen in ___, although
imaging as far back as ___ with R pleural effusion. Unclear
etiology, most likely chronic hepatic hydrothorax in the setting
of portal HTN. Pleural fluid analysis this admission most
consistent with transudative effusion.
# Hypokalemia
# Hypomagnesium
Felt to be in the setting of diuresis. He takes home supplements
which were held on admission. He was repleted as needed.
# GERD
Continued home pantoprazole.
# Asthma
Continued home Advair and PRN albuterol
# Depression
Continued home sertraline
TRANSITIONAL ISSUES:
======================================================
[] Will need labs on ___, follow up Cr, liver labs, and Na
[] Will need close follow-up and titration of diuresis as he has
been frequently admitted for volume overload
[] Has R loculated pleural effusion. Able to remove about 150cc
with chest tube this admission but no significant change on CXR.
Pleural fluid with elevated LDH but overall consistent with
transudative effusion, likely ___ portal HTN. Consider following
up with regular imaging.
[] He has recent imaging concerning for recurrent ___ ___ MRI
showing 1.4 cm lesion in segment VIII/VII meet OPTN 5A criteria
for HCC) that will need follow up.
[] Consider repeat stress test given chest pain symptoms this
admission.
[] discharged on increased torsemide dose of 60mg will need
weight checked in the outpatient setting
MEDICATION CHANGES:
======================================================
- Torsemide increased from 40mg to 60mg daily
DISCHARGE WEIGHT: 229.2lb
DISCHARGE CREATININE: 0.8
DISCHARGE HEMOGLOBIN: 8.9
CODE: FULL CODE
CONTACT: ___ (wife) ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
2. Aspirin 325 mg PO DAILY
3. Ciprofloxacin HCl 500 mg PO DAILY
4. Digoxin 0.125 mg PO DAILY
5. Diltiazem Extended-Release 120 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Lactulose 30 mL PO DAILY:PRN if do not have to 2 to 3 BM
daily
8. Magnesium Oxide 400 mg PO TID
9. Midodrine 5 mg PO QAM
10. Multivitamins 1 TAB PO DAILY
11. Pantoprazole 40 mg PO Q24H
12. Rifaximin 550 mg PO BID
13. Sertraline 50 mg PO DAILY
14. Spironolactone 50 mg PO QAM
15. Ursodiol 500 mg PO BID
16. Vitamin D ___ UNIT PO 1X/WEEK (SA)
17. Potassium Chloride 20 mEq PO DAILY
18. Fluticasone Propionate NASAL 2 SPRY NU BID
congestion/allergies
19. Torsemide 40 mg PO DAILY
Discharge Medications:
1. Lactulose 30 mL PO TID if do not have to 2 to 3 BM daily
RX *lactulose 10 gram/15 mL (15 mL) 30 ml by mouth every 8 hours
Disp #*3 Bottle Refills:*0
2. Torsemide 60 mg PO DAILY
RX *torsemide 20 mg 3 tablet(s) by mouth once daily Disp #*90
Tablet Refills:*0
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
4. Aspirin 325 mg PO DAILY
5. Ciprofloxacin HCl 500 mg PO DAILY
6. Digoxin 0.125 mg PO DAILY
7. Diltiazem Extended-Release 120 mg PO DAILY
8. Fluticasone Propionate NASAL 2 SPRY NU BID
congestion/allergies
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
10. Magnesium Oxide 400 mg PO TID
11. Midodrine 5 mg PO QAM
12. Multivitamins 1 TAB PO DAILY
13. Pantoprazole 40 mg PO Q24H
14. Potassium Chloride 20 mEq PO DAILY
Hold for K > 4
15. Rifaximin 550 mg PO BID
16. Sertraline 50 mg PO DAILY
17. Spironolactone 50 mg PO QAM
18. Ursodiol 500 mg PO BID
19. Vitamin D ___ UNIT PO 1X/WEEK (SA)
20.Outpatient Lab Work
Please obtain BMP ___ for Dx: m150.3 (heart failure) and fax
results ___ Fax: Fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
#Volume overload
#___ cirrhosis
#Loculated R pleural effusion
SECONDARY:
#Atrial fibrillation
#___
#HTN
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 worsening
swelling in your legs.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were given IV diuretics to help remove the extra fluid in
your body.
- You had a fever and infection was ruled out.
- A chest tube was placed on the right side and some fluid was
removed from around your lungs. This showed no infection and is
likely a buildup from your liver disease.
- Your diuretic regimen was changed:
torsemide 40mg daily was changed to torsemide 60mg daily
spironolactone 50mg daily was kept the same
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- please be sure to have your labs checked at the clinic on
___
- 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:
___
|
10692563-DS-19
| 10,692,563 | 25,982,065 |
DS
| 19 |
2193-11-10 00:00:00
|
2193-11-10 21:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Fish Containing Products
Attending: ___
Chief Complaint:
worsening ___ edema and recurrent falls
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with NASH cirrhosis c/b HCC s/p segment ___ MWA (___),
ascites s/p TIPS (___), hepatic hydrothorax, non-occlusive
portal vein + SMV thrombosis, HE, bleeding EV s/p banding, and
SBP who initially presented to ___ for worsening lower
extremity edema,recurrent falls since yesterday. At outside
hospital patient found to have a white count to 22, and T bili
up
to 9 from 6 previously. No imaging was obtained. Patient is on
liver transplant list and was transferred for further eval and
admission.
Patient reports that for two days he has been having malaise,
aches and has gait instability. He states that he has fallen
multiple times. He endorses confusion. He states that he has
been
taking his lactulose but has not had bowel movements today.
History obtained form OSH ED notable for subacute increase in
leg
swelling, patient was at a party and eating more salty foods.
Since that time having achy diffuse joint pain.
Patient denies respiratory symptoms, denies nasal congestion,
denies cough, denies chest pain, denies shortness of breath,
denies nausea, denies abdominal pain, denies dysuria. Denies
neck
stiffness. Denies headache.
In the ___ ED,
Initial Vitals: T 98.8 HR 122 BP 138/95 RR 20 O298% RA
Exam:
"Constitutional: Ill-appearing, intermittently falling asleep.
HEENT: Normocephalic, atraumatic, PERRL, icteric sclera
Resp: Normal work of breathing, symmetric chest expansion, CTA
bilaterally.
CV: Regular rate and rhythm, no M/G/R
Abd: Soft, nontender, nondistended, no masses or organomegaly,
normoactive bs
Skin: No rashes or lesions
Extremities: No edema, erythema or tenderness
Neurologic exam: Cranial nerves II through XII intact, 5+
strength in all extremities, sensation intact in all
extremities,
finger nose finger normal, gait normal, speech is garbled,
patient appears lethargic falling asleep during conversation
with
decreased attention span. Asterixis is present
Psych: Poor attention, sleeping.
Rectal: Stool guaiac positive"
Patient subsequently spiked temperature to 101.6.
Labs:
WBC 21.6, Hgb 12, Plt 100
Na 131, K 4.3, Cl 96, Bicarb 22, BUN 19, Cr 0.8, Glu 87
ALT 23, AST 64, Alk Phos 175, Lipase 114, T. Bili 8.5, Alb 2.6
Mg 1.7 P 3.5
Lactate 2.5
PTT 39.3 INR 1.7
Blood cx obtained
UA - hazy with few hyaline casts but no signs of infection
Imaging:
RUQUS with doppler: "-Limited exam due to body habitus and
patient movement.
-Patent TIPS.
-Stable splenomegaly. No ascites.
-Evaluation of hepatic parenchyma is severely limited."
CXR: pulmonary vascular congestion, haziness R>L with
obscuration
of right diaphragm
EKG: atrial fibrillation, borderline QRS prolongation, Q waves
in
V1, V2
NCHCT: no acute intracranial abnormality
Consults:
Hepatology: recommended infectious/septic work up and management
Interventions:
Albumin 25% (12.5g / 50mL) 75 g
Ceftriaxone
Flagyl 500mg IV
VS Prior to Transfer:
HR 118 BP 105/68 RR 14 O2 95% RA
ROS: Negative except as above. Patient reporting generalized
weakness and achiness.
Past Medical History:
- Atrial fibrillation (was on warfarin, this was stopped due to
varices)
- NASH cirrhosis c/b previous GIB, esophageal varices s/p
banding, non-occlusive portal vein and SMV thrombus, ascites,
portal HTN, recurrent hepatic hydrothorax s/p thoracenteses
- Asthma
- HTN
- HLD
- GERD
- Sleep apnea
- Heart failure with preserved EF
Social History:
___
Family History:
Per chart, No h/o premature ASCVD
Mother died of NASH cirrhosis in ___
Brother died of NASH cirrhosis in ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: Reviewed in OMR
GEN: older man in no acute distress
HEENT: pupils reactive, no vesicular lesions, dry mucous
membranes
NECK: supple, no meningismus, active and passive range of
motion
intact
CV: tachycardic, irregular, no appreciable murmurs
RESP: clear to auscultation bilaterally
GI: soft, nontender, nondistended
BACK: mild palpable tenderness of lower lumbar back; no
paraspinal tenderness
MSK: superficial bruising of bilateral shins
SKIN: warm
NEURO: alert and oriented to person and place, not date; has
asterixis, moves all extremities with purpose, strength of lower
legs 4+ bilaterally; reflexes symmetric
PSYCH: mood appropriate
DISCHARGE PHYSICAL EXAM
=======================
VS: 24 HR Data (last updated ___ @ 816)
Temp: 97.7 (Tm 99.5), BP: 117/75 (114-129/66-78), HR: 106
(87-106), RR: 16 (___), O2 sat: 98% (95-98), O2 delivery: Ra,
Wt: 233.4 lb/105.87 kg
General: jaundiced man, NAD, alert and interactive, pleasant; no
noted hiccups
HEENT: Scleral icterus, MMM
Lung: CTAB on anterior auscultation
Card: RRR, ___ systolic murmur best heard on right sternal
border, no rubs or gallops
Abd: soft, non-distended and nontender to palpation, no guarding
or rebound; right-sided abdominal hernia with scarring present
Ext: b/l 1+ pitting edema to mid-shins, R knee ecchymotic and
swollen right greater than left, no erythema or increased warmth
Neuro: trace asterixis, A&Ox3, yes day, month, & year, president
and able to recount days of week backwards faster than
yesterday.
Pertinent Results:
ADMISSION LABS:
===============
WBC 21.6, Hgb 12, Plt 100
Na 131, K 4.3, Cl 96, Bicarb 22, BUN 19, Cr 0.8, Glu 87
ALT 23, AST 64, Alk Phos 175, Lipase 114, T. Bili 8.5, Alb 2.6
Mg 1.7 P 3.5
Lactate 2.5
PTT 39.3 INR 1.7
Blood cx obtained
UA - hazy with few hyaline casts but no signs of infection
Imaging:
RUQUS with doppler: "-Limited exam due to body habitus and
patient movement.
-Patent TIPS.
-Stable splenomegaly. No ascites.
-Evaluation of hepatic parenchyma is severely limited."
CXR: pulmonary vascular congestion, haziness R>L with
obscuration
of right diaphragm
EKG: atrial fibrillation, borderline QRS prolongation, Q waves
in
V1, V2
NCHCT: no acute intracranial abnormality
INTERVAL LABS
=============
___ 08:25AM BLOOD Digoxin-<0.4*
DISCHARGE LABS
==============
___ 06:32AM BLOOD WBC-6.4 RBC-3.51* Hgb-11.3* Hct-34.4*
MCV-98 MCH-32.2* MCHC-32.8 RDW-16.0* RDWSD-57.1* Plt Ct-92*
___ 06:32AM BLOOD ___ PTT-43.6* ___
___ 06:32AM BLOOD Glucose-109* UreaN-13 Creat-0.6 Na-140
K-3.3* Cl-98 HCO3-29 AnGap-13
___ 06:32AM BLOOD ALT-23 AST-53* AlkPhos-188* TotBili-5.2*
___ 06:32AM BLOOD Albumin-2.8* Calcium-8.2* Phos-2.5*
Mg-1.5*
MICRO
=====
Blood cultures - no growth to date
Urine culture - no growth
MRSA screen - negative
IMAGING
=======
Duplex Doppler Abdomen ___
1. Limited exam due to body habitus and patient movement.
2. Patent TIPS.
3. Stable splenomegaly. No ascites.
4. Evaluation of hepatic parenchyma is severely limited.
CT Head w/o contrast ___
- No acute intracranial abnormality.
Right knee (AP, Lat, Oblique) ___
- Probably bone island within the proximal medial tibial
metaphysis. Superior patellar enthesopathy. Mild diffuse soft
tissue swelling around the knee joint. Trace joint effusion. No
displaced fractures.
CT Abdomen and Pelvis without contrast ___
1. Redemonstration of cirrhosis with a new 2.2 cm lesion noted
in the hepatic
dome for which further evaluation with liver MRI is recommended.
2. Interval development and growth of cystic structures in the
pancreas,
likely representing IPMNs which can be better evaluated in the
previously
recommended MRI (measured up to 1.4 cm on that MRI).
3. Right epigastric ventral hernia with no evidence of
strangulation.
4. No evidence of intra-abdominal infection.
TTE ___
- Mild symmetric left ventricular hypertrophy with preserved
biventricular systolic function. Mild to moderate tricuspid
regurgitation. Normal pulmonary pressure.
- EF 66%
Brief Hospital Course:
TRANSITIONAL ISSUES
===================
[] Patient with return to baseline mental status at time of
discharge oriented to name, location, time, year, and able to
recount days of week backwards. Please ensure lactulose
adherence at home.
[] Of note, patient's digoxin level notably <0.4; may consider
adjustment as outpatient.
[] CT A/P confirmed pancreatic cysts up to 1.1 cm now, with
interval growth from MRI in ___.
- For management of pancreatic cyst(s) between 6-15 mm in
patients less than ___ years at presentation, recommend annual
non-contrast
MRCP follow-up for ___ years, then every other year up to a total
of ___ years.
- For cysts measuring up to 1.5 cm:
(a) These guidelines apply only to incidental findings, and not
to patients
who are symptomatic, have abnormal blood tests, or have history
of pancreas
neoplasm resection.
(b) Clinical decisions should be made on a case-by-case basis
taking into
account patient's comorbidities, family history, willingness to
undergo
treatment, and risk tolerance.
Discharge labs required: LFTs, BMP
Discharge MELD: 19
Code Status: Full code presumed
Contact: ___, wife, ___
BRIEF HOSPITAL SUMMARY
======================
___ with history of afib, diastolic CHF, MR, TR, celiac artery
aneurysm, GERD, OSA, asthma, duodenal ulcer and NASH cirrhosis
c/b esophageal varices s/p banding, ascites and pleural
effusions s/p TIPS ___, non-occlusive SMV thrombus, peripheral
edema, hyponatremia, encephalopathy, SBP, and HCC, who is on the
liver transplant list, who was transferred from ___. He
originally presented with worsening ___ edema and recurrent
falls, found to have leukocytosis, fever, and encephalopathy.
Patient required overnight ICU stay given concern for worsening
sepsis vs decompensated cirrhosis. He was treated with
antibiotics and lactulose. Given hemodynamic stability, lack of
focal symptoms, ongoing body myalgias, he was presumed to have a
viral infection and received just 48 hours of antibiotics
without further fevers or infectious symptoms. His
encephalopathy improved to baseline with frequent lactulose. He
was discharged home without services.
ACTIVE ISSUES
=================
#Presumed viral infection, not otherwise specified.
Most concerning for infection, with neutrophilic predominance
suggestive of bacterial infection but clinical presentation
(high fever, myalgia) suggestive of viral. Patient
immuno-compromised with underlying hepatitis. Only symptom
abdominal pain for which CT was unrevealing. Notably no ascites
to tap, CXR with known right infiltrate but no pulmonary
symptoms. Respiratory viral panel negative. Flu swab negative.
Blood cultures without growth. Considered CNS infection given
encephalopathy; however it looks like his AMS is mild and due to
his known hepatic encephalopathy, so LP deferred. Patient
initially treated with vanc/zosyn/fl (one dose) that was
transitioned to vanc/ceftazidine/flagyl for a total of 48hrs of
treatment.
# Altered mental status
Differential includes infection (per above), hepatic
encephalopathy, digoxin toxicity. He was treated with lactulose
and antibiotics per above with improvement to baseline. Digoxin
<0.4.
# NASH CIRRHOSIS (CP: C, MELD 19), complicated by:
# Esophageal varices s/p banding - Patient had no signs or
symptoms of acute bleeding
# Ascites status post TIPS: Patient had patent TIPS on
ultrasound. Diuretics resumed at time of discharge.
# Encephalopathy- Patient treated with lactulose and rifaximin.
# Coagulopathy - Patient given vitamin K trial. INR stable at
1.2 at discharge.
# History of SBP - Broad spectrum antibiotics per above.
Re-started home ciprofloxacin by time of discharge.
#Right knee trauma: Right knee tenderness with swelling
secondary to trauma from
fall. X-ray showed soft tissue swelling, small effusion, but not
evidence of infection.
# Hypotension (resolved)
Blood pressure slightly low from baseline. Patient notably had
not received midodrine in the ED, which likely contributed. Also
in setting of hypovolemia, concern for burgeoning sepsis.
Patient continued on home midodrine.
# Atrial fibrillation:
Continued home digoxin, aspirin. Digoxin level <0.4. Held
diltiazem in ICU given concern for sepsis, reinitiated at time
of discharge.
# Depression:
Continued on home sertraline 50 mg daily
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Digoxin 0.125 mg PO DAILY
3. Lactulose 30 mL PO TID
4. Midodrine 15 mg PO TID
5. Rifaximin 550 mg PO BID
6. Sertraline 75 mg PO DAILY
7. Spironolactone 100 mg PO DAILY
8. Torsemide 80 mg PO DAILY
9. Ursodiol 500 mg PO BID
10. Pantoprazole 40 mg PO Q12H
11. Ciprofloxacin HCl 500 mg PO DAILY
12. Diltiazem Extended-Release 120 mg PO DAILY
13. Magnesium Oxide 400 mg PO TID
14. Multivitamins 1 TAB PO DAILY
15. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Ciprofloxacin HCl 500 mg PO DAILY
3. Digoxin 0.125 mg PO DAILY
4. Diltiazem Extended-Release 120 mg PO DAILY
5. Lactulose 30 mL PO TID
6. Magnesium Oxide 400 mg PO TID
7. Midodrine 15 mg PO TID
8. Multivitamins 1 TAB PO DAILY
9. Pantoprazole 40 mg PO Q12H
10. Rifaximin 550 mg PO BID
11. Sertraline 75 mg PO DAILY
12. Spironolactone 100 mg PO DAILY
13. Torsemide 80 mg PO DAILY
14. Ursodiol 500 mg PO BID
15. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
Viral infection not otherwise specified
SECONDARY DIAGNOSES
===================
Hepatic encephalopathy
___ cirrhosis
Ascites s/p TIPS
Right knee trauma
Hyponatremia
Lower extremity edema
Atrial fibrillation
Depression
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Confused - sometimes.
Discharge Instructions:
Dear, Mr. ___,
You were admitted to the hospital because you had fevers and
swelling in your legs.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were given antibiotics for your infection. These were
eventually discontinued because the source of your illness was
believed to be viral.
- You were given medications to reduce the amount of fluid in
your body.
- You were given medications to reduce your confusion.
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Keep your follow up appointments with your doctors
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight changes by more
than 3 pounds
- Please stick to a low salt diet and monitor your fluid intake
- If you experience any of the danger signs listed below please
call your primary care doctor or come to the emergency
department immediately.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team
Followup Instructions:
___
|
10692563-DS-22
| 10,692,563 | 29,613,531 |
DS
| 22 |
2194-02-01 00:00:00
|
2194-02-01 17:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Fish Containing Products /
shellfish derived
Attending: ___
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
===============
___ 12:58AM BLOOD WBC-7.4 RBC-2.70* Hgb-8.6* Hct-26.4*
MCV-98 MCH-31.9 MCHC-32.6 RDW-16.0* RDWSD-56.6* Plt ___
___ 12:58AM BLOOD Neuts-74.9* Lymphs-7.3* Monos-13.6*
Eos-2.9 Baso-0.8 Im ___ AbsNeut-5.51 AbsLymp-0.54*
AbsMono-1.00* AbsEos-0.21 AbsBaso-0.06
___ 12:58AM BLOOD Glucose-72 UreaN-14 Creat-0.6 Na-128*
K-4.2 Cl-94* HCO3-24 AnGap-10
___ 12:58AM BLOOD ALT-17 AST-46* AlkPhos-173* TotBili-6.2*
___ 12:58AM BLOOD Lipase-82*
___ 12:58AM BLOOD Albumin-2.7* Calcium-7.8* Phos-2.8
Mg-1.5*
___ 01:05AM BLOOD Lactate-1.1
MICRO:
======
Blood culture ___
No growth
Urine culture ___
No growth
IMAGING:
========
CT abdomen pelvis with contrast ___
IMPRESSION:
1. No acute abdominopelvic process.
2. Status post ablation of the mid hepatic dome with stable
postprocedural
changes.
3. Stable small pericardial effusion and right pleural effusion.
Right
rounded atelectasis.
4. Cirrhotic liver morphology with stable splenomegaly and no
abdominal
ascites.
5. Stable appearance of right epigastric small large bowel
containing ventral hernia with no evidence of obstruction or
strangulation.
6. Multiple pancreatic cysts, better characterized on recent
abdominal MRI.
Abdominal vascular ultrasound ___
1. Patent TIPS, similar veolcities as prior. Limited
quantitative assessment of TIPS velocities.
2. Cirrhotic liver morphology with stable splenomegaly and no
appreciable
ascites.
DISCHARGE LABS:
===============
___ 05:25AM BLOOD WBC-4.1 RBC-2.78* Hgb-9.1* Hct-27.6*
MCV-99* MCH-32.7* MCHC-33.0 RDW-16.5* RDWSD-60.5* Plt ___
___ 04:40AM BLOOD Neuts-74.1* Lymphs-7.5* Monos-14.7*
Eos-2.5 Baso-0.7 Im ___ AbsNeut-5.53 AbsLymp-0.56*
AbsMono-1.10* AbsEos-0.19 AbsBaso-0.05
___ 05:25AM BLOOD ___
___ 05:25AM BLOOD Glucose-95 UreaN-13 Creat-0.8 Na-134*
K-4.4 Cl-95* HCO3-27 AnGap-12
___ 05:25AM BLOOD ALT-10 AST-29 LD(LDH)-215 AlkPhos-153*
TotBili-5.6*
___ 05:25AM BLOOD Albumin-3.8 Calcium-9.1 Phos-3.2 Mg-1.6
Brief Hospital Course:
PATIENT SUMMARY
=================
___ with history of afib, diastolic CHF, MR, TR, celiac artery
aneurysm, GERD, OSA, asthma, duodenal ulcer and NASH cirrhosis
c/b esophageal varices s/p banding, ascites, ___ edema, HE, SBP
and pleural effusions s/p TIPS ___, non-occlusive SMV thrombus,
and HCC s/p microwave ablation of 3 segment IV hepatocellular
carcinomas, currently on the liver transplant list, who
presented with worsening abdominal pain after recent ablation
and was found to be hyponatremic. His abdominal pain improved
with supportive measures. His hyponatremia improved with albumin
and temporarily holding his home diuretics. His diuretics were
restarted and his sodium remained stable prior to discharge. He
also finished his course of antibiotics for klebsiella
bacteremia and was transitioned back to SBP prophylaxis with PO
ciprofloxacin.
TRANSITIONAL ISSUES
====================
[] Please ensure patient takes lactulose as scheduled. He
becomes encephalopathic easily with if he takes only 1 dose of
lactulose per day and requires ___ doses per day.
[] Patient was found to be non-immune to ___ and HepB on
___, and was given the second dose of hepatitis A vaccine
on ___. Hepatitis b hepsilav is not stocked on the
inpatient floor. He will need this dosed in liver clinic.
[] He did not require midodrine while inpatient, with blood
pressures 110s/70s. Please restart as outpatient if indicated.
Discharge MELD: 23
Discharge Weight: 104.96 kg (231.39 lb)
Discharge Cr: 0.8
Discharge Na: 134
Discharge Tbili: 5.6
Discharge INR: 1.9
ACUTE ISSUES
=============
#Post ablation pain
#HCC s/p ablation
3 segment VIa lesions measuring up to 2.3cm now s/p microwave
ablation on ___. On follow up MRI, the 3 targeted segment 4
lesions are no longer visualized. There was no evidence of
residual disease and no new worrisome hepatic lesion. Patient
presented with abdominal pain that resolved with over several
days with supportive care. His pain was well-controlled prior to
discharge.
# Hyponatremia
Due to cirrhosis. Improved with albumin and holding diuretics.
His diuretics were restarted and titrated back to his home dose
with a stable sodium prior to discharge.
# Klebsiella bacteremia
Finished antibiotic course on ___. He was restarted on SPB
prophylaxis with ciprofloxacin prior to discharge. Midline was
removed on ___.
# NASH Cirrhosis currently listed for transplant
# s/p TIPS ___
# HCC
Cirrhosis complicated by esophageal varices with history of
significant GIB, now s/p banding. Also with history of ascites,
improved since TIPS ___, and was without ascites during this
admission. RUQUS on admission with patent TIPS. History of
encephalopathy, not encephalopathic this admission, continued on
home lactulose and rifaximin (he becomes rapidly encephalopathic
if he misses doses of lactulose). History SBP, restarted on
cipro ppx after finishing treatment for klebsiella bacteremia.
Is currently listed for transplant. No alcohol use in past
several years. Continued home lactulose, rifaximin, ursodiol,
multivitamin.
CHRONIC ISSUES
===============
#HFpEF
Held diuretics while hyponatremic. Restarted prior to discharge.
# Anemia
# Thrombocytopenia
Chronic and due to cirrhosis. No evidence of current bleed.
# Atrial fibrillation
s/p several failed ablations. Not on anticoagulation due to
previous bleeding from varices. Continued digoxin and Diltiazem
and aspirin.
# Depression
Continued sertraline 75 mg daily
# GERD
Continue home protonix 40mg BID
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Digoxin 0.125 mg PO DAILY
2. Diltiazem Extended-Release 120 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Pantoprazole 40 mg PO Q12H
5. rifAXIMin 550 mg PO BID
6. Sertraline 75 mg PO DAILY
7. Spironolactone 100 mg PO DAILY
8. Torsemide 80 mg PO DAILY
9. Ursodiol 500 mg PO BID
10. Vitamin D ___ UNIT PO DAILY
11. Ertapenem Sodium 1 g IV ONCE
12. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
13. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
14. Ciprofloxacin HCl 500 mg PO Q24H
15. Sarna Lotion 1 Appl TP TID:PRN dry skin
16. Magnesium Oxide 400 mg PO TID
17. Baclofen 10 mg PO TID hiccups
18. Aspirin 325 mg PO DAILY
19. Lactulose 30 mL PO TID
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Baclofen 10 mg PO TID hiccups
3. Ciprofloxacin HCl 500 mg PO Q24H
4. Digoxin 0.125 mg PO DAILY
5. Diltiazem Extended-Release 120 mg PO DAILY
6. Lactulose 30 mL PO TID
7. Magnesium Oxide 400 mg PO TID
8. Multivitamins 1 TAB PO DAILY
9. Pantoprazole 40 mg PO Q12H
10. rifAXIMin 550 mg PO BID
11. Sarna Lotion 1 Appl TP TID:PRN dry skin
12. Sertraline 75 mg PO DAILY
13. Spironolactone 100 mg PO DAILY
14. Torsemide 80 mg PO DAILY
15. Ursodiol 500 mg PO BID
16. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Decompensated Non-alcoholic steatohepatitis (NASH) cirrhosis
Secondary diagnoses:
Hepatocellular carcinoma
Liver transplant candidate
Post ablation syndrome
Hyponatremia
Klebsiella bacteremia
Heart failure with preserved ejection fraction
Anemia
Thrombocytopenia
Atrial fibrillation
Depression
Gastroesophageal reflux disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a privilege taking care of you at ___
___.
WHY WAS I IN THE HOSPITAL?
You were admitted due to worsening pain and nausea and vomiting
after microwave ablation of your hepatocellular carcinoma.
WHAT HAPPENED TO ME IN THE HOSPITAL?
You were supported with fluids and pain medications to control
your symptoms.
Sodium level in your blood was found to be low. We temporarily
stopped your water pills (torsemide, Spironolactone) and gave
you albumin through your IV. This resulted in an improvement in
your blood sodium levels.
We restarted you on your home water pills and your sodium level
remained stable.
We gave you your second dose of the hepatitis A vaccine.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below). You
took one dose of lactulose before leaving, and should make sure
to take your next dose when you get home tonight.
- You did not take your diuretic medications (water pills,
spironolactone and torsemide) before leaving the hospital. You
should make sure to take these pills tonight.
- 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 in 1 day or 5 pounds in 2 days
- Please stick to a low salt diet and limit your fluid intake to
1.5 liters per day
- Because your liver disease makes you prone to confusion and
drowsiness, you should refrain from driving or operating heavy
machinery. You also need to take your lactulose every day as
prescribed to prevent confusion.
- You decided to go to outpatient physical therapy when you are
home. Continue to work on your mobility and strength with their
help!
- If you experience any of the danger signs listed below please
call your primary care doctor or come to the emergency
department immediately.
We wish you the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10692563-DS-5
| 10,692,563 | 22,918,785 |
DS
| 5 |
2192-05-09 00:00:00
|
2192-05-09 16:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Fish Containing Products
Attending: ___
Chief Complaint:
diarrhea
Major Surgical or Invasive Procedure:
___ Guided Paracentesis ___
History of Present Illness:
___ year old man with cirrhosis c/b portal hypertension,
esophageal varices s/p banding, non-occlusive SMV thrombus, h/o
atrial fibrillation, HFpEF, asthma, pleural effusions controlled
with diuretics who presents with fatigue shortness of breath.
Mr. ___ presents with 7 days of nausea without vomiting,
abdominal cramping, diarrhea and associated malaise/fatigue.
Diarrhea with crampy suprapubic pain, ___ bowel movements daily,
last this afternoon. No tenesmus nor dysuria, urinary frequency.
He has no BRBPR or melena. He has had no sick contacts, no
unusual foods, no recent antibiotics. He has no colonoscopy on
record, last ___ EGD ___ with resolution of esophageal
varcies s/p banding, he had a repeat EGD ___ at ___
found to have portal gastropathy. He has lost 12 lbs (270->258
on his home scale) in the last six months, although he does
report having anorexia and diminished appetite.
He has also had subacute worsening of his chronic SOB. He notes
mildly worsened orthopnea, he lies on his right side at night
which he finds helps his shortness of breath. He denies PND. He
continues to take furosemide 80 mg daily, spironolactone 100 mg
tablet and has not noted worsening abdominal distention (other
than his chronic ventral hernia). He has a history of R sided
hepatic hydrothorax which prior to doubling his oral diuretic
doses ~ ___ years ago required almost weekly taps (none since).
He has had 1 therapeutic paracentesis in the past, > ___ years
ago. He follows with Dr. ___, here at ___ for his
dyspnea with recent PFTs and evaluation concerning for asthma
and sinus disease. He continues on azelastine every ___ days,
advair, Flonase. He did have a recent "COPD exacerbation" at
___ where he received a steroid burst and taper with
good relief of his SOB.
In the ED initial vitals: T: 96.8 HR: 72 BP: 115/76 RR: 17
SO2: 100% RA
- Exam notable for: Diminished RLL, exp wheeze scant throughout
worse with cough. No tappable pocket on bedside US
- Imaging notable for:
CXR w/ right pleural effusion
RUQUS: Imaged portions of the main and left portal veins
were patent with hepatopetal flow. Areas of nonocclusive
thrombus in the portal venous system were better evaluated on
recent MRI.
- Labs notable for
WBC: 7.1 Hgb: 10.2 Plt: 145
Na 135 K 4.3 BUN: 12 crt: 0.7
Ca: 8.1 Mg: 1.6 P: 3.0
ALT: 17 AST: 37 AP: 150 Tbili: 3.3 Alb: 2.8
Flu PCR negative
- Patient was given: nothing
- Vitals prior to transfer: HR: 73 BP: 111/65 RR: 16 SO2:
100% RA
REVIEW OF SYSTEMS: Per HPI, denies fever, chills, night sweats,
headache, vision changes, rhinorrhea, congestion, sore throat,
cough, shortness of breath, chest pain, hematochezia, dysuria,
hematuria.
Past Medical History:
#Atrial fibrillation not on coumadin
#NASH cirrhosis c/b previous GIB (esophageal varices s/p
banding,
non-occlusive SMV thrombus)
#asthma
#HTN
#HLD
#GERD
#Sleep apnea
#Diastolic HF preserved EF
#Esophageal varices
#Recurrent pleural effusions
Social History:
___
Family History:
No h/o premature ASCVD. Mother with ___, brother with ___.
Physical Exam:
ADMISSION PHYSICAL:
===================
GENERAL: NAD, friendly, alert and interactive gentleman who is
cachectic with abdominal distention
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2 P2 not apparent inferiorly no RV heave, no
murmurs, gallops, or rubs
LUNGS: CTAB, late end expiratory wheeze, dullness to percussion
RLL without egophany and decreased tactile fremitus breathing
comfortably without use of accessory muscles
ABDOMEN: large right sided ventral hernia, reducible, distended,
nontender in all quadrants, no rebound/guarding
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, no
asterixis
DISCHARGE PHYSICAL:
===================
24 HR Data (last updated ___ @ 513)
Temp: 98.2 (Tm 98.5), BP: 105/67 (102-120/64-71), HR: 58
(58-98), RR: 18 (___), O2 sat: 96% (96-98), O2 delivery: Ra
GENERAL: NAD
HEENT: MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, dullness to percussion RLL and decreased breath
sounds at the right base, breathing comfortably without use of
accessory muscles
ABDOMEN: large right sided ventral hernia, reducible, distended,
nontender in all quadrants, no rebound/guarding. difficult to
appreciate fluid wave.
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, no
asterixis
SKIN: warm and well perfused, excoriations over abdomen, left
arm, nodule on left back
Pertinent Results:
ADMISSION LABS:
===============
___ 09:00PM BLOOD WBC-7.1 RBC-3.91* Hgb-10.2* Hct-32.4*
MCV-83 MCH-26.1 MCHC-31.5* RDW-15.1 RDWSD-45.7 Plt ___
___ 09:00PM BLOOD Neuts-60.0 Lymphs-12.2* Monos-13.6*
Eos-12.7* Baso-1.1* Im ___ AbsNeut-4.28 AbsLymp-0.87*
AbsMono-0.97* AbsEos-0.91* AbsBaso-0.08
___ 09:00PM BLOOD Glucose-88 UreaN-12 Creat-0.7 Na-135
K-4.3 Cl-99 HCO3-24 AnGap-12
___ 09:00PM BLOOD ALT-17 AST-37 AlkPhos-150* TotBili-3.3*
___ 09:00PM BLOOD Albumin-2.8* Calcium-8.1* Phos-3.0 Mg-1.6
Iron-31*
___ 09:00PM BLOOD calTIBC-328 VitB12-1079* Ferritn-23*
TRF-252
INTERVAL LABS
===============
___ 04:10AM BLOOD GGT-85*
___ 09:00PM BLOOD calTIBC-328 VitB12-1079* Ferritn-23*
TRF-252
___ 04:10AM BLOOD 25VitD-18*
___ 04:05AM BLOOD Cortsol-3.1
___ 11:23PM BLOOD Cortsol-4.0
___ 12:00AM BLOOD Cortsol-12.3
___ 12:30AM BLOOD Cortsol-14.9
___ 04:05AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 04:10AM BLOOD PSA-0.5
___ 04:05AM BLOOD ___ CEA-3.1
___ 04:05AM BLOOD IgG-___ IgA-___* IgM-115
IMAGING:
=========
___ Panorex
The patient presents with a poor dentition and multiple missing
teeth. The is evidence of past root canal treatment and crowns.
There is no evidence of gross caries or acute dental infection.
There is no evidence of dental abscess.
___ TTE
The left atrial volume index is moderately increased. No
evidence for a patent foramen ovale or atrial septal defect by
agiated saline contrast at rest. No late contrast is seen in the
left heart (suggesting absence of intrapulmonary shunting).
Normal left ventricular wall thickness, cavity size, and
regional/global systolic function (3D LVEF = 58%). The right
ventricular cavity is moderately dilated with normal free wall
contractility. The ascending aorta is mildly dilated. 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
mildly thickened. Mild (1+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. The tricuspid
regurgitation jet is eccentric and may be underestimated. [Due
to acoustic shadowing, the severity of tricuspid regurgitation
may be significantly UNDERestimated.] There is borderline
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: No significant intrapulmonary shunting seen. Normal
left ventricular systolic function. Dilated right ventricle with
normal RV systolic function. At least moderate tricuspid
regurgitation. Borderline pulmonary hypertension.
___ PARACENTESIS. 1. Technically successful diagnostic and
therapeutic paracentesis with 2.1 cm of clear straw-colored
ascites fluid removed from the right lower quadrant under
ultrasound guidance.
___ Cardiac Perfusion Study: 1. No evidence of myocardial
perfusion defect. 2. Normal left ventricular cavity size with
normal systolic function. EF = 63%.
___ CXR: There is a new moderate right-sided pleural effusion
with adjacent atelectasis. The left lung is clear. Cardiac
silhouette is within normal limits. No acute osseous
abnormalities.
___ LIVER US
Imaged portions of the main and left portal veins were patent
with Hepatopetal flow. Areas of nonocclusive thrombus in the
portal venous system were better evaluated on recent MRI.
MICRO:
======
___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
No E. coli O157:H7 found.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
VARICELLA-ZOSTER IgG SEROLOGY (Final ___:
EQUIVOCAL BY EIA.
Equivocal results indicate probable low levels of antibody
which may
or may not confer full immunity. Contact laboratory if
further
testing is required.
Brief Hospital Course:
SUMMARY:
==========
Mr. ___ is a ___ year old man with cirrhosis c/b
portal hypertension, esophageal varices s/p banding,
non-occlusive SMV thrombus, h/o atrial fibrillation, HFpEF,
asthma, pleural effusions controlled with diuretics who presents
with diarrea and dyspnea with imaging findings concerning for
worsening ascites, pleural effusion. He additionally underwent
an expedited inpatient transplant evaluation.
Issues Addressed:
===========================
# Diarrhea
# abdominal pain: Patient reported a 7 day history of diarrhea.
He was noted to have 1 bowel movement daily while inpatient and
stool cultures (including norovirus) and C. Diff were negative.
He had two episodes of diarrhea on the day prior to discharge,
which happened after eating lunch. He will undergo outpatient
colonoscopy given his persistent diarrhea and unclear etiology.
# Subjective dyspnea
# Chronic Right sided pleural effusion: Initial CXR demonstrated
chronic right sided pleural effusion. Notably patient with
normal oxygen saturations. He has a history of asthma and was
continued on his home Advair at the maximum dose and received
duonebs PRN (these were discontinued as the patient said they
made his cough worse). He underwent ECHO with bubble study to
evaluate for hepatopulmonary syndrome which demonstrated no
significant intrapulmonary shunting. Nadolol was discontinued
given concern it was contributing to bronchospasm and
generalized fatigue.
# NASH cirrhosis: Na-MELD of ___ Childs B, c/b esophageal
varices (none demonstrated on ___ EGD), portal
hypertension, SMV. Initial abdominal ultrasound ___
demonstrated a moderate amount of ascites with re-demonstration
of known SMV. He underwent an ___ guided paracentesis ___ that
was negative for SBP. He continued his home lasix 80mg and
spironolactone 100mg daily. He underwent an inpatient evaluation
for transplant.
# SMV Thrombus: Diagnosed ___ with evidence on ___ MRI
of progression to including main and right portal vein. Concern
that in setting of ascites, hepatopulmonary syndrome would
consider need for possible thrombectomy and TIPs procedure in
the future.
# Intermittent Hypotension: SBP 90-100 during admission, notably
in setting of Nadolol 40mg dosing. Less likely in setting of
infection given stable WBC. Nadolol discontinued given fatigue,
hypotension and no varices. AM cortisol was low so patient
underwent cosyntropin stimulation test that showed appropriate
response.
# Atrial fibrillation: CHADS-Vasc of 1 given h/o HTN, continued
full dose aspirin. Home Diltiazem was continued.
# Acute on Chronic Anemia: Hemoglobin 12 at last outpatient
check, 10.2 on admission. Iron studies demonstrated iron
deficiency anemia and was started on iron supplementation.
TRANSITIONAL ISSUES:
=============================
[] Dexascan needed as an outpatient.
[] Outpatient MRI for transplant evaluation.
[] VZV equivocal, repeat vaccination needed.
[] Continue iron supplementation for iron deficiency anemia and
uptitrate dose as tolerated and consider IV iron administration.
[] Moderate TR - should be evaluated by transplant
anesthesiology. Follow up to bed scheduled with Dr. ___
___ by the transplant team.
[] Should undergo annual EKG, TTE, stress echo as long as he
remains on transplant list.
[] Would start anticoagulation ASAP after transplant for atrial
fibrillation.
[] Patient should be seen for re-fitting of CPAP mask and
strongly encourage patient to use it
[] TTG pending at the time of discharge, please follow up to
rule out celiac disease as a cause of his diarrhea.
[] Patient scheduled for outpatient colonoscopy with Dr. ___
___ workup of diarrhea.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
2. Spironolactone 200 mg PO DAILY
3. Nadolol 40 mg PO DAILY
4. Albuterol Inhaler 2 PUFF IH Q4H
5. Aspirin 325 mg PO DAILY
6. azelastine 0.15 % (205.5 mcg) nasal BID
7. Diltiazem Extended-Release 120 mg PO DAILY
8. Vitamin D ___ UNIT PO 1X/WEEK (SA)
9. Fluticasone Propionate NASAL 2 SPRY NU BID
10. Furosemide 80 mg PO DAILY
11. Ranitidine 300 mg PO DAILY
12. Sucralfate 1 gm PO BID
13. Ursodiol 500 mg PO BID
14. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. 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
2. Albuterol Inhaler 2 PUFF IH Q4H
3. Aspirin 325 mg PO DAILY
4. azelastine 0.15 % (205.5 mcg) nasal BID
5. Diltiazem Extended-Release 120 mg PO DAILY
6. Fluticasone Propionate NASAL 2 SPRY NU BID
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. Furosemide 80 mg PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. Ranitidine 300 mg PO DAILY
11. Spironolactone 200 mg PO DAILY
12. Sucralfate 1 gm PO BID
13. Ursodiol 500 mg PO BID
14. Vitamin D ___ UNIT PO 1X/WEEK (SA)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
==================
___ Cirrhosis
Right Pleural Effusion
Asthma
Diarrhea
Secondary Diagnosis:
====================
Atrial Fibrillation
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 ___ as your site of care.
Why was I admitted to the hospital?
-You were having diarrhea at home and increased shortness of
breath.
What was done for me while I was hospitalized?
-We tested your stool for various types of infection and all of
the testing was negative. Your diarrhea got better at first but
then you started having diarrhea again.
-We tested the fluid in your abdomen and there was no signs of
infection.
-You had testing of your heart which was normal as part of your
transplant evaluation.
-You also had x-rays done of your teeth which didn't show any
infection.
-You were started on iron supplementation for your iron
deficiency.
-You completed most of the workup for liver transplant while you
were in the hospital.
What should I do when I leave the hospital?
-Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
-Please continue all of your medications as prescribed.
-Follow up with your doctors as listed below.
We wish you the best,
Your ___ team
Followup Instructions:
___
|
10692563-DS-6
| 10,692,563 | 27,682,788 |
DS
| 6 |
2192-07-07 00:00:00
|
2192-07-08 10:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Fish Containing Products
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Chest tube placement ___, removed on ___
History of Present Illness:
Mr. ___ is ___ year old man with ___ cirrhosis c/b portal
hypertension, esophageal varices s/p banding, non-occlusive SMV
thrombus, atrial fibrillation, HFpEF, asthma and pleural
effusion
who presents with dyspnea and found to have right pleural
effusion.
The patient states that for the last ___ days he has noticed
increasing shortness of breath. Felt like this is similar to
exactly what has had in the past with his pleural effusions. His
exercise tolerance has severely diminished over the course of
the
past several months, but he did note that over the past 2 days
it
became acutely worse, and on the night prior to admission he was
working hard to breath all night. He also had worsening
orthopnea
over the several days prior to admission. He could only relieve
this by sleeping on his right side in a recliner. Along with
this, he noticed worsening swelling in the bilateral lower
extremities. His abdomen is more swollen, but not necessarily
significantly worse over the past two days.
His cough has been stable, he denies fevers and chills, his
diarrhea has improved significantly since his last admission,
he's had no nausea or vomiting, and no dysuria, melena,
hematochezia. Denies sick contacts or changes in diet.
Past Medical History:
#Atrial fibrillation not on coumadin
#NASH cirrhosis c/b previous GIB (esophageal varices s/p
banding,
non-occlusive SMV thrombus)
#asthma
#HTN
#HLD
#GERD
#Sleep apnea
#Diastolic HF preserved EF
#Esophageal varices
#Recurrent pleural effusions
Social History:
___
Family History:
- No h/o premature CVD.
- Mother with ___, brother with ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VITALS: T 98.6; BP 125/83; HR 90; RR 18; ___
GENERAL: Comfortable appearing man sitting up in bed and
speaking
to me in complete sentence, in no apparent distress.
HEENT: Mild slceral icterus. Mild oropharyngeal erythema without
exudate. Pupils equal and reactive. Extraocular eye movements
normal.
NECK: JVP at angle of jaw at 45 degrees. No lymphadenopathy.
CARDIAC: S1/S2 irregular, tachycardic.
LUNGS: Deep breathing illicts persistent dry cough. Poor air
movement. Basilar crackles, diminished lung sounds at right
base.
BACK: Chest tube in R back with some blood.
ABDOMEN: Distended. No clear fluid wave. Hernia near surgical
scar in right upper quadrant. No pain to deep palpation.
EXTREMITIES: 2+ pitting edema up to the knee bilaterally. Good
pedal pulses with warm feet.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. AOx3. No
asterixis.
DISCHARGE PHYSICAL EXAM:
========================
VS: 98.2 PO 113 / 76 L Sitting 96 16 96 RA
GENERAL: Well-appearing, sitting in bed, in NAD
HEENT: NC/AT, EOMI, mildly icteric sclera, MMM
CARDIAC: RRR, normal S1/S2, no m/r/g
LUNGS: Diminished at the right base compared to left, otherwise
CTAB, no wheezes/rhonci/rales, no crackles
ABDOMEN: Distended, soft, large hernia near surgical scar in
RUQ,
no pain with palpation, active bowel sounds, no appreciable
fluid
wave
EXTREMITIES: No c/c/e
NEUROLOGIC: Alert, oriented, moving all extremities with
purpose,
no asterixis
Pertinent Results:
ADMISSION LABS:
===============
___ 02:01PM PLEURAL TOT PROT-1.2 GLUCOSE-118 CREAT-0.5
LD(___)-64 ALBUMIN-0.7 CHOLEST-18 TRIGLYCER-34 proBNP-170
___ 02:01PM OTHER BODY FLUID PH-7.45
___ 02:01PM PLEURAL TNC-742* ___ POLYS-66*
LYMPHS-26* MONOS-0 ATYPS-1* MESOTHELI-4* MACROPHAG-3*
___ 01:29PM URINE HOURS-RANDOM
___ 01:29PM URINE UCG-NEGATIVE
___ 01:29PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 01:29PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.5
LEUK-NEG
___ 10:58AM GLUCOSE-80 UREA N-14 CREAT-0.6 SODIUM-130*
POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-21* ANION GAP-12
___ 10:58AM estGFR-Using this
___ 10:58AM ALT(SGPT)-46* AST(SGOT)-62* LD(___)-305* ALK
PHOS-166* TOT BILI-3.5*
___ 10:58AM LIPASE-44
___ 10:58AM proBNP-121
___ 10:58AM TOT PROT-6.7 ALBUMIN-3.0* GLOBULIN-3.7
CALCIUM-8.4 PHOSPHATE-3.1 MAGNESIUM-1.9
___ 10:58AM LACTATE-1.9
___ 10:58AM WBC-8.4 RBC-4.21* HGB-11.0* HCT-35.1* MCV-83
MCH-26.1 MCHC-31.3* RDW-20.6* RDWSD-62.7*
___ 10:58AM NEUTS-77.0* LYMPHS-8.6* MONOS-12.8 EOS-1.0
BASOS-0.1 IM ___ AbsNeut-6.46* AbsLymp-0.72* AbsMono-1.07*
AbsEos-0.08 AbsBaso-0.01
___ 10:58AM PLT COUNT-90*
___ 10:58AM ___ PTT-28.2 ___
DISCHARGE LABS:
===============
___ 04:50AM BLOOD WBC-4.4 RBC-3.71* Hgb-10.0* Hct-30.6*
MCV-83 MCH-27.0 MCHC-32.7 RDW-20.7* RDWSD-61.5* Plt Ct-59*
___ 04:50AM BLOOD Plt Ct-59*
___ 04:50AM BLOOD ___ PTT-43.1* ___
___ 04:50AM BLOOD Glucose-89 UreaN-13 Creat-0.7 Na-131*
K-4.3 Cl-95* HCO3-23 AnGap-13
___ 04:50AM BLOOD ALT-19 AST-29 AlkPhos-115 TotBili-2.4*
___ 04:50AM BLOOD Albumin-3.7 Calcium-8.5 Phos-3.1 Mg-1.8
MICROBIOLOGY:
============
___ Blood cx: pending
___ Stool ova and parasites: pending
IMAGING:
========
___ RUQUS:
1. Cirrhotic liver, without evidence of focal lesion.
2. Lack of wall-to-wall color flow within the proximal main
portal vein could reflect the known nonocclusive thrombus,
though this is not well assessed due to patient difficulty with
breath holding instructions.
3. Moderate ascites and splenomegaly.
4. Right pleural effusion.
___ CXR:
Interval placement of right basilar chest tube with decreased
size of the
right pleural effusion now appearing moderate in size with
associated right basilar atelectasis.
___ CXR:
Comparison to ___. No relevant change is seen. The
right-sided
pleural effusion, seen on both the frontal and the lateral
image, is stable in extent and severity. Stable normal
appearance of the cardiac silhouette and the left lung. The
small air collection in the cervical right-sided soft tissues is
also stable.
___ CT A&P:
1. No significant change in the known, nonocclusive thrombus of
the main
portal vein and SMV compared to the prior MRI.
2. 2.6 cm segment 7 hepatic lesion, which is hyperenhancing on
the arterial phase and demonstrates mild washout, worrisome for
HCC. No other hepatic lesions.
3. Cirrhosis, with sequela of portal hypertension, including
moderate volume ascites and splenomegaly. No evidence of
significant splenorenal shunt.
4. Moderate right pleural effusion with associated atelectasis.
Subcutaneous air of the right lateral chest wall, likely from
recent chest tube placement.
5. 8 mm cystic lesion of the pancreatic body, previously
characterized as an IPMN.
6. Unchanged 1.4 cm aneurysm of the celiac axis.
___ EGD:
- Scaring in distal esophagus cf prior banding. No esophageal
varices.
- Portal hypertensive gastropathy
- No gastric varices
- Normal duodenum
___ Colonoscopy:
- Fair prep. No polyps seen, though lesions less than 5mm may
have been missed. Recommend repeat colonoscopy in ___ year given
suboptimal prep. Plan on extended bowel prep for next procedure.
___ TTE:
LEFT ATRIUM (LA)/PULMONARY VEINS: Mildly increased LA volume
index.
RIGHT ATRIUM (RA)/INTERATRIAL SEPTUM/INFERIOR VENA CAVA (IVC):
Mildly dilated
RA. No atrial septal defect by 2D/color Doppler. Normal IVC
diameter with reduced inspiratory
collapse==>RA pressure ___ mmHg.
LEFT VENTRICLE (LV): Normal wall thicknesses. Normal cavity
size. Normal regional systolic
function. Hyperdynamic ejection fraction. Normal cardiac index
(>2.5 L/min/m2). No resting outflow
tract gradient.
EMR 2853-P-IP-OP (O___) Name: ___ MRN: ___
Study Date: ___ 14:30:00 p. ___
RIGHT VENTRICLE (RV): Normal cavity size. Normal free wall
motion.
AORTA: Normal sinus diameter for gender. Normal ascending
diameter for gender. Normal arch
diameter.
AORTIC VALVE (AV): Normal/thin (3) leaflets. No stenosis. No
regurgitation.
MITRAL VALVE (MV): Normal leaflets. No systolic prolapse.
Trivial regurgitation.
PULMONIC VALVE (PV): Normal leaflets. Physiologic regurgitation.
TRICUSPID VALVE (TV): Normal leaflets. Mild [1+] regurgitation.
Mild pulmonary artery systolic
hypertension.
PERICARDIUM: No effusion.
Brief Hospital Course:
Mr. ___ is a ___ with PMH of NASH cirrhosis (Child C, MELD
24 on admission) currently undergoing transplant evaluation,
decompensated by ascites, portal HTN, esophageal varices s/p
banding, GI bleeding, non-occlusive PVT and recurrent pleural
effusions, who presents with dyspnea ___ large R pleural
effusion, s/p pigtail catheter placement in ED and improved
volume status, now s/p chest tube removal
ACUTE ISSUES
============
# ___ cirrhosis decompensated by pleural effusion
# NASH cirrhosis (Child C, MELD 21) c/b ascites, portal HTN,
esophageal varices s/p banding, GI bleeding, non-occlusive PVT,
recurrent pleural effusion: Unclear trigger for his hepatic
hydrothorax and ascites. This may have occurred in the setting
of occasional missed diuretic doses vs insufficient dose of
diuretics vs dietary nondiscretion (as he endorses eating out
___ food once per week). Admission weight of 258 lbs, up
from his baseline of 253 lbs. We diuresed with IV lasix 80 mg IV
doses, and then continued him on his home dose of furosemide 80
mg and spironolactone 200 mg. On this regimen, his weight and
creatinine stayed stable
- VOLUME: See above
- INFECTION: Unable to perform paracentesis here given abdominal
hernia. However, treated for SBP with ceftriaxone x5 days
(___) given pleural fluid with elevated WBC.
- BLEEDING: No e/o active bleeding; last EGD ___ with
obliterated varices and portal hypertensive gastropathy. Repeat
EGD here on ___ showed scarring in distal esophagus c/w prior
banding and portal hypertensive gastropathy. Colonoscopy on ___
showed normal colon but fair prep, so repeat colonoscopy in ___
year was recommended.
- ENCEPHALOPATHY: Unclear hx; reportedly prescribed lactulose by
PCP for high ammonia levels, but hasn't taken recently. No
asterixis while inpatient.
- TRANSPLANT STATUS: Currently undergoing evaluation for
transplant. Will follow up with Dr. ___ in clinic.
- Seen by transplant ID where here. Received Tdap vaccine and
PCV13 vaccine prior to discharge on ___.
# Hepatic lesion: 2.6 cm segment 7 hepatic lesion again
visualized on CT triphasic from ___. The patient was discussed
at tumor conference, and plan was made for outpatient RFA to
this lesion.
# Hepatic hydrothorax: Diagnosed on admission CXR. He initially
had hypoxia, dyspnea, and pain associated with hydrothorax. IP
was consulted and placed chest tube on ___. Over 2L were
drained and chest tube was removed on ___ without complication.
His breathing improved and hypoxia resolved. F/up CXR showed
improvement of effusion. Pleural fluid cultures negative. He
will follow-up with IP in 2 weeks.
# HFpEF
Last TTE ___ with EF 58%, moderate TR, moderate pHTN.
Initially appeared volume overloaded, but volume status improved
with IV lasix for diuresis. As mentioned above, he was
discharged on a PO diuretic regimen of Lasix 80 mg daily and
spironolactone 300 mg daily. TTE prior to discharge showed EF
75% with 1+ TR, and mild pHTN.
# Chronic Dyspnea
# OSA
Followed by Dr ___ likely reactive airways
disease/asthma. Recently was on a 2 week prednisone taper that
will complete ___. He also has chronic OSA but has not been
wearing his CPAP recently. We continued advair, Flonase, and
prednisone 10 mg (last day ___.
# Atrial fibrillation
CHADs-Vasc of 1. We continued home diltiazem (fractionated),
digoxin, and aspirin. At portal vein conference on ___, it was
discussed that PV clot may be too small for thrombectomy. Plan
instead was to initiate anticoagulation and stop aspirin. He was
started on warfarin 3 mg daily on ___ along with lovenox ___ mg
SC BID to bridge. The lovenox was stopped prior to discharge.
INR on discharge was 1.6. He will have INR checked on ___ and
followed up by ___.
# SMV Thrombus
Diagnosed ___ with evidence on ___ MRI of progression to
including main and right portal vein. CT triphasic on ___
showed stable size of the clot. As above, plan was for
initiation of anticoagulation as the thrombus may be too small
for thrombectomy. Warfarin was started as above.
# Cardiovascular disease:
He was started on atorvastatin 40 mg daily.
# Iron deficiency anemia
Stable. Continued home iron
TRANSITIONAL ISSUES:
====================
[] Discharge weight: 107.5 kg (236.99 lb)
[] Please follow-up INR on ___ and ___ will adjust
warfarin dose accordingly. INR goal is ___ for portal vein
clot. Discharged on warfarin 3 mg daily.
[] Subsequent INR to be followed by Dr. ___
[] Consider thrombophilia work-up, though is being discharged on
AC and would need to be done off AC
[] Will need RFA of liver lesion; ensure warfarin is stopped 5d
prior to procedure
[] Ensure follow-up with transplant ID
[] Patient needs repeat colonoscopy in ___ year (___) due to
suboptimal prep on ___ colonoscopy
[] Will need pneumovax 23 in 8 weeks
[] Will need shingrix vaccine
[] HAV serology pending; please follow-up and if ___,
___ need twinrix vaccine
[] Continue iron supplementation for iron deficiency anemia and
uptitrate dose as tolerated and consider IV iron administration.
[] Moderate TR - should be evaluated by transplant
anesthesiology. Follow up to bed scheduled with Dr. ___
___ by the transplant team.
[] Should undergo annual EKG, TTE, stress echo as long as he
remains on transplant list.
[] Patient should be seen for re-fitting of CPAP mask and
strongly encourage patient to use it
# CODE: Presumed FULL
# CONTACT: ___
Relationship: HCP/Ex-wife
Phone number: ___
Cell phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Fluticasone Propionate NASAL 2 SPRY NU BID
3. Furosemide 80 mg PO DAILY
4. Pantoprazole 40 mg PO Q24H
5. Spironolactone 200 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. Albuterol Inhaler 2 PUFF IH Q4H
8. azelastine 0.15 % (205.5 mcg) nasal BID
9. Diltiazem Extended-Release 120 mg PO DAILY
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
11. Ranitidine 300 mg PO DAILY
12. Sucralfate 1 gm PO BID
13. Ursodiol 500 mg PO BID
14. Vitamin D ___ UNIT PO 1X/WEEK (SA)
15. Digoxin 0.25 mg PO DAILY
16. PredniSONE 10 mg PO DAILY
Tapered dose - DOWN
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*14
Tablet Refills:*0
2. Ciprofloxacin HCl 500 mg PO DAILY
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth daily
Disp #*14 Tablet Refills:*0
3. Warfarin 3 mg PO DAILY16
RX *warfarin [Coumadin] 3 mg 1 tablet(s) by mouth daily Disp
#*14 Tablet Refills:*0
4. Albuterol Inhaler 2 PUFF IH Q4H
5. Aspirin 325 mg PO DAILY
6. azelastine 0.15 % (205.5 mcg) nasal BID
7. Digoxin 0.25 mg PO DAILY
8. Diltiazem Extended-Release 120 mg PO DAILY
9. Ferrous Sulfate 325 mg PO DAILY
10. Fluticasone Propionate NASAL 2 SPRY NU BID
11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
12. Furosemide 80 mg PO DAILY
13. Pantoprazole 40 mg PO Q24H
14. Ranitidine 300 mg PO DAILY
15. Spironolactone 200 mg PO DAILY
16. Ursodiol 500 mg PO BID
17. Vitamin D ___ UNIT PO 1X/WEEK (SA)
18.Outpatient Lab Work
ICD-10: I48.0 Paroxysmal atrial fibrillation
Draw on ___
Labs: ___, PTT, INR
Please fax results to: ___, MD. Fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
- Hepatic hydrothorax
- Right pleural effusion
Secondary diagnoses:
- NASH cirrhosis
- Ascites
- Lower extremity edema
- Atrial fibrillatino
- Heart failure with preserved ejection fraction
- Obstructive sleep apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital for shortness of breath. You
were found to have a large fluid collection under your right
lung called a pleural effusion. The interventional pulmonary
team placed a chest tube to drain this fluid collection, which
helped you feel better. We also started you on warfarin for your
atrial fibrillation. A full list of medication changes is
included in this discharge packet.
Please weigh yourself daily. If your weight increases or
decreases by more than 3 lbs from your baseline weight, please
call the clinic as this may require you to change your
medication dosing.
You have follow-up appointments scheduled with your PCP, ___.
___ transplant ID team, and the interventional pulmonary
team.
It was a pleasure to take care of you!
Sincerely,
Your ___ team
Followup Instructions:
___
|
10692563-DS-8
| 10,692,563 | 24,797,402 |
DS
| 8 |
2192-08-30 00:00:00
|
2192-08-31 15:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Fish Containing Products
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Thoracentesis (___)
Therapeutic paracentesis (___)
Thoracentesis (___)
Transjugular Intrahepatic Portosystemic Shunt (___)
History of Present Illness:
___ with PMH NASH cirrhosis (Child C, MELD 22 on admission, on
transplant list) decompensated by ascites, portal HTN,
esophageal varices s/p banding, GI bleed, recurrent pleural
effusions requiring chest tube, non-occlusive PVT, a-fib,
asthma/COPD, GERD, HTN, OSA presenting as transfer from ___
___ for one week of increasing fluid retention and SOB. Pt
states he has been feeling increasingly fluid overloaded over
the past several days. For the past few days he has been
experiencing increasing SOB and cough such that it is now
difficult to ambulate. He feels he cannot breathe when laying on
his back or left side, can only sleep with right side down. Has
had multiple chest tubes placed in past for right pleural
effusion, at one point saying he received them once every week.
He has cough that is productive of clear-white sputum. Denies
hemoptysis. He notes mild increased swelling in his leg Pt
reports missing one day of medications this week due to a
funeral, including his daily Lasix 80mg and spironolactone
200mg. States dry weight 239lbs but has been up to 243lbs at
home this week. Due to his increasing SOB he presented to ___
___ last night, was given ??mg IV Lasix with ~600ml
urine produced, and was transferred to ___ for eval by
transplant team.
In the ED initial vitals: 97.1 80 111/66 18 95% RA
- Exam notable for: Decreased breath sounds at right lung base,
left lung CTA. 2+ pitting edema halfway up bilateral lower legs.
Mild asterixis in right hand only.
- Labs notable for:
11.8
7.4>---<109
35.6
133 97 11 AGap=14
------------<86
4.2 22 0.8
ALT: 25 AP: 155 Tbili: 7.3 Alb: 3.2
AST: 49
Lactate: 2
- Imaging notable for: CXR w/ large R pleural effusion
- Consults: Hepatology recommended admission
- Patient was given: 80 IV Lasix, home meds: aspirin 325, cipro
500mg, digoxin 0.25mg, Dilt 120mg, pantoprazole 40mg,
spironolactone 200mg, ursodiol 500mg
On arrival to the floor, patient reports history as above. He
denies any recent fevers, chills, N/V, abd pain, chest pain,
dysuria, new weakness, numbness/tingling. He notes occasional
loose stools, but is not out of the ordinary. He states after
receiving IV Lasix, his dyspnea feels improved, but not back to
baseline.
Past Medical History:
- Atrial fibrillation (on warfarin)
- ___ cirrhosis c/b previous GIB, esophageal varices s/p
banding,
non-occlusive SMV thrombus, ascites, portal HTN, recurrent
pleural effusions
- Asthma
- HTN
- HLD
- GERD
- Sleep apnea
- Heart failure with preserved EF
Social History:
___
Family History:
No h/o premature ASCVD. Mother with ___, brother with ___.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS:98.1 ___ 20 96% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, icteric sclera, pink conjunctiva, MMM
NECK: Supple, no LAD, no JVD
HEART: Irregularly irregular, S1/S2, no murmurs, gallops, or
rubs
LUNGS: Diminished breath sounds in R base, otherwise CTAB,
breathing comfortably on RA, frequent coughing fits
ABDOMEN: Distended, large hernia near surgical scar in RUQ,
soft, non-tender to palpation in all quadrants, active bowel
sounds
EXTREMITIES: No cyanosis, clubbing, or edema
SKIN: Warm, well-perfused, no rashes
NEURO: A&Ox3, moving all 4 extremities with purpose, no
asterixis
DISCHARGE PHYSICAL EXAM:
OBJECTIVE:
24 HR Data (last updated ___ @ 729)
Temp: 97.4 (Tm 98.5), BP: 117/70 (98-135/59-80), HR: 83
(71-83), RR: 18 (___), O2 sat: 97% (94-99), O2 delivery: Ra,
Wt: 232.0 lb/105.24 kg
Fluid Balance (last updated ___ @ 419)
Last 8 hours Total cumulative -250ml
IN: Total 0ml
OUT: Total 250ml, Urine Amt 250ml
Last 24 hours Total cumulative -350ml
IN: Total 700ml, PO Amt 700ml
OUT: Total 1050ml, Urine Amt 1050ml
GENERAL: NAD
HEENT: PERRL, icteric sclera, pink conjunctiva
NECK: Supple, JVP elevated
HEART: Irregularly irregular, S1/S2, no murmurs, gallops, or
rubs
LUNGS: Crackles in bilateral lung bases, breath sounds on R
diminished compared to left
ABDOMEN: Non-distended, large hernia near surgical scar in RUQ,
soft, non-tender to palpation in all quadrants
EXTREMITIES: 1+ pitting edema to ankle
SKIN: Warm, well-perfused, no rashes
NEURO: A&Ox3, moving all 4 extremities with purpose, no
asterixis
Pertinent Results:
ADMISSION LABS:
___ 11:44AM LACTATE-2.0
___ 11:40AM GLUCOSE-86 UREA N-11 CREAT-0.8 SODIUM-133*
POTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-22 ANION GAP-14
___ 11:40AM estGFR-Using this
___ 11:40AM ALT(SGPT)-25 AST(SGOT)-49* ALK PHOS-155* TOT
BILI-7.3* DIR BILI-1.7* INDIR BIL-5.6
___ 11:40AM LIPASE-30
___ 11:40AM proBNP-104
___ 11:40AM ALBUMIN-3.2*
___ 11:40AM WBC-7.4 RBC-4.04* HGB-11.8* HCT-35.6* MCV-88
MCH-29.2 MCHC-33.1 RDW-16.9* RDWSD-55.1*
___ 11:40AM NEUTS-74.1* LYMPHS-9.3* MONOS-10.9 EOS-3.4
BASOS-1.2* IM ___ AbsNeut-5.49 AbsLymp-0.69* AbsMono-0.81*
AbsEos-0.25 AbsBaso-0.09*
___ 11:40AM ___
___ 11:40AM PLT COUNT-109*
___ 06:30AM URINE HOURS-RANDOM
___ 06:30AM URINE UHOLD-HOLD
___ 06:30AM URINE GR HOLD-HOLD
___ 06:30AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 06:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 04:49AM URINE HOURS-RANDOM
___ 04:49AM URINE UHOLD-HOLD
___ 04:49AM URINE TYPE-RANDOM COLOR-Yellow APPEAR-Clear SP
___- *
___ 04:49AM URINE BLOOD- NITRITE- PROTEIN- GLUCOSE-
KETONE- BILIRUBIN- UROBILNGN- * PH- * LEUK-
___ 04:49AM URINE RBC-1 WBC-2 BACTERIA-FEW* YEAST-NONE
EPI-0
___ 04:49AM URINE HYALINE-42*
___ 04:49AM URINE MUCOUS-MOD*
IMAGING:
ABD U/S:
IMPRESSION:
1. Limited study due to patient body habitus and positioning.
2. Patent main, right anterior and left portal vein,
demonstrating hepatopetal
flow. The right posterior portal vein is not well seen.
3. Cirrhotic liver with splenomegaly. Small volume ascites.
4. Previously reported lesion in the right hepatic lobe is much
better
evaluated on the dedicated CT.
5. Right pleural effusion, partially visualized.
CXR
IMPRESSION:
Slight interval decrease in size of the right pleural effusion
which however remains small to moderate in volume. No
pneumothorax is identified.
===============
DISCHARGE LABS:
===============
___ 04:35AM BLOOD WBC-7.0 RBC-3.11* Hgb-9.2* Hct-27.8*
MCV-89 MCH-29.6 MCHC-33.1 RDW-19.2* RDWSD-57.3* Plt Ct-72*
___ 04:35AM BLOOD ___ PTT-40.0* ___
___ 04:35AM BLOOD Glucose-74 UreaN-22* Creat-1.0 Na-140
K-4.3 Cl-102 HCO3-24 AnGap-14
___ 04:35AM BLOOD ALT-18 AST-38 AlkPhos-117 TotBili-5.6*
DirBili-2.1* IndBili-3.5
___ 04:35AM BLOOD Albumin-3.9 Calcium-8.7 Phos-2.9 Mg-1.4*
___ 04:43AM BLOOD Digoxin-0.7
___ 03:15AM BLOOD ___ pO2-59* pCO2-39 pH-7.40
calTCO2-25 Base XS-0 Comment-GREEN TOP
___ 03:15AM BLOOD Lactate-2.1*
MICROBIOLOGY:
___ 11:40 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
OF TWO COLONIAL MORPHOLOGIES.
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ AT
12:30PM ___.
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
___ 6:30 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000
CFU/mL.
IMAGNING:
TTE ___: IMPRESSION: Normal left ventricular cavity size
with normal regional and hyperdynamic global systolic
function. Mild-moderate tricuspid regurgitation. Mild pulmonary
artery systolic hypertension. Biatrial
enlargement.
ABD U/S ___
IMPRESSION:
1. Patent TIPS.
2. Very heterogeneous liver with at least 1 lesion at the dome.
Note is made
that the liver was better evaluated for lesions on the prior CT
of ___.
3. Splenomegaly.
4. Large right pleural effusion.
ABD XRAY ___
IMPRESSION:
1. There are a few prominent small bowel loops in the mid
abdomen, which are
nonspecific and may represent mild ileus versus developing
obstruction,
however, gas is seen throughout the colon and in the rectum.
2. High density within the right abdominal wall, which may be
postoperative or
represent a hematoma.
3. Moderate right-sided pleural effusion. Small left-sided
pleural effusion.
CXR ___
IMPRESSION:
In comparison with the study of ___, there again is a
moderate right
pleural effusion with compressive atelectasis at the base.
Small effusion on
the left is seen on the lateral view. Cardiomediastinal
silhouette is stable
the with mild elevation pulmonary venous pressure.
Asymmetric opacification is seen at the left base and left
apical region. In
the appropriate clinical setting, either or both of these could
represent
developing consolidation that should be carefully checked on
subsequent views.
Brief Hospital Course:
PATIENT SUMMARY
==================
___ with PMH NASH cirrhosis (Child ___, MELD 25), on
transplant list) decompensated by ascites, portal HTN,
esophageal
varices s/p banding, GI bleed, recurrent pleural effusions
requiring chest tube, non-occlusive PVT, a-fib, reactive airway
disease, GERD, HTN, OSA presenting as transfer from ___
for one week of increasing fluid retention and SOB found to have
large R pleural effusion c/f hepatic hydrothorax.
ACUTE ISSUES
==================
#Ascites/Hepatic hydrothorax
Patient presented with with fluid retention and increased SOB
found to have
worsening hepatic hydrothorax. Had been mostly compliant with
medications though did note missing 1 dose of diuretics. Likely
combination of
slow accumulation with missed diuretic dose. Patient underwent
thoracentesis on ___ with removal of 1.5 L of fluid with was
consistent with a transudative effusion. Patient continued to
have exertional dyspnea, w/diuresis limited by ___. Due to
recurrent volume overload with inability to increase diuresis,
decision was made to pursue TIPS placement. Patient underwent
therapeutic paracentesis (3L removed),
thoracentesis (2.4L removed), and TIPS placement on ___ with
significant
improvement of symptoms. Subsequently, however patient continued
to appear volume overloaded, with increased coughing and concern
for worsened pleural effusions or pulmonary edema in setting of
holding diuresis. CXR on ___ revealed
increased pulmonary edema and moderate pleural effusion compared
to ___ CXR. Worsened symptoms, increased weight considered
likely cardiogenic in the setting of known HFpEF while holding
diuretics for ___. TTE on ___ consistent with diastolic
dysfunction on prior study, no new systolic dysfunction.
Post-TIPS US on ___ showed patent TIPS.
# ___, concern for HRS
Creatinine elevated from baseline to 2.0 at highest, initially
in setting of diuresis. Urine Na <20, renal US unremarkable,
urine sed revealed no evidence of ATN. Given negative workup and
failure to respond to albumin, patient was
managed for HRS. Creatinine remained stable at 2.0 upon stopping
diuretics, and began to downtrend to 1.8. Patient started on
octreotide and midodrine on ___ for probable HRS w/mild
improvement of creatinine from 2 to 1.8. Octreotide and
midodrine dosing increased, and patient redosed with albumin.
However, creatinine worsened to 2.1 on ___, likely
contrast-induced nephropathy iso TIPS contrast load on ___.
Creatinine subsequently downtrended to 1.1 on ___ on
octreotde/midorine and holding diuretics. His octreotide was
discontinued, his midodrine was continued on discharge. His
diuretics were held.
# ___ cirrhosis (Child ___, MELD-Na 25) c/by ascites, recurrent
pleural effusion, portal HTN, esophageal varices s/p banding,
SBP, non-occlusive PVT. No evidence of cholangitis on recent US,
bilirubin downtrended.
- VOLUME: Initially agressively diuresed with subsequent ___,
held diuresis as above, s/p TIPS
- INFECTION: Continued on ciprofloxacin for ppx.
- BLEEDING: Prior variceal bleed s/p banding. Last EGD ___
without varices.
- ENCEPHALOPATHY: None
- TRANSPLANT STATUS: On transplant list
- Continued on home ursodiol
#Hemoptysis
Patient developed intermittent low volume hemoptysis this
hospitalization. He has previously experienced intermittent
hemoptysis, and had to discontinue anticoagulation for atrial
fibrillation due to hemoptysis. Unclear if any workup in the
past. Described as sputum with small red spots. Patient remained
hemodynamically stable, Hgb stable. There was low suspicion for
GIB
as low volume of hemoptysis w/hemodynamic stability. Mostly
mucosal bleeding in setting of liver dysfunction and frequent
coughing, no suspicious lesions noted on fiberoscopy on ___ by
ENT. Sputum cytology was pending on discharge.
# ___
Found to have 2.6cm exophytic liver mass c/f HCC. Plan for him
to
undergo outpatient liver ablation by ___.
# SMV Thrombus with extension to right portal vein
Discussed at ___ conference; clot deemed too small for
intervention with TIPS, and decision made to manage medically
with anticoagulation with warfarin complicated by hemoptysis and
subsequently discontinued.
# Atrial fibrillation
Previously on ASA 325mg daily for AC; transitioned to warfarin
with short lovenox bridge during prior admission iso PVT but
discontinued secondary to hemoptysis. Digoxin was held and dosed
intermittently in the setting of acute kidney inury. Resumed on
discharge.
# CoNS Bacteremia. Patient with GPCs growing from ___ anaerobic
blood cultures from one set ___ with morphology consistent with
coag negative Staphylococcus. Patient was placed on cefepime,
Flagyl, and Vancomycin while GPCs speciated. Patient with no
fever, hypotension or leukocytosis concerning for infection, and
had no indwelling foreign devices concerning for source of
infection. Given clinical status and speciation, cultures were
likely contaminants and did not require further antibiotic
therapy. Patient remained afebrile and clinically stable off
antibiotics.
#Myalgias
Following his TIPS, the patient developed diffuse myalgias
concerning for
myositis or rhabdomyolysis. Given recent decompensation of liver
failure and reported history of similar symptoms, atorvastatin
was discontinued. CK was not elevated. Given improvement since
stopping atorvastatin and prior history of myalgias on statin,
atorvastatin held at discharge. Although data from multiple
clinical trials does not provide evidence for statin-associated
myalgias (aside from rare rhabdomyolysis), risk not well studied
in setting of decompensated liver failure and may be elevated.
However, it is unclear if patient is truly statin intolerant.
Although atorvastatin was held, patient may tolerate alternative
statin or resumption of atorvastatin as outpatient.
CHRONIC ISSUES:
==============
# HFpEF
Last TTE ___ with EF >75%, mild TR, mild pHTN. Repeat TTE on
___ revealed no interval change in ventricular function.
# Chronic Dyspnea
# OSA
Followed by Dr ___ likely reactive airways
disease/asthma, continued on home advair and flonaise.
#GERD
Continued on home ranitidine, pantoprazole
#HLD: Holding statin as above.
#Malnutrition
Consulted nutrition for assessment.
TRANSITIONAL ISSUES
===================
- Held home diuretics on discharge as patient was s/p TIPS and
recovered from ___ while here. Please reevaluate the need for
them outpatient.
- Held home statin as above due to myalgias. Please restart if
tolerated and necessary.
- Started on midodrine 15 mg TID for blood pressure support.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H
2. Atorvastatin 40 mg PO QPM
3. Ciprofloxacin HCl 500 mg PO DAILY
4. Digoxin 0.25 mg PO DAILY
5. Diltiazem Extended-Release 120 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. Fluticasone Propionate NASAL 2 SPRY NU BID
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. Furosemide 80 mg PO DAILY
10. Pantoprazole 40 mg PO Q24H
11. Ranitidine 300 mg PO DAILY
12. Spironolactone 200 mg PO DAILY
13. Ursodiol 500 mg PO BID
14. Vitamin D ___ UNIT PO 1X/WEEK (SA)
15. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Midodrine 15 mg PO TID
RX *midodrine 5 mg 3 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
2. Ranitidine 150 mg PO HS
3. Albuterol Inhaler 2 PUFF IH Q4H
4. Aspirin 325 mg PO DAILY
5. Ciprofloxacin HCl 500 mg PO DAILY
6. Digoxin 0.25 mg PO DAILY
7. Diltiazem Extended-Release 120 mg PO DAILY
8. Ferrous Sulfate 325 mg PO DAILY
9. Fluticasone Propionate NASAL 2 SPRY NU BID
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
11. Pantoprazole 40 mg PO Q24H
12. Ursodiol 500 mg PO BID
13. Vitamin D ___ UNIT PO 1X/WEEK (SA)
14. HELD- Atorvastatin 40 mg PO QPM This medication was held.
Do not restart Atorvastatin until cleared by your doctors.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hepatic Hydrothorax
Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ with volume overload. You were found
to have fluid in your lungs and abdomen. You underwent a
procedure called Transjugular Intrahepatic Portosystemic Shunt
or TIPS to help with this. You had an injury to the kidney which
improved while you were here. It is now safe for you to be
discharged. It was a pleasure caring for you.
Wishing you the best,
Your ___ Team
Followup Instructions:
___
|
10692563-DS-9
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2192-09-14 21:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Fish Containing Products
Attending: ___.
Chief Complaint:
DYPNEA
Major Surgical or Invasive Procedure:
Thoracentesis 1.4L removed ___
Thoracentesis 600cc removed ___
History of Present Illness:
___ year old Man with PMH NASH cirrhosis ___ B, MELD 21),
on transplant list, h/o hepatic hydrothorax, ascites now s/p
TIPS
___, HFpEF, atrial fibrillation and non-occlusive PVT not on
anticoagulation due to hemoptysis who presents with lower
extremity edema, dyspnea after discontinuation of diuretics.
Mr. ___ began experiencing worsening shortness of breath
about three days after his last discharge. He was recently
hospitalized at ___ ___ for one week of
increasing fluid retention and SOB found to have large R pleural
effusion c/f hepatic hydrothorax which was drained. Course was
complicatd by ___ from hepatorenal failure +/- CIN for which he
was started on cotreotide and midodrine. Warfarin for his atrila
fibrillation and PVT was held iso hemoptysis. This admission
was
notable for thoracentesis x2, therapeutic paracentesis x2,
transjugular Intrahepatic Portosystemic Shunt (___). TTE on
___ consistent with diastolic dysfunction on prior study, no
new systolic dysfunction. Post-TIPS US on ___ showed patent
TIPS. Home diuretics were held on discharge.
At home, he noticed shortness of breath when laying on right
side, worsened orthopnea (no platypnea), swelling in his legs
that while usually decreases nightly became persistent. Although
he was watching salt intake (other than one hot dog) he gained 6
lbs in three days. His chronic cough has been "drier than ever"
with clear phlegm, no fevers. Leg swelling is bilateral.
In the ED initial vitals: T: 99.1 HR: 105 BP: 110/62 RR: 18
SO2: 100% RA
- Exam notable for: ill appearing, jaundiced elederly man. On
auscultation irregular rhythm, decreased breath sounds over the
right middle and right lower lobe crackles apparent bilaterally.
Abdomen with obese, nontender to palpation, ventral hernia at
the
right upper quadrant mild discomfort with palpation no rebound
tenderness or peritoneal signs. Extremities with 3+ pitting
edema
to the posterior thigh. Asterixis not commented upon.
- Labs notable for:
CBC: WBC: 5.8 Hgb: 9.7 (bl ___ Plt: 94
Chem7: Glucose: 81 UreaN: 8 Creat: 0.7 Na: 138 K: 3.7 Cl: 101
HCO3: 25 AnGap: 12
LFTs: ALT: 22 AST: 52* AlkPhos: 157* TotBili: 8.9* DirBili:
2.9* IndBili: 6.0
Coags: ___: 17.7 PTT: 33.0 INR: 1.6
- Imaging notable for: CXR with Redemonstration of moderate
to
large right pleural effusion which is partially loculated
laterally, minimally increased in size from the prior exam, with
right basilar atelectasis.
- Consults: Hepatology who recommended admission to ___. And diagnostic paracentesis if tappable pocket (per report
from ED).
- Patient was given: nothing.
REVIEW OF SYSTEMS: Positive per HPI, remaining 10 point ROS
reviewed and negative.
Past Medical History:
- Atrial fibrillation (on warfarin)
- NASH cirrhosis c/b previous GIB, esophageal varices s/p
banding,
non-occlusive SMV thrombus, ascites, portal HTN, recurrent
pleural effusions
- Asthma
- HTN
- HLD
- GERD
- Sleep apnea
- Heart failure with preserved EF
Social History:
___
Family History:
No h/o premature ASCVD. Mother with ___, brother with ___.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
============================
VS: ___ 0020 Temp: 98.6 PO BP: 129/74 R Lying HR: 89 RR:
18 O2 sat: 98% O2 delivery: Ra
GENERAL: NAD, jaundiced friendly bearded man
HEENT: AT/NC, EOMI, PERRL, icteric sclera, pink conjunctiva
NECK: supple, no LAD, +JVD 12cm
HEART: irregular, S1/S2, no murmurs, gallops, or rubs
LUNGS: decreased breath sounds RLL, dullness to percussion
otherwise scattered expiratory wheezes throughout,
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: 2+ edema to thighs, no cyanosis, clubbing, ___
nails
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, no
asterixis, right sided mild intention tremor
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
=======================
PHYSICAL EXAMINATION:
24 HR Data (last updated ___ @ 903)
Temp: 98.2 (Tm 98.6), BP: 122/80 (112-136/67-80), HR: 90
(84-94), RR: 20 (___), O2 sat: 96% (95-98), O2 delivery: Ra,
Wt: 223.6 lb/101.42 kg
GENERAL: NAD, jaundiced friendly bearded man
HEENT: AT/NC, EOMI, PERRL, icteric sclera, pink conjunctiva, no
sinus tenderness
NECK: supple, no LAD, +JVD 12cm
HEART: irregular, S1/S2, no murmurs, gallops, or rubs
LUNGS: decreased breath sounds R, dullness to percussion
otherwise scattered expiratory wheezes throughout, greater in R
compared to left. ___ site with dressing c/d/I.
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: 2+ edema to knees L>R, no cyanosis, clubbing,
___ nails
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, no
asterixis, right sided mild intention tremor
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
==============
___ 10:22PM GLUCOSE-81 UREA N-8 CREAT-0.7 SODIUM-138
POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-25 ANION GAP-12
___ 10:22PM estGFR-Using this
___ 10:22PM ALT(SGPT)-22 AST(SGOT)-52* ALK PHOS-157* TOT
BILI-8.9* DIR BILI-2.9* INDIR BIL-6.0
___ 10:22PM LIPASE-46
___ 10:22PM cTropnT-<0.01
___ 10:22PM proBNP-767*
___ 10:22PM ALBUMIN-3.7 CALCIUM-8.8 PHOSPHATE-2.6*
MAGNESIUM-1.6
___ 10:22PM WBC-5.8 RBC-3.17* HGB-9.7* HCT-29.9* MCV-94
MCH-30.6 MCHC-32.4 RDW-20.8* RDWSD-70.4*
___ 10:22PM NEUTS-72.8* LYMPHS-8.8* MONOS-11.2 EOS-6.0
BASOS-0.9 IM ___ AbsNeut-4.21 AbsLymp-0.51* AbsMono-0.65
AbsEos-0.35 AbsBaso-0.05
___ 10:22PM PLT COUNT-94*
___ 10:22PM ___ PTT-33.0 ___
___ 09:21PM GLUCOSE-86 LACTATE-1.5 NA+-135 K+-4.1 CL--103
TCO2-23
___ 09:21PM HGB-9.8* calcHCT-29
___ 07:50PM URINE HOURS-RANDOM
___ 07:50PM URINE UHOLD-HOLD
___ 07:50PM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 07:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM* UROBILNGN-2* PH-6.0
LEUK-TR*
___ 07:50PM URINE RBC-2 WBC-7* BACTERIA-FEW* YEAST-NONE
EPI-1
___ 07:50PM URINE AMORPH-OCC*
___ 07:50PM URINE MUCOUS-RARE*
IMAGING:
=======
CXR ___
IMPRESSION: Redemonstration of moderate to large right pleural
effusion which is partially loculated laterally, minimally
increased in size from the prior exam, with
right basilar atelectasis.
RUQUS ___:
IMPRESSION:
Severely limited examination, mostly due to respiratory
variation and patient
inability to breath hold.
1. Within limitations of this exam, TIPS appears patent, with
velocities as
above.
2. Limited evaluation of the hepatic parenchyma shows persistent
heterogeneity. Previously seen lesions are better assessed on
prior
examinations.
3. Persistent splenomegaly, measuring up to 16.4 cm (previously
15.3 cm).
4. Unchanged large right pleural effusion.
LENIS ___
IMPRESSION: No evidence of deep venous thrombosis in the right
or left lower extremity
veins.
CXR ___
IMPRESSION: No significant interval change since prior despite
the provided clinical
history of a right thoracentesis
CT ABD ___:
IMPRESSION:
1. The 2.6 cm hepatic segment VI lesion appears slightly less
conspicuous and
exophytic compared to prior CT but continues to demonstrate mild
arterial
enhancement and washout. Findings remain concerning for ___.
2. No new liver lesions are identified.
3. Postsurgical changes from TIPS placement with interval
decrease in the
size of multiple prominent collateral vessels in the mesentery,
gastrohepatic
and gastrosplenic regions.
4. Trace amount of perihepatic ascites.
5. Moderate right pleural effusion with compressive atelectasis
of the right
middle lobe and right lower lobe.
MICROBIOLOGY:
==============
BLOOD CULTURES PENDING - NO GROWTH TO DATE (___)
URINE CULTURE NEGATIVE
PLEURAL FLUID ___ PRELIMINARY NO GROWH TO DATE
PATHOLOGY/CYTOLOGY:
===================
Pleural fluid, right: ___
NEGATIVE FOR MALIGNANT CELLS.
- Mesothelial cells and lymphocytes in a background of fibrinous
debris.
DISCHAGE LABS:
=============
___ 05:02AM BLOOD WBC-4.2 RBC-2.98* Hgb-8.9* Hct-27.6*
MCV-93 MCH-29.9 MCHC-32.2 RDW-19.9* RDWSD-67.5* Plt Ct-82*
___ 05:02AM BLOOD ___ PTT-37.1* ___
___ 05:02AM BLOOD Glucose-81 UreaN-10 Creat-0.7 Na-141
K-4.2 Cl-102 HCO3-28 AnGap-11
___ 05:02AM BLOOD ALT-14 AST-33 AlkPhos-150* TotBili-5.7*
___ 05:02AM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:02AM BLOOD Albumin-2.9* Calcium-8.0* Phos-2.8 Mg-1.9
___ 06:37PM BLOOD pH-7.38 Comment-PLEURAL FL
Brief Hospital Course:
___ year old Man with PMH NASH cirrhosis ___ B, MELD 21),
on transplant list, h/o hepatic hydrothorax, ascites now s/p
TIPS
___, HFpEF, atrial fibrillation and non-occlusive PVT not on
anticoagulation due to hemoptysis who presents with lower
extremity edema, dyspnea after discontinuation of diuretics.
# Ascites/Hepatic hydrothorax: Driven by pulmonary edema and
hepatic
hydrothorax. Evidence of volume overload on exam with CXR
showing persistent hepatic hydrothorax. S/p TIPS, patent without
increased velocities on Doppler. Active diuresis with IV lasix
on discharge, home diuretic regimen will be furosemide 80mg PO
BID and spironolactone 200mg PO Daily. Interventional
pulmonology did two thoracenteses ___ with 1.4L removed and ___
with 600ml removed. IP followed with concern for possible
trapped lung and recommended follow-up with IP in 2 weeks.
Breathing improved to baseline on discharge. Discharge weight:
101.4 kg.
# Chronic Dyspnea
# OSA
#reactive airway disease: Followed by Dr ___ likely
reactive airways disease/asthma. Continued home advair and
Flonase.
# HFpEF: Last TTE ___ with EF >75%, mild TR, mild pHTN. NO
clear dietary trigger will trend trop x2 for r/o. Active
diuretic management as above. Strict I/O and low Na diet. LENIs
negative.
# Hx of HRS: creat 0.7, prior crt to 2.0 was though to reflect
hepatorenal (failed albumin challenge, no e/o ATN) and CIN iso
TIPS. Recevied octreotide/midodrine last admission. Continued
midodrine.
# NASH cirrhosis (Child B, MELD-Na ___) c/b ascites, recurrent
pleural effusion, portal HTN, esophageal varices s/p banding,
SBP, non-occlusive PVT. Active diuresis s/p TIPS. Continued
ciprofloxacin for ppx. Prior variceal bleed s/p banding. Last
EGD ___ without varices. Not on home lactulose. On
transplant list. Continued home ursodiol.
# HCC: Found to have 2.6cm exophytic liver mass c/f HCC. Plan
was
for him to undergo outpatient liver ablation by ___. CT liver
completed ___, plan for repeat RFA on ___.
CHRONIC ISSUES:
==============
# SMV Thrombus with extension to right portal vein
Previously discussed at ___ conference; initially managed
medically with AC w/warfarin c/b hemoptysis and subsequently
discontinued.
# Atrial fibrillation: Previously on ASA 325mg daily for AC;
transitioned to warfarin given PVT but discontinued secondary to
hemoptysis. Continued home digoxin 0.125mg x1 today (half home
dose), continued home diltiazem. Not on AC ___ hemoptysis.
#GERD: Continued home ranitidine, pantoprazole
#HLD: Stopped statin iso leg pain and myalgias during prior
admission.
TRANSITIONAL ISSUES:
[] Diuretic regimen: furosemide 80mg PO BID and spironolactone
200mg PO daily, titrate as appropriate, discharge weight 101.4
kg
[] CT liver completed ___ for RFA planning scheduled for
___.
[] Held statin iso leg pain, may consider to restart or change
medication
[] Patient will require weekly labs while on diuretics for
monitoring of electorlytes and renal function.
[] Please arrange for follow-up in ___ clinic in 2 weeks for
further management of hepatic hydrothorax, possible trapped
lung.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Ciprofloxacin HCl 500 mg PO DAILY
3. Diltiazem Extended-Release 120 mg PO DAILY
4. Fluticasone Propionate NASAL 2 SPRY NU BID
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Pantoprazole 40 mg PO Q24H
7. Ranitidine 150 mg PO HS
8. Ursodiol 500 mg PO BID
9. Midodrine 15 mg PO TID
10. Albuterol Inhaler 2 PUFF IH Q4H
11. Digoxin 0.25 mg PO DAILY
12. Ferrous Sulfate 325 mg PO DAILY
13. Vitamin D ___ UNIT PO 1X/WEEK (SA)
14. Atorvastatin 40 mg PO QPM
Discharge Medications:
1. Furosemide 80 mg PO BID
RX *furosemide 80 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
2. Spironolactone 200 mg PO DAILY
RX *spironolactone 100 mg 2 tablet(s) by mouth DAILY Disp #*60
Tablet Refills:*0
3. Albuterol Inhaler 2 PUFF IH Q4H
4. Aspirin 325 mg PO DAILY
5. Ciprofloxacin HCl 500 mg PO DAILY
6. Digoxin 0.25 mg PO DAILY
7. Diltiazem Extended-Release 120 mg PO DAILY
8. Ferrous Sulfate 325 mg PO DAILY
9. Fluticasone Propionate NASAL 2 SPRY NU BID
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
11. Midodrine 15 mg PO TID
12. Pantoprazole 40 mg PO Q24H
13. Ranitidine 150 mg PO HS
14. Ursodiol 500 mg PO BID
15. Vitamin D ___ UNIT PO 1X/WEEK (SA)
16.Outpatient Lab Work
Blood, Standing order for every 7 days starting ___, exp.
___: CBC; Sodium; Potassium; Chloride; Bicarbonate; BUN;
Creatinine; Alk Phos; ___ (includes INR); Glucose; ALT; AST;
Total Bili; Albumin; please fax results to ___
ICD-10: K75.81 NONALCOHOLIC STEATOHEPATITIS (___)
___.82 AWAITING ORGAN TRANSPLANT STATUS
Discharge Disposition:
Home
Discharge Diagnosis:
Hepatic hydrothorax
Volume overload
NASH cirrhosis s/p TIPS decompensated by ascites, portal HTN,
esophageal varices s/p banding
___
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 of fluid in your
lungs. You underwent a procedure called thoracentesis to remove
this fluid. You also received high doses of medications to help
your body get rid of this fluid. You continued to do well and
your shortness of breath improved. It is now safe for you to go
home. It was a pleasure caring for you!
Wishing you the best,
Your ___ Team
Followup Instructions:
___
|
10692574-DS-20
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2121-08-13 00:00:00
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2121-08-15 00:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L radial fracture, hypertensive emergency
Major Surgical or Invasive Procedure:
___: Washout and debridement open forearm fracture down to
and inclusive of bone
History of Present Illness:
___ with no known PMHx who is being transferred from the ortho
trauma service, where ___ was admitted for surgical repair or a L
open distal radial/ulnar forearm fracture, to medicine for
ongoing management of hypertensive emergency. Please see the
initial medicine consultation note from ___ for relevant
history
until ___.
To manage his hypertension, labetalol 200 mg BID was started.
Cardiology was consulted, who felt his EKG changes and troponin
leak were due to demand ischemia in the setting of BPs as high
as
260/140. They felt that a TTE would be useful at some point
during this admission, but was not acutely needed prior to
operative repair. With initiation of labetalol, his blood
pressure initially improved to as low as systolic 150s without
any symptoms of hypotension.
In the morning of ___, ___ went to the pre-op area after
receiving labetalol at 430 AM. ___ was noted to be hypertensive
with SBP over 200, asymptomatic. ___ received 10 mg IV labetalol
with decrease in SBP to < 200, and surgery was deferred given
persistent hypertension. Upon initial evaluation on the floor
after returning from pre-op by the medical consult resident, ___
was pain free and otherwise without chest pain, pre-syncopal
symptoms, respiratory distress. His labetalol was changed to 200
mg q8h, and the next labetalol dose decreased his BP to ~165/95.
Upon re-evaluation at 5 pm ___ was hypertensive to 220/110 on
manual check with bilateral rales on lung exam, which was new
from the morning. ___ had IV fluids running as ___ had been NPO.
These were stopped. A chest xray was ordered, as was 10 mg IV
Lasix and 12.5 mg captopril. ___ was subsequently transferred to
medicine for further management.
Past Medical History:
None
Social History:
___
Family History:
Multiple family members with HTN. No premature CAD. Father died
of suicide, mother is elderly and independent.
Physical Exam:
Exam on Admission:
Vitals: T38, SBP ___ 97% RA
General: NAD
HEENT: Slightly dry MM
Neck: No JVD
CV: Tachy, systolic murmurs heard at the LLSB and apex
Lungs: CTAB
Abdomen: Soft, NT/ND
Ext: WWP, L forearm is wrapped with guaze and splinted
Neuro: Minimal movement of LUE
Skin: See above
Psych: AAOx3
Exam on Discharge:
PHYSICAL EXAMINATION:
Vitals: 98.2, 98.6, 176/93 (160-180s/90s), 83, 16, 97% on RA
General: NAD
HEENT: Slightly dry MM
Neck: No JVD
CV: RRR, systolic murmurs heard at the LLSB and apex
Lungs: CTAB
Abdomen: Soft, NT/ND
Ext: WWP, L forearm is wrapped with guaze and splinted
Neuro: Minimal movement of LUE
Skin: See above
Psych: AAOx3
Pertinent Results:
Labs on Admission:
___ 08:45PM BLOOD WBC-14.5* RBC-5.34 Hgb-15.3 Hct-45.8
MCV-86 MCH-28.7 MCHC-33.4 RDW-14.0 RDWSD-43.2 Plt ___
___ 08:45PM BLOOD Glucose-127* UreaN-15 Creat-1.0 Na-136
K-3.9 Cl-97 HCO3-26 AnGap-17
___ 08:15AM BLOOD CK(CPK)-993*
___ 08:15AM BLOOD CK-MB-11* MB Indx-1.1 cTropnT-0.05*
___ 08:45PM BLOOD LtGrnHD-HOLD
___ 09:36PM URINE Color-Straw Appear-Clear Sp ___
___ 09:36PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 09:36PM URINE Hours-RANDOM
___ 09:36PM URINE Uhold-HOLD
___ 09:36PM URINE
___ 09:36PM URINE Mucous-RARE
Labs on Discharge:
___ 04:55AM BLOOD WBC-8.2 RBC-4.34* Hgb-12.1* Hct-38.3*
MCV-88 MCH-27.9 MCHC-31.6* RDW-14.2 RDWSD-45.9 Plt ___
___ 08:45PM BLOOD Neuts-87.0* Lymphs-7.4* Monos-4.6*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-12.60* AbsLymp-1.07*
AbsMono-0.67 AbsEos-0.01* AbsBaso-0.03
___ 04:55AM BLOOD Plt ___
___ 04:55AM BLOOD Glucose-93 UreaN-17 Creat-1.1 Na-138
K-4.3 Cl-102 HCO3-26 AnGap-14
Imaging:
___ LUE:
FINDINGS:
AP and lateral views of the left forearm were provided. There
are acute
fractures involving the distal shaft of both radius and ulna.
There is
surrounding edema. There is volar angulation of the distal
radial fracture
fragment. The distal ulnar fracture fragment is displaced
laterally by ___
bone width with small adjacent fracture fragments. Ulnar
styloid fracture
also noted. Left elbow appears intact. Carpal alignment
appears preserved.
IMPRESSION:
Fractures involving the distal shaft radius and ulna as detailed
above.
Brief Hospital Course:
___ yo M without known PMH who presents s/p L open distal
both-bone forearm fracture. Medicine is consulted for assistance
with managing hypertension and tachycardia and pre operative
risk assessment who was found to have HTN emergency, and ORIF
for L radial fractures.
#Hypertensive Emergency: The patient most likely has chronic
underlying HTN given clear LVH seen on his EKG, though his
baseline is unclear. Given that his profound HTN has persisted
from ___ to here, despite improvement in pain score,
___ likely has chronic severe hypertension which is exacerbated
at times by pain. Sinus tachycardia on ortho service likely ___
hydralazine, as rapid decrease in BP required compensatory HR
response. ___ was found to have a troponin leak and was therefore
seen by cardiology who did not recommend intervention other than
BP control given this was thought to be due to demand ischemia
in the setting of poorly controlled htn. TTE demonstrated EF
>55% with symmetrical LVH, no valvular abnormalities. His blood
pressure was challenging to control in the inpatient setting.
Ultimately, ___ was well-controlled on Labetalol 400mg PO Q8H and
Lisinopril 40mg PO qday, amlodipine 10mg PO qday and
chlorthalidone 12.5 daily. Given one BP in the 120s on
discharge, labetolol was decreased to 200 q8 right before dc to
prevent hypotension. ___ was discharged with ___ for close BP
montoring and instructed to purchase a home cuff and check BP
2x/day, call if BPs <100 or greater than 180. ___ will need
close PCP ___ for BP monitoring and titration of meds, this was
arranged prior to dc.
#Radial Fractures: ___ received a full washout by Ortho in the
OR, but given that the arm was inflammed and blistering, and his
BP were not well controlled, plans were made to defer surgery
until after discharge.
Transitional Issues:
[] Please continue to monitor blood pressure closely and
optimize regimen.
[] Labs pending at discharge: renal, aldosterone, plasma.
metanephrines to eval for causes of secondary htn
[] Patient is scheduled for follow-up with orthopedics on
___ (they will arrange ORIF).
[] Please obtain thyroid ultrasound (CXR showed large partially
retrosternal goiter).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Acetaminophen 1000 mg PO Q8H pain
3. Atorvastatin 20 mg PO QPM
4. Labetalol 300 mg PO Q8H
5. Lisinopril 40 mg PO DAILY
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
7. Senna 8.6 mg PO BID
8. Docusate Sodium 100 mg PO BID
9. Amlodipine 10 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
===================
Hypertensive emergency
Fracture of left radius and ulna
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 during your hospitalization at
___. You were admitted for a
forearm fracture, which you sustained during an injury. You
were found to have very high blood pressures, so we started you
on several medications to lower your blood pressure. The
orthopedic surgeons took you to the operating room but were
unable to repair your fracture due to concern for an infection.
You were treated with an IV antibiotic and you will see them in
clinic on ___ to reschedule the surgery.
It is very important that you continue to take all of your
medications as prescribed. You should also schedule an
appointment with a primary care physician so that your blood
pressure can continue to be monitored.
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10692607-DS-24
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2125-08-07 00:00:00
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2125-08-07 12:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Gait instability, voice changes, facial numbness
Major Surgical or Invasive Procedure:
LP
History of Present Illness:
___ yr old woman with history of class III obesity and chronic
back pain who was brought in to the ED by her daughter for left
facial numbness and slurred speech for 2 days. Per daughter, 2
weeks ago they came to the ED for acute left ear pain and left
hip pain with associated fatigue and chills. There was no clear
diagnosis and she was referred to see a PCP for follow up. PCP
requested multiple general screening labs and imaging as
routine. Patient's daughter reports that she has not been
herself since. She seems fatigued, has a poor appetite and no
energy. Yesterday daughter noted her speech was slurred and
today she seemed "glazed" and zones out. When asked what's wrong
she reports left facial numbness since the day prior. She was
also noted be clumsy and unsteady. She reports mild HA with her
initial ear pain 2 weeks ago but none now. No numbness, tingling
for weakness anywhere else. No history of recent fever URI
symptom dog Gi symptoms though she did have 1 episode of emesis
2 days ago while in the car.
Past Medical History:
Arthritis, chronic back pain.
Social History:
___
Family History:
non-contributory
Physical Exam:
===ADMISSION EXAM===
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits.
Pulmonary: CTABL. No R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G
Abdomen: soft, NT/ND, +BS, no masses or organomegaly noted.
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 2. Participates in parts of
the history, seems tearful. Attentive, able to name ___
backward without difficulty. She had intact repetition and
comprehension but seemed slow to respond . Normal prosody. She
had some paraphasic errors while reading from stroke card. Pt
was able to name both high and low frequency objects. Speech is
mildly dysarthria unclear if that sis because she has no upper
teeth or if it was from mild encephalopathy. 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.
V: Facial sensation decreased to light touch at v1,v2
distribution an increased-parasthesi ago temp an pain in the
same distributio
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout in her upper or lower
extremities.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 1
R 1 1 1 1 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, mild dysmetria on FNF b/l
left > right , also she had dysmetria to HKS bilaterally.
-Gait: deferred
===DISCHARGE EXAM===
Gen: NAD, sitting up in chair
Pulm: breathing comfortably without increased WOB
CV: warm and well perfused, no edema
Ext: no deformities
Neuro
MS: alert, oriented, able to relate history without difficulty
CN: PERRL bilaterally. Conjugate primary gaze, but few saccadic
intrusions on R gaze, normal smooth pursuit on L. No nystagmus,
otherwise EOMI. numbness most prominent in left lower face in V3
distribution. face appears symmetric. diminished R gag reflex.
voice with mildly ataxic quality. tongue is midline. right
weakness on face puff
Motor: ___ b/l deltoids, biceps. 4+/5 IP b/l. Minimal parietal
drift on L.
Pertinent Results:
===ADMISSION LABS===
___ 12:22AM BLOOD WBC-6.5 RBC-5.02 Hgb-14.6 Hct-43.5 MCV-87
MCH-29.1 MCHC-33.6 RDW-12.4 RDWSD-39.3 Plt ___
___ 12:22AM BLOOD ___ PTT-31.1 ___
___ 12:22AM BLOOD Glucose-84 UreaN-11 Creat-0.9 Na-138
K-3.2* Cl-99 HCO3-26 AnGap-16
___ 06:30PM BLOOD ALT-14 AST-21 AlkPhos-62 TotBili-0.7
___ 11:11AM BLOOD CK-MB-5 cTropnT-<0.01
___ 11:11AM BLOOD TotProt-6.9 Albumin-3.7 Globuln-3.2
Calcium-9.1 Phos-3.2 Mg-1.9 Cholest-134
___ 11:11AM BLOOD %HbA1c-5.3 eAG-105
___ 11:11AM BLOOD Triglyc-80 HDL-36 CHOL/HD-3.7 LDLcalc-82
___ 11:11AM BLOOD TSH-3.9
___ 05:35PM BLOOD Free T4-1.5
___ 05:35PM BLOOD ANCA-NEGATIVE B
___ 05:35PM BLOOD ___
___ 11:11AM BLOOD CRP-18.3*
___ 05:40AM BLOOD b2micro-1.8
___ 05:35PM BLOOD HIV Ab-Negative
___ 06:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
===IMAGING===
___ CTA HEAD AND NECK
IMPRESSION:
1. No acute hemorrhage. No CT evidence for an acute major
vascular
territorial infarction.
2. Technically limited neck CTA, mainly due to body habitus. No
carotid
stenosis by NASCET criteria. Mild irregularity of V1 and V2
segments of
bilateral vertebral arteries, which may be artifactual.
3. Unremarkable head CTA.
___ MR HEAD WITHOUT CONTRAST
1. Signal abnormality within the midbrain and pons and extending
into the
superior cerebellum. Findings are nonspecific, but may
represent
rhomboencephalitis. Alternatively, although felt less likely
given the normal CTA, finding may be related to acute to early
subacute infarction.
___ MR BRAIN AND SPECTROSCOPY
1. The analyzed perfusion imaging demonstrate no evidence of
increased
perfusion. The multi voxel spectroscopy demonstrates no
evidence of increase choline peak with well-maintained NAA peak
suggestive of normal appearance.
2. Diffuse signal abnormality within the brainstem and extending
into the
middle cerebellar peduncles, with abnormal nodular superficial
enhancement and intraparenchymal enhancement within the
brainstem, as above.
3. The most likely possibility includes CLIPPER (chronic
lymphocytic
inflammation with pontine perivascular enhancement responsive to
steroids), with other top differential considerations including
lymphoma and or sarcoidosis.
4. Other less likely differential considerations include
paraneoplastic
syndrome, rhomboencephalitis, and demyelinating disease.
5. Additional enhancing lesions within the right thalamus/
posterior internal capsule and right periatrial region.
___ CT CHEST WITH CONTRAST
1. Acute-appearing pulmonary embolus involving multiple right
lower lobe
segmental branches. No evidence of right heart strain or
pulmonary infarct.
___ MR HEAD W/ AND W/O CONTRAST
1. Nodular enhancement is seen involving the bilateral VIIth
nerves, left
greater than right, similar to the prior exam.
2. Asymmetric enhancement along the origin of the right sixth
nerve appears more prominent compared to the prior exam.
3. No significant interval change in the extent of
punctate/curvilinear
enhancing lesions along the midbrain, pons, middle cerebellar
peduncles and posterior limb of the right internal capsule/
inferior thalamus.
4. No acute intracranial abnormalities identified.
___ MRI CERVICAL AND THORACIC SPINE
1. Possible 2 mm punctate focus of enhancement along the
anterior aspect of the spinal cord at the level of C6, may be
secondary to a small enhancing lesion, artifact, or a prominent
crossing vessel. No other enhancing lesions identified
throughout the cervical or thoracic spine.
2. Cervical spondylosis, most pronounced at C4-C5 and C5-C6, as
described
above.
3. Diffusely T1 hypointense bone marrow signal throughout the
cervical and
thoracic spine may be secondary to a systemic process such as
anemia, however an infiltrative process cannot be excluded.
Recommend correlation with clinical labs.
4. Minimal degenerative changes are seen throughout the thoracic
spine.
===RELEVANT LABS===
___ 03:00PM CEREBROSPINAL FLUID (CSF) WBC-22 RBC-495*
Polys-12 ___ Monos-11 Eos-1
___ 03:00PM CEREBROSPINAL FLUID (CSF) WBC-32 RBC-10*
Polys-6 ___ Monos-12 Eos-1
___ 03:00PM CEREBROSPINAL FLUID (CSF) TotProt-50*
Glucose-59 LD(LDH)-19
___ 03:57PM CEREBROSPINAL FLUID (CSF) WBC-24 RBC-52*
Polys-0 ___ Macroph-3
___ 03:57PM CEREBROSPINAL FLUID (CSF) WBC-24 RBC-12*
Polys-3 ___ Macroph-3 Other-0
___ 03:57PM CEREBROSPINAL FLUID (CSF) TotProt-40 Glucose-61
Vit-B12:316 Folate:<2
Iron: 55
calTIBC: 290
Ferritn: 703
TRF: 223
HCV-Ab: Negative
Fibrinogen: 309
HIT Antibodies negative
___ 05:14AM BLOOD WBC-8.9 RBC-3.55* Hgb-10.2* Hct-32.1*
MCV-90 MCH-28.7 MCHC-31.8* RDW-13.9 RDWSD-42.5 Plt ___
___ 05:17AM BLOOD ___ PTT-26.9 ___
___ 05:14AM BLOOD Glucose-117* UreaN-24* Creat-0.8 Na-140
K-4.0 Cl-104 HCO3-25 AnGap-15
___ 04:24AM BLOOD WBC-11.0* RBC-3.37* Hgb-10.2* Hct-30.8*
MCV-91 MCH-30.3 MCHC-33.1 RDW-14.4 RDWSD-43.8 Plt ___
___ 04:24AM BLOOD Glucose-122* UreaN-24* Creat-0.9 Na-141
K-4.3 Cl-105 HCO3-25 AnGap-15
___ 02:23PM BLOOD LMWH-0.93
___ 04:24AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.2
Brief Hospital Course:
Ms. ___ was admitted for subacute gait instability, voice
changes, and left facial numbness. Given significant brain stem
findings, we obtained an MRI which showed FLAIR hyperintensities
involving the pons, midbrain. Initial differential was quite
broad, including infectious (TB, listeria), inflammatory
(CLIPPER, MS, NMO, sarcoid), malignancy (lymphoma, glioma). She
was treated with empiric vancomycin, ceftriaxone, acyclovir, and
Bactrim (was started for Whipple ds coverage, later discontinued
on ___ due to thrombocytopenia as below) in the interim, and
discontinued sequentially based on negative CSF results. Prior
history was notable for an episode of optic neuritis and
papillitis in ___, for which she underwent serial MRIs, which
was also notable for a punctate FLAIR hypertenintensity in the
cerebral peduncle. According to prior reports, this lesion was
stable on serial scans, and was not followed any further. She
underwent an MR-SPECT that made a brainstem glioma less likely
(NSGY felt would not be amenable to biopsy), as well as
CSF/serum testing that made lymphoma less likely. Despite the
lack of a clear diagnosis, we started her on empiric steroids
(methylprednisolone 1gm IV x5 days), followed by prolonged
steroid taper. She is to remain on Prednisone 60mg daily until
seen by Dr. ___ as an outpatient.
Her hospital course was complicated by the following issues:
#Pulmonary embolus--as part of a work up for sarcoidosis, she
underwent a CT of the chest which incidentally revealed a
pulmonary embolism without evidence of right heart strain or
hemodynamic instability. This was felt to be due to prolonged
immobility in the setting of her gait issues. She was started on
a heparin drip which reached therapeutic PTT levels on ___ and
was discontinued on ___. She was thereafter transitioned to
Apixaban, however she started to develop decreasing platelet
count concerning for HIT, so Hematology was consulted. Apixaban
was discontinued and pt was started on an Argabatron drip until
the HIT antibodies resulted. She was subsequently transitioned
to Lovenox bridge and ultimately Coumadin.
#Thrombocyotpenia-- Hematology was consulted. Pt was deemed an
intermediate risk for HIT (heparin induced thrombocytopenia) so
HIT antibodies were went and pt was started on an Argabatron
drip. At the same time, Bactrim was discontinued on ___ due to
its anti-platelet effects. HIT antibodies resulted as negative.
Argabatron drip was discontinued on ___ and pt was started on
Lovenox. Coumadin was started on ___. LMWH was monitored
with goal level 0.6-1.2. Goal INR ___.
#Nausea and vomiting--likely ___ colonic ileus, as she had a
period of a few days with no bowel movement and a KUB
demonstrating . She had an NG tube placed on ___ for gastric
decompression and was given docusate and polyethylene glycol PO,
resulting in a large bowel movement and subsequently removal of
the NG tube.
#Hypoglycemia--Ms. ___ became hypoglycemic down to 52 with
unknown etiology on the evening of ___. Serum C-protein was
measured during the incident and found to be mildly elevated at
3.95 ng/mL (reference: 0.8-3.85 ng/mL). She underwent a
cosyntropin challenge test for possible adrenal insufficiency,
to which she had an appropriate increase in cortisol, ruling out
adrenal insufficiency.
#Hyponatremia--likely ___ SIADH given euvolemic, hypoosmolar
status. Ms. ___ levels trended downwards, reaching a
nadir of 126 on ___, though pt was never symptomatic. She was
placed on a fluid-restricted diet and saw resolution of the
hyponatremia when her Bactrim and D5W were discontinued.
#Acute kidney injury--likely ___ volume depletion in the setting
of poor PO intake and difficulty swallowing. Pt's Cr reached 1.6
from a baseline of 0.9. ___ resolved with improved PO intake.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Sarcoid vs. Inflammatory vs. Demyelinating disease NOS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital for a change in voice, as well
as gait instability. An MRI showed a lesion in your brainstem.
You underwent an extensive work up which was suggestive of an
inflammatory process, so you were treated with a course of IV
steroids and will continue on oral steroids until you follow up
with Dr. ___ as an outpatient. While in the hospital,
you were found to have a blood clot in your lungs, for which you
were treated with blood thinners. You are being discharged to
a SNF on Coumadin (a blood thinner) and will require frequent
blood tests to monitor.
Thank you for allowing us to participate in your care,
___ Neurology
Followup Instructions:
___
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2152-06-18 00:00:00
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2152-06-18 11:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Cephalosporins
Attending: ___.
Chief Complaint:
___ year old female who transferred from ___ for ERCP
in the setting of 7 recent epsiodes of RUQ abdominal pain. The
worst pain occurred on the day of admission where the pain awoke
her from sleep.
Major Surgical or Invasive Procedure:
___ ERCP (endoscopic retrograde cholangiopancreatography)
___ Laparoscopic cholecystectomy
History of Present Illness:
Mrs. ___ is a ___ year-old female with no significant past
medical history. She was transferred from ___ for
ERCP in the setting of 7 recent
epsiodes of RUG abdominal pain, worst on the evening of
admission, where the pain awoke her from sleep.
Timing: Sudden Onset, Intermittent
Severity: Severe
Duration: Hours
Location: Right upper quadrant
Context/Circumstances: Awoke from sleep
Associated Signs/Symptoms: Vomiting
A RUQ ultrasound conducted at the outside hospital revealed a
common bile duct measuring 1.4 cm with possible large stone at
level of pancreatic head, multiple mobile stones within GB
itself, no GB wall thickening or pericholecystic fluid.
Past Medical History:
No significant past medical history.
Social History:
___
Family History:
Not obtained.
Physical Exam:
ADMISSION:
Temp: 97.4 HR: 60 BP: 106/62 Resp: 16 O(2)Sat: 99 Normal
Constitutional: Heavyset, pleasant, in no acute distress
Chest: Normal
Cardiovascular: Normal
Abdominal: Soft, obese, tender to palpation in the right
upper quadrant
Skin: Warm and dry
Neuro: Speech fluent
Psych: Normal mentation
___: No petechiae
DISCHARGE:
Temp: 97.8 HR 76 BP 129/64 Resp 16 O2 Sat 100% RA.
Constitutional: Pleasant, in no acute distress.
Neuro: AAO x 3.
Cardiovascular: S1, S2 regular.
Lungs: Clear bilaterally.
Abdominal: Soft, obese, tender to palpation around trocar sites.
Skin: Warm and dry.
Pertinent Results:
___ 12:10PM BLOOD WBC-8.5 RBC-4.76 Hgb-12.4 Hct-38.3
MCV-81* MCH-26.1* MCHC-32.4 RDW-15.7* Plt ___
___ 12:10PM BLOOD Neuts-72.7* ___ Monos-4.5 Eos-0.8
Baso-0.6
___ 06:50AM BLOOD WBC-8.4 RBC-4.22 Hgb-11.1* Hct-34.1*
MCV-81* MCH-26.2* MCHC-32.4 RDW-15.8* Plt ___
___ 12:10PM BLOOD Glucose-84 UreaN-11 Creat-0.6 Na-139
K-4.0 Cl-106 HCO3-24 AnGap-13
___ 06:45AM BLOOD ALT-55* AST-70* AlkPhos-153* Amylase-867*
TotBili-0.9
___ 06:45AM BLOOD Lipase-5660*
___ 06:50AM BLOOD Glucose-87 UreaN-3* Creat-0.6 Na-138
K-3.7 Cl-102 HCO3-28 AnGap-12
___ 06:50AM BLOOD ALT-24 AST-18 AlkPhos-120* Amylase-85
TotBili-0.8
___ 06:50AM BLOOD Lipase-99*
Brief Hospital Course:
Mrs. ___ was admitted on ___ under the acute care surgery
service for management of her acute cholecystitis. She first
underwent an ERCP where a sphincterotomy was completed.
Post-procedure, Mrs. ___ lipase level was 5660. Serial
levels were obtained to evaluate for resolution of her lipase
levels before she underwent a choleystectomy.
The patient was taken to the operating room on ___ and
underwent a laparoscopic cholecystectomy. Please see operative
report for details of this procedure. She tolerated the
procedure well and was extubated upon completion. She we
subsequently taken to the PACU for recovery. She was
transferred to the surgical floor hemodynamically stable. Her
vital signs were routinely monitored and she remained afebrile
and hemodynamically stable. She was initially given IV fluids
postoperatively, which were discontinued when she was tolerating
PO's. Her diet was advanced on the morning of ___ to regular,
which she tolerated without abdominal pain, nausea, or vomiting.
She was voiding adequate amounts of urine without difficulty.
She was encouraged to mobilize out of bed and ambulate as
tolerated, which she was able to do independently. Her pain
level was routinely assessed and well controlled at discharge
with an oral regimen as needed.
On ___, she was discharged home with scheduled follow up
with her PCP and ___ clinic in 2 - 3 weeks.
Mrs. ___ is currently hemodynamically stable with only general
"soreness" to her abdomen. Discharge instructions have been
provided.
Medications on Admission:
Prenatal Vitamin
Discharge Medications:
1. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ Capsule(s) by mouth every four (4) hours
Disp #*20 Capsule Refills:*0
2. Docusate Sodium 100 mg PO BID
3. Acetaminophen 325-650 mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Symptomatic cholelithiasis and choledocholithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for 4 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
___
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2151-05-14 07:10:00
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Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tetracycline Analogues / Statins-Hmg-Coa Reductase Inhibitors
Attending: ___.
Chief Complaint:
Dizziness, malaise, N/V/D
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o female with T2DM ___ A1C 9.3), HTN,
Afib on warfarin, and CAD w/ drug-eluting stent who presented
with nausea, vomiting, abdominal pain, and BRBPR.
Patient gets frequent eye injections at ___. She most
recently
had an injection on ___. She said the procedure went well,
but upon arriving home had general malaise. She then had poor
appetite, no PO intake, and later that night experienced dry
heaves and gradual onset abdominal pain, dull, diffuse, and
___ in severity. She thought the abdominal pain was related
to
dry heaving.
The next day, she had 3 bowel movements which were looser than
usual but no blood in her stool. She then developed nausea,
vomiting, and dizziness and continued to have poor PO intake.
She
presented to the ___ ED.
In the ED, initial vitals were T 97.9, HR 70, BP 177/87, RR 19,
O2 97% RA. An exam was not documented. Her initial labs were
notable for leukocytosis which resolved, Hgb of 15.2, INR of
1.8,
lactate of 3.5 which down-trended to 2.6, and anion gap of 19
which resolved after 4L of IV fluids. CXR and RUQUS were
negative, respectively, for intrathoracic process or acute
cholecystitis, but did show cholelithiasis. ACS was consulted
who
did not feel her presentation was consistent with acute
cholecystitis.
She was able to tolerate PO, but then had BRBPR on 3AM on ___.
She describes it as frankly bloody, roughly 100cc. A CT
abdomen/pelvis with contrast was obtained, which showed colonic
wall thickening and fat stranding from the splenic flexure to
the
junction of the descending and sigmoid colon, most compatible
with colitis. She was started on cipro/flagyl and then admitted
to the floor.
No recent hospitalizations, antibiotic use, sick contacts, or
travel out of country.
Upon arrival to the floor, she explains that her symptoms have
all resolved. She denies abdominal pain, nausea, and headaches.
She has not had any more BMs.
ROS:
(+) per HPI
10 point ROS reviewed and negative other than those stated in
HPI.
Past Medical History:
DM ___ A1C 9.3)
HTN
Atrial Fibrillation w/ history of ___
CAD s/p drug-eluting stent
Hyperlipidemia
Autonomic Neuropathy
Social History:
___
Family History:
Parents with afib and HTN
Physical Exam:
ADMISSION EXAM:
Vitals: 98.3, BP 138 / 72, HR 77, RR 18, O2 99 Ra
GEN: Alert, lying in bed, no acute distress
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
Lungs: Clear to auscultation bilaterally
CV: Regular rate and rhythm, no murmurs
GI: Soft, obese, non-tender, non-distended. Decreased BS
Ext: Warm, 2+ distal pulses, trace ___ edema
Neuro: A&Ox3, conversational, moving all extremities
DISCHARGE EXAM:
Vitals: Tmax 100.2, BP 120-140s/70s, HR ___, RR 18, O2 96 Ra
GEN: Alert, lying in bed, no acute distress
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
Lungs: Clear to auscultation bilaterally
CV: Regular rate and rhythm, ___ systolic murmur loudest at RUSB
GI: Soft, obese, non-tender, non-distended. +BS
Ext: Warm, 2+ distal pulses, trace ___ edema
Neuro: A&Ox3, conversational, moving all extremities
Pertinent Results:
Admission labs:
___ 05:05PM BLOOD WBC-8.1 RBC-4.71 Hgb-13.6 Hct-40.4 MCV-86
MCH-28.9 MCHC-33.7 RDW-13.6 RDWSD-42.4 Plt ___
___ 05:05PM BLOOD Neuts-77.4* Lymphs-14.3* Monos-6.9
Eos-0.4* Baso-0.6 Im ___ AbsNeut-6.29* AbsLymp-1.16*
AbsMono-0.56 AbsEos-0.03* AbsBaso-0.05
___ 05:13PM BLOOD ___ PTT-32.5 ___
___ 05:05PM BLOOD Glucose-370* UreaN-25* Creat-1.2* Na-135
K-4.2 Cl-97 HCO3-19* AnGap-19*
___ 05:05PM BLOOD Albumin-3.7 Calcium-9.6 Phos-2.8 Mg-1.3*
___ 06:41PM BLOOD ___ pH-7.44
___ 06:41PM BLOOD Glucose-309* Na-136 K-4.1 Cl-99
calHCO3-23
___ 04:44AM BLOOD Lactate-3.5* K-6.7*
___ 08:31AM BLOOD K-3.7
Discharge labs:
___ 06:17AM BLOOD WBC-14.1* RBC-4.29 Hgb-12.1 Hct-38.0
MCV-89 MCH-28.2 MCHC-31.8* RDW-14.3 RDWSD-45.6 Plt ___
___ 10:00AM BLOOD ___ PTT-30.7 ___
___ 06:17AM BLOOD Glucose-191* UreaN-11 Creat-1.2* Na-142
K-3.9 Cl-103 HCO3-24 AnGap-15
___ 06:17AM BLOOD Calcium-9.2 Phos-3.5 Mg-1.8
Studies:
CXR ___:
No acute intrathoracic process
RUQUS ___:
Cholelithiasis without gallbladder wall thickening or other
sonographic evidence of acute cholecystitis.
CT abd/pelvis with contrast ___:
1. Colonic wall thickening with adjacent fat stranding from the
splenic flexure to the junction of the descending and sigmoid
colon is compatible with colitis. Given the location, an
ischemic etiology is favored, however infectious/inflammatory
etiologies are also possible.
2. Endometrial thickening. Recommend nonemergent pelvic
ultrasound for further evaluation.
3. Cholelithiasis and moderate hiatus hernia.
Brief Hospital Course:
Patient Summary
===============
___ year-old woman with T2DM ___ A1C 9.3), HTN, Afib on
warfarin, and CAD w/ drug-eluting stent who presented with
nausea, vomiting, abdominal pain, and BRBPR.
Acute Issues
============
# Ischemic colitis: Developed gradual onset abdominal pain and
BRBPR in the ED. Admission CTAP demonstrating colonic wall
thickening and fat stranding most compatible with colitis. This
most likely represents ischemic colitis as the distribution is
consistent with watershed reasons. Cause of ischemic colitis is
likely from poor PO intake and DKA. Patient was made NPO for
bowel rest for 24 hours and then started on diet. She had a
second small episode of BRBPR on ___ AM (24 hours after the
first episode), which likely is residual from the first episode.
She was started on ceftriaxone/flagyl for empiric antibiotics.
She should continue antibiotic therapy with cefpodoxime 400 mg
PO q12h and metronidazole 500 mg PO q8h for a one-week course
(___). Warfarin was held on admission but resumed prior to
discharge. Last colonoscopy in ___ showed normal colon, and
as hemoglobin and hemodynamics remained stable, we did not feel
inpatient colonoscopy would add further value. She was educated
on return precautions.
# Type 2 DM
# DKA: Patient with longstanding diabetes, last A1C 9.3. Has had
end organ damage with autonomic neuropathy and diabetic
retinopathy. Had anion gap and glucose levels in 300s in the ED
concerning for DKA, which was treated with 4L IVFs. Anion gap
resolved in the ED. The patient should continue her home insulin
regimen: Lantus 35U qAM and qHS + HISS.
Chronic Issues
==============
# Afib: History of ___ in ___. CHADS2 score of 2, does
not meet criteria for bridging as per bridge trial. Last
warfarin dose on ___. The patient was continued on her home
sotalol 100 mg BID. Her home warfarin was held for one day given
BRBPR and resumed at a reduced dose of 3mg daily on ___. She
should have her INR checked on ___ with her PCP with warfarin
dose re-evaluated at that time.
# HTN: The patient was continued on her home losartan 100 mg
daily with holding parameters.
# Hypothyroid: The patient was continued on her home
levothyroxine 100 mcg daily.
# Peripheral neuropathy: The patient was continued on her home
duloxetine 60 mg daily.
# HLD: The patient was continued on her home rosuvastatin 20 mg
daily and home aspirin 81 mg daily.
# Mood: The patient was continued on her home buproprion 300 mg
daily.
# Other: The patient was continued on her home vitamin D 5000U
daily and home pantoprazole 20 mg daily.
Transitional Issues
===================
# Post-menopausal bleeding: CT on admission showed endometrial
thickening. This is already being worked up as an outpatient.
Patient will need endometrial biopsy, which has been scheduled.
- CONTINUE cefpodoxime 400 mg PO q12h and metronidazole 500 mg
PO q8h for 1 week (___).
- CONTINUE warfarin at 3mg PO daily (reduced dose due to being
on metronidazole). Next INR check on ___ at ___
___, confirmed by phone.
- Discharge INR 1.7.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. azelastine 137 mcg (0.1 %) nasal DAILY
2. BuPROPion XL (Once Daily) 300 mg PO DAILY
3. DULoxetine 60 mg PO DAILY
4. Glargine 35 Units Breakfast
Glargine 35 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Losartan Potassium 100 mg PO DAILY
7. Pantoprazole 20 mg PO Q24H
8. Rosuvastatin Calcium 20 mg PO QPM
9. Sotalol 120 mg PO BID
10. Warfarin 4 mg PO DAILY16
11. Aspirin 81 mg PO DAILY
12. Vitamin D 5000 UNIT PO DAILY
Discharge Medications:
1. Cefpodoxime Proxetil 400 mg PO/NG Q12H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth every twelve (12)
hours Disp #*24 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*18 Tablet Refills:*0
3. Glargine 35 Units Breakfast
Glargine 35 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Warfarin 3 mg PO DAILY16
Please take this dose until notified by your PCP
___ *warfarin [Coumadin] 3 mg 1 tablet(s) by mouth daily Disp
#*10 Tablet Refills:*0
5. Aspirin 81 mg PO DAILY
6. azelastine 137 mcg (0.1 %) nasal DAILY
7. BuPROPion XL (Once Daily) 300 mg PO DAILY
8. DULoxetine 60 mg PO DAILY
9. Levothyroxine Sodium 100 mcg PO DAILY
10. Losartan Potassium 100 mg PO DAILY
11. Pantoprazole 20 mg PO Q24H
12. Rosuvastatin Calcium 20 mg PO QPM
13. Sotalol 120 mg PO BID
14. Vitamin D 5000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Ischemic colitis
Type 2 DM
Diabetic ketoacidosis
Afib
HTN
Hypothyroid
Peripheral neuropathy
HLD
Mood
Post-menopausal bleeding
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized for an episode of ischemic colitis likely
brought about by diabetic ketoacidosis. While in the hospital,
you received intravenous fluids and antibiotics. Once your
digestive tract had rested for a day, we resumed your diet to
facilitate its healing. We were reassured that your blood levels
were stable and did not think a colonoscopy would be needed at
this time.
When you leave the hospital, please continue to take your
medications, including the antibiotics we have prescribed for
you this hospitalization, and please follow-up with your primary
care physician.
If you have increased amounts of bleeding, we would recommend
that you return to the emergency room!
It was a pleasure to take part in your care!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10692735-DS-13
| 10,692,735 | 20,914,478 |
DS
| 13 |
2184-04-28 00:00:00
|
2184-04-28 09:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
atenolol / doxycycline / lisinopril / Verapamil
Attending: ___.
Chief Complaint:
hypoglycemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ year old female with past medical history of
systolic CHF, bioprosthetic AVR, type 2 diabetes, with recent
admission to ___ ___ - ___ for hyperosmolar hyperglycemic
state and ATN, thought to potentially relate to dehydration /
___, subsequently discharged home off metformin and on
glimepiride, who was brought in by ambulance after being found
unresponsive by daughter with ___ of 37. Per patient and
daughter
report, since discharge home, patient had been in normal state
of
health. No changes in PO intake. No nausea, vomiting,
diarrhea.
Had been taking medications as prescribed. No fevers/chills or
other signs of illness. Night prior to presentation she ate
normal dinner and had bedtime ___ 114. The following morning,
patient could not be awoken, was not following commands. 911
was
called, EMS arrived and found ___ was 37. She received D50 with
improved in mentation and responsiveness. Patient reports
feeling like she was in a ___ state, unable to move or
respond and feeling sleepy--all this resolved with D50. Repeat
___ was 122.
In the ED, initial VS were 96.8 106 130/76 20 96% RA. Exam
was
reported as "1+ lower extremity edema that is chronic. Clear
lungs and normal heart sounds. Mentating well. Blood sugar is
108." Labs were notable for WBC 18.1, Hgb 8.7, Plt 253; Na 127,
K
4.6, Cr 1.4; UA w 13WBC, no bacteria. Patient was given 1.5L
normal saline. Repeat labs showed Na 126, Cr 1.2. Patient was
admitted to medicine for further management.
On arrival to the floor, patient confirmed above. She reported
15lb weight loss in recent months, but is not sure if this was
"water weight" or "fat". Full 10 point review of systems
positive where noted, otherwise negative.
Past Medical History:
- Aortic Insufficiency
- ___ Cardiomyopathy
- Hypertension
- Dyslipidemia
- Diabetes type II x ___ years
- History of SVT
- Obesity
- Diverticulosis
- Anxiety and Depression
- Gout
- Glaucoma
- Cataracts, visual floaters bilaterally
- Vitamin D deficiency
- History of sepsis ___ to diverticulitis)
- TMJ syndrome
- Arthritis, mostly right knee
Social History:
___
Family History:
Father had an MI in his late ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
___ Temp: 98.3 PO BP: 99/64 Lying HR: 88 RR: 16 O2
sat: 99% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___
___ FSBG: 132
___ FSBG: 145
___ 2201 FSBG: 170
Gen: sitting up in bed, comfortable appearing
Eyes - EOMI, PERRL
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft obese nontender, normoactive bowel sounds
Ext - 1+ nonpitting edema of lower legs bilaterally
Skin - fungal rash of pannus;
Vasc - 2+ DP/radial pulses
Neuro - AOx3, moving all extremities
Psych - appropriate
DISCHARGE PHYSICAN EXAM:
___ 2341 Temp: 97.7 PO BP: 90/61 R Lying HR: 90 RR: 18 O2
sat: 97% O2 delivery: Ra
GENERAL: Alert and in no apparent distress, appears fatigued
EYES: iceteric sclera, EOMI, PERRLA
ENT: mmm
RESP: Breathing room air comfortably
GI: Abdomen soft, ___, RUQ tenderness without guarding
or rebound tenderness
EXT: Warm and well perfused. 1+ ___ edema b/l
NEURO: A&O x3
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS:
=============
___ 10:28AM BLOOD ___
___ Plt ___
___ 10:28AM BLOOD ___
___
___ 10:28AM BLOOD ___
CXR ___
FINDINGS:
Status post median sternotomy.No focal consolidation is seen.
No pleural
effusion or pneumothorax is seen. The cardiac and mediastinal
silhouettes are unremarkable. No evidence of pulmonary edema is
seen. Evidence of DISH is seen along the thoracic spine.
IMPRESSION:
No acute cardiopulmonary process.
CT A/P ___
IMPRESSION:
1. Enhancing 4.7 cm mass in the pancreatic body with associated
upstream
dilation of the main pancreatic duct and surrounding
peripancreatic lymph
nodes is concerning for primary pancreatic neoplasm, with
enhancement pattern favoring neuroendocrine tumor over
adenocarcinoma ( within limitations of lack of an arterial
phase).Enlarged retropancreatic lymph nodes are suspicious.
2. Three heterogeneously enhancing solid mass in the right
kidney measuring up to 3.1 cm, which could also represent
primary RCC versus metastatic disease.
3. Diffuse hepatic metastatic disease. Right adrenal nodules
are also
concerning for metastases.
TTE ___
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The ascending aorta is mildly
dilated. A bioprosthetic aortic valve prosthesis is present. The
aortic valve prosthesis appears well seated, with normal
leaflet/disc motion and transvalvular gradients. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Well seated aortic
bioprosthesis with normal leaflet motion / gradients and no
paravalvular leak. Mild symmetric left ventricular hypertrophy
with normal cavity size, and global systolic function. Wall
motion abnormalities cannot be excluded due to suboptimal image
quality. No definite pathologic valvular flow identified.
CXR ___
INDICATION: ___ year old woman with DM2, CHF, metastatic CA with
unknown
primary, complaining of cough, has ___ elevated WBC//
cough,
leukocytosis, assess for PNA cough, leukocytosis, assess for
PNA
IMPRESSION:
Compared to chest radiographs ___.
Lung volumes are lower, but lungs are clear. Heart size is
normal. No
pleural abnormality.
Discharge labs
___ 05:34AM BLOOD ___
___ Plt ___
___ 05:34AM BLOOD ___
___
___ 05:34AM BLOOD ___
___
___ 05:34AM BLOOD ___
Liver biopsy pathology:
"Poorly differentiated carcinoma with extensive necrosis."
"While not specific, this immunophenotype and the tumor
morphology... are most suggestive of metastasis from an
undifferentiated pancreatic carcinoma in the reported context of
a large pancreatic lesion that is radiographically suspicious
for a primary pancreatic neoplasm."
Brief Hospital Course:
___ year old female with past medical history of systolic CHF EF
___, bioprosthetic AVR, type 2 diabetes, with recent
admission to ___ ___ - ___ for hyperosmolar hyperglycemic
state and ATN, thought to potentially relate to dehydration /
___, subsequently discharged home off metformin and on
glimepiride, now admitted with unresponsive episode in setting
of severe hypoglycemia
# Stage 4 metastatic pancreatic carcinoma
Metastatic to liver and kidneys and complicated by liver failure
and acute kidney injury. Oncology has discussed with her and her
family that she is not a candidate for palliative chemotherapy
because of her liver and kidney failure. They decided they would
like her to go home with hospice.
#Encephalopathy
#Acute liver failure
#Coagulopathy
#Elevated LFTs - likely related to numerous mets in liver,
unclear if there could also be a component of congestive
hepatopathy increased over admission, although volume status was
difficult to assess. Patient received vitamin K without
improvement in her coagulopathy. Her LFTs continued to rise over
admission. On ___, patient noted to be more lethargic and
confused concerning for hepatic encephalopathy. Her home
lorazepam was held and patient started on lactulose. Her mental
status subsequently improved.
# Diabetes with hypoglycemia
Was initially unresponsive with ___ 37 at home; improved with
dextrose; unclear what precipitated this event but it does
appear that there may have been confusion on when to take
glimepiride (was told to take with large meals if BG post meals
is >180 and appears she was taking it regardless). While in
hospital, she had recurrent hypoglycemia while on HISS. She no
longer needs insulin or blood glucose control for her diabetes,
likely because of her significant weight loss and liver
metastases impairing gluconeogenesis.
# Leukocytosis - Pt had elevated WBC throughout this admission
and last, though worsened during this admission. Afebrile but
endorsing urinary urgency/frequency and UCx now growing GNRs.
She was treated for UTI however this did not improve her
leuokcytosis. CXR was without e/o PNA. No evidence of biliary
obstruction or cholagitis on CT A/P per radioalogy. C. Diff was
checked and was negative. BCx with
no growth to date. Repeat UCx with no growth to date.
Leukocytosis was most likely a stress response in the setting of
malignancy and acute liver failure.
# ___: Baseline Cr around ___. Last admission pt had ATN, Ct
was 1.8 on discharge. Worsened from 1.2 to 1.5 with IVFs and pt
had pitting edema with elevated BNP, therefore lasix was
restarted. Her edema improved today however patient then became
orthostatic so lasix held. She was given IVF as UNa low however
this did not improve her renal function. It was then thought ___
could represent CRS and lasix was given. Cr continued to worsen
therefor renal was consulted. ___ possibly from contrast induced
nephropathy - patient's volume status was unclear so
differentiation between hypovolemia and CRS was difficult.
# Hyponatremia: Together with hypoglycemia, adrenal
insufficiency was on ddx. AM cortisol was checked and was wnl.
Patient also appeared fluid overloaded on exam so may have been
from heart failure as well vs. liver failure. She was maintained
on a 1L fluid restriction until she was transitioned to
hospice/care measures only.
# Chronic systolic CHF: during admission, pt's volume status was
difficult to determine as she initially appeared volume
overloaded after receiving IVF in the ED however developed
symptoms or orthostatic hypotension after initiation of home
lasix. Repeat TTE showed EF of 55% and no valvular
abnormalities.
# Anemia: at baseline Hgb ___. No evidence of bleeding, low
suspicion for hemolysis. Fe studies consistent with anemia of
chronic disesae. She required transfusion on ___ for Hgb 6.9.
She responded appropriately to transfusion.
# s/p aortic valve replacement
- Home ASA discontinued as she was made CMO
# Seasonal allergies
- Her home cetirizine was held.
# Depression
- Her home citalopram was continued.
# Fungal skin infection
- miconazole powder was continued
# Gait instability
- ___ was consulted
# Lower back pain
per ___, receives prescriptions for oxycodone from PCP
- prn ___, oxycodone, lidocaine patches
Ms. ___ is clinically stable for discharge today. The total
time spent today on discharge planning, counseling and
coordination of care was greater than 30 minutes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 70 mg PO QSUN
2. Aspirin 81 mg PO DAILY
3. Cetirizine 10 mg PO DAILY
4. Citalopram 40 mg PO DAILY
5. Metoprolol Succinate XL 200 mg PO QAM
6. Metoprolol Succinate XL 100 mg PO QPM
7. Multivitamins 1 TAB PO DAILY
8. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
9. Simvastatin 20 mg PO QPM
10. Vitamin D 1000 UNIT PO DAILY
11. Sodium Bicarbonate 650 mg PO BID
12. DiphenhydrAMINE ___ mg PO QHS:PRN Insomnia
13. Estrogens Conjugated 0.5 gm VG 3X/WEEK (___)
14. glimepiride 1 mg oral DAILY
15. nystatin 100,000 unit/gram topical DAILY
16. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
17. Furosemide 40 mg PO DAILY
18. LORazepam 1 mg PO TID:PRN Anxiety
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp
#*90 Tablet Refills:*0
2. Dronabinol 2.5 mg PO BID
RX *dronabinol 2.5 mg 2.5 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
3. Lactulose 30 mL PO TID:PRN titrate to 3 bowel movements per
day
RX *lactulose 10 gram/15 mL 30 mL by mouth three times per day
Refills:*0
4. Lidocaine 5% Patch 1 PTCH TD QAM back pain
RX *lidocaine HCl 3 % Apply thin film Daily Refills:*0
5. MethylPHENIDATE (Ritalin) 5 mg PO DAILY
RX *methylphenidate HCl 5 mg 1 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*0
6. Miconazole Powder 2% 1 Appl TP TID
RX *miconazole nitrate 2 % Apply power to rash daily Disp #*1
Spray Refills:*0
7. LORazepam 0.25 mg PO Q8H:PRN anxiety
RX *lorazepam 0.5 mg 0.5 (One half) tab by mouth every eight (8)
hours Disp #*30 Tablet Refills:*0
8. Metoprolol Succinate XL 100 mg PO QAM
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
9. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*30 Tablet Refills:*0
10. Citalopram 40 mg PO DAILY
RX *citalopram 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
11. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
12. nystatin 100,000 unit/gram topical DAILY
13. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Stage IV pancreatic carcinoma metastatic to the liver and
kidneys
Acute liver failure
Acute kidney failure
Diabetes complicated by hypoglycemia
Urinary tract infection
acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ with low blood sugars. You were seen
by our diabetes doctors and changes were made to your diabetes
medications. On imaging you were found to have tumors in your
abdomen. One of the tumors in the liver was biopsied and it was
consistent with pancreatic carcinoma metastatic to the liver and
kidneys. Oncology was consulted. We discussed that because of
the liver and kidney failure, giving chemotherapy is not safe.
We discussed with you and your family and ultimately decided to
go home with hospice.
It has been a pleasure taking care of you and we wish you all
the best,
Your ___ Care Team
Followup Instructions:
___
|
10692761-DS-21
| 10,692,761 | 28,596,477 |
DS
| 21 |
2156-08-26 00:00:00
|
2156-08-26 10:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Bactrim DS / ACE Inhibitors
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
___ with past medical history of CAD status post stenting,
hypercholesterolemia, ___ transferred from OSH w/RUQ pain,
dilated CBD and abnormal LFTs.
The patient presented to ___ with sudden onset epigastric &
right upper quadrant pain for several hours. This was associated
with nausea, no vomiting. The pain was sharp but non-radiating.
She had similar pain 5 days ago that resolved on its own over
the course of several hours. She denies any fevers or chills.
Denies diarrhea, flank pain, dysuria, urinary frequency or
urgency. Denies BRBPR, melena. No chest pain, shortness of
breath, diaphoresis.
On presentation to ___ her VS were: Temp: 98 HR: 66 BP:
201/100 Resp: 22 O(2)Sat: 97 Normal. She was found to have
dilated CBD and intrahepatic biliary ducts on abdominal CT
suggesting obstructing stone. She received Zofran, morphine, and
Zosyn at ___. Patient transferred here for ERCP.
Initial VS in the ___ ED: 98.0 62 182/64 22 100% 2L NC. On the
floor, she denies pain or nausea but complains of left knee pain
(chronic ___ osteoarthritis).
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:
1. CAD, status post non-STEMI ___. DES to mid LAD, DES to LCX,
residual 50-70% dLAD and 50% pRCA disease. (No beta-blocker due
to symptomatic bradycardia.)
2. Peripheral vascular disease (h/o claudication, abnormal
ABIs).
3. Hypertension (amlodipine 10 mg).
4. Dyslipidemia, on Prava 40 mg, omega-3 fatty acids, niacin
500. 4.11: TC171/T117/H83/L72
5. Raynaud's phenomenon.
6. Back surgery/spinal stenosis
Social History:
___
Family History:
Father died of heart disease at age ___. Mother died of
aneurysm.Son w/ MI at age ___.
Physical Exam:
ADMISSION EXAM:
Vitals: T: 98.1 BP: 137/66 P: 70 R: ___ O2: 100%RA
General: NAD, alert, oriented, pleasant, speech clear and fluent
HEENT: OP clear, MM dry, sclera anicteric
Neck: soft, supple, no LAD
CV: RRR, no m/r/g, normal S1, S2
Lungs: CTAB, no w/r/r
Abdomen: soft, mildly distended, significant R sided TTP without
rebound or guarding
GU: no foley, deferred
Ext: warm, well perfused, 2+ pulses
Neuro: CN ___ intact, sensation intact to light touch, gait
deferred
Skin: multiple ecchymoses over UE bilaterally, ro rash
Pertinent Results:
ADMISSION LABS:
___ 04:40AM BLOOD WBC-9.1# RBC-3.69* Hgb-11.2* Hct-34.0*
MCV-92 MCH-30.2 MCHC-32.8 RDW-14.5 Plt ___
___ 04:40AM BLOOD Neuts-73.1* ___ Monos-5.2 Eos-1.5
Baso-0.8
___ 11:00AM BLOOD ___ PTT-26.2 ___
___ 04:40AM BLOOD Glucose-134* UreaN-21* Creat-0.9 Na-130*
K-3.9 Cl-92* HCO3-24 AnGap-18
___ 04:40AM BLOOD ALT-274* AST-266* AlkPhos-299*
TotBili-1.4
___ 08:20AM BLOOD Calcium-9.2 Phos-3.6 Mg-1.6
RADIOLOGY:
-KUB:
1. Nonspecific bowel gas pattern without evidence of free air
or obstruction. Followup imaging at this time should be based on
the clinical assessment
PATHOLOGY:
-Common bile duct, brushings: NEGATIVE FOR MALIGNANT CELLS.
ERCP REPORT:
-Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique.
-A limited pancreatogram showed a normal caliber main pancreatic
duct.
-The common bile duct was found to be dilated up to 13-14mm,
with a tapered distal duct. No clear obstructing lesion or
stricture were seen.
-A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
-Several balloon sweeps were performed with extraction of some
sludge.
-Cytology samples were obtained for histology using a brush,
from the distal CBD.
-A 5cm by ___ double pigtail biliary stent was placed
successfully.
-Otherwise normal ercp to third part of the duodenum
Brief Hospital Course:
Patient was admitted to the general medical service after
presenting to ___ with acute onset RUQ pain. Was found
to have partially obstructing stones on CT as well as
transaminitis on labs. Was transferred for ERCP where a
sphincterotomy was performed with expression of sludge.
Cytology from brushings of a dilated CBD were negative for
malignancy and patient was transferred to the surgical service
for cholecystectomy given persistant pain.
HTN: patient was noted to be extremely anxious and aggitated
over her hospitalization without a change in level of arousal.
While she was maintained on her home antihypertensive regimen
she had intermittent elevations in her systolics to the 180-200s
while awaiting surgery. There was no change in neurologic exam
during these episdoes and the patient's acute hypertension was
felt to be due to anxiety as she would become normotensive with
redirection and calming.
The patient underwent laparoscopic cholecystectomy on ___
which went well without complication. Post-operatively, after a
brief uneventful stay in the PACU, the patient arrived on the
floor. The patient's diet was advanced, which she tolerated
well. She was able to void independently.
At the time of discharge, the patient was ambulating
independently, able to tolerate PO, and voiding independently,
she was able to verbalize understanding with the discharge
plan/instructions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fish Oil (Omega 3) 1000 mg PO DAILY
2. ALPRAZolam 0.5 mg PO DAILY
3. Carvedilol 6.25 mg PO BID
4. Psyllium 1 PKT PO BID
5. Amlodipine 2.5 mg PO DAILY
6. Atorvastatin 60 mg PO DAILY
7. Furosemide 10 mg PO BID
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Nitroglycerin SL 0.3 mg SL PRN chest pain
10. Acetaminophen w/Codeine 1 TAB PO BID:PRN pain
11. Glucosamine-Chondr-D3 (C & Mn) *NF*
(gluc-chondr-colgencomp-D3-C-Mn) UNK Oral UNK
12. Naproxen Dose is Unknown PO Frequency is Unknown
13. Omeprazole 20 mg PO BID
14. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit Oral daily
15. Aspirin 81 mg PO DAILY
16. Citalopram 10 mg PO DAILY
17. Hydrochlorothiazide 12.5 mg PO DAILY
18. Cyanocobalamin Dose is Unknown PO Frequency is Unknown
19. Ascorbic Acid Dose is Unknown PO Frequency is Unknown
20. ALPRAZolam 1 mg PO QHS
21. Artificial Tears ___ DROP BOTH EYES PRN dry eye
Discharge Medications:
1. ALPRAZolam 1 mg PO QHS
2. Artificial Tears ___ DROP BOTH EYES PRN dry eye
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 60 mg PO DAILY
5. Carvedilol 6.25 mg PO BID
6. Citalopram 10 mg PO DAILY
7. Hydrochlorothiazide 12.5 mg PO DAILY
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Omeprazole 20 mg PO BID
10. Acetaminophen 650 mg PO TID
RX *acetaminophen 325 mg 2 tablet(s) by mouth three times a day
Disp #*30 Tablet Refills:*0
11. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*1
12. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 bid by mouth constipation Disp
#*20 Tablet Refills:*0
13. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*20 Tablet Refills:*0
14. Amlodipine 2.5 mg PO DAILY
15. Ascorbic Acid ___ mg PO Frequency is Unknown
16. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit Oral daily
17. Cyanocobalamin 0 mcg PO Frequency is Unknown
18. Fish Oil (Omega 3) 1000 mg PO DAILY
19. Furosemide 10 mg PO BID
20. Glucosamine-Chondr-D3 (C & Mn) *NF*
(gluc-chondr-colgencomp-D3-C-Mn) 0 mg ORAL Frequency is Unknown
21. Nitroglycerin SL 0.3 mg SL PRN chest pain
22. Psyllium 1 PKT PO BID
23. Ibuprofen 600 mg PO Q8H:PRN pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Bactrim DS / ACE Inhibitors
Attending: ___.
Chief Complaint:
Abdominal pain, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ year old female with a history of CAD s/p lap
cholecystectomy on ___ who has had non-bloody diarrhea and
abdominal pain for the past 6 days. Mrs. ___ was discharged
on ___ and since then has experienced constant ___
abdominal pain. The diarrhea started on
the ___ with 5 episodes of watery diarrhea. She visited her PCP
who prescribed cholestyramine and ordered stool cultures. Blood
and stool cultures showed no signs of infection. Mrs. ___
symptoms have progressively improved throughout the week as she
was able to pass a formed solid stool today. She denies fevers,
chills, nausea and vomiting.
Past Medical History:
Past Medical History: CAD, peripheral vascular disease,
hypertension, dyslipidemia, chronic back pain, and Raynaud's.
Past Surgical History: Lap cholecystectomy (___),
Coronary
Stents ___, and ___ Right shoulder surgery, Back
surgery, Bilateral Cataracts ___ and ___ hysterectomy; 2
ectopic pregnancies
Social History:
___
Family History:
Father died of heart disease when he was ___. Mother died at ___
from CVA. No hx of cancer in the family.
Physical Exam:
On admission:
Vitals: T: 99.2, HR: 58, BP: 170/69, RR: 20; O2 sat: 100%
GEN: Patient was oriented x 3. Seems nervous but in no acute
distress.
HEENT: No scleral icterus, mucus membranes are dry.
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, non-distended, tenderness to palpation over right
mid-abdomen, no rebound or guarding, normoactive bowel sounds,
no
palpable masses
Ext: No ___ edema, ___ warm and well perfused
On discharge:
VS 98.4, 80, 148/59, 18, 100% on room air
Pertinent Results:
___ 06:30PM BLOOD WBC-6.7 RBC-2.92* Hgb-8.7* Hct-26.5*
MCV-91 MCH-29.9 MCHC-32.9 RDW-14.3 Plt ___
___ 07:00AM BLOOD WBC-6.2 RBC-3.24* Hgb-9.7* Hct-30.1*
MCV-93 MCH-30.0 MCHC-32.3 RDW-14.5 Plt ___
___ 07:15AM BLOOD WBC-5.2 RBC-2.93* Hgb-8.6* Hct-26.7*
MCV-91 MCH-29.5 MCHC-32.4 RDW-14.3 Plt ___
___ 06:30PM BLOOD Neuts-53.2 ___ Monos-8.1 Eos-2.5
Baso-0.8
___ 07:15AM BLOOD ___ PTT-27.3 ___
___ 07:15AM BLOOD ___ 06:30PM BLOOD Glucose-107* UreaN-20 Creat-0.9 Na-130*
K-4.3 Cl-96 HCO3-20* AnGap-18
___ 11:47PM BLOOD Glucose-104* UreaN-11 Creat-0.7 Na-130*
K-4.3 Cl-100 HCO3-19* AnGap-15
___ 07:00AM BLOOD Glucose-105* UreaN-11 Creat-0.8 Na-127*
K-5.0 Cl-97 HCO3-18* AnGap-17
___ 03:40PM BLOOD Glucose-153* UreaN-12 Creat-1.0 Na-127*
K-4.9 Cl-95* HCO3-17* AnGap-20
___ 07:15AM BLOOD Glucose-90 UreaN-13 Creat-0.8 Na-129*
K-4.6 Cl-100 HCO3-20* AnGap-14
___ 06:30PM BLOOD ALT-40 AST-43* AlkPhos-178* TotBili-0.2
___ 06:30PM BLOOD Lipase-89*
___ 06:30PM BLOOD Albumin-3.9 Calcium-9.5 Phos-2.3*# Mg-1.7
___ 11:47PM BLOOD Calcium-9.2 Phos-2.9 Mg-1.5*
___ 07:00AM BLOOD Calcium-9.7 Phos-3.2 Mg-3.6*
___ 03:40PM BLOOD Calcium-9.9 Phos-2.8 Mg-2.5
___ 07:15AM BLOOD Calcium-9.2 Phos-3.6 Mg-1.9
___ 08:39PM BLOOD Lactate-1.8
IMAGING:
___ CT abdomen and pelvis with contrast
1. 1.9 x 0.9 cm subcapsular hypodense fluid collection in the
inferior right hepatic lobe along the gallbladder fossa, which
may represent seroma, biloma or abscess. If there is clinical
concern for biloma, further evaluation with HIDA scan is
recommended.
2. Status postcholecystectomy with right biliary stent in place
and mild
residual right intrahepatic biliary dilation.
3. No acute bowel pathology.
Brief Hospital Course:
Mrs. ___ presented to ___ on ___ with complaints of
abdominal pain and nausea. She had no leukocytosis or fever.
She underwent a CT of the abdomen and pelvis on the day of
admission. There were no acute bowel processes/pathology
identified. A small subcapsular hypodense fluid collection in
the inferior right hepatic lobe along the gallbladder fossa was
identified, but was not concerning. The patient was admitted to
the inpatient ward for further management and observation.
The patient was kept NPO (except medications) and given IV
maintenance fluids. She was intermittently hypertensive with
SBPs in the 190s, which required hydralazine IV. Once she
received her home BP medications, her systolic pressure
normalized to 150 or less. Mrs. ___ was notably anxious at
times, likely contributing to her hypertension. The patient was
also hyponatremic with a Na of 127-130. She was started on her
prior home medications of Lasix (10mg BID) and HCTZ (12.5mg
daily) at time of admission, likely causing some hyponatremia.
She had no signs or symptoms of hyponatremia, however. On the
day of discharge, her Lasix was discontinued as she stated she
doesn't take any more. She was started on a regular diet with
no sodium restriction, although for discharge, should continue
to watch her sodium intake secondary to her significant cardiac
history.
Just prior to discharge, Mrs. ___ SBP again rose from the
140-150s to 180s. Her IV was already discontinued so serial
blood pressures were taken over 2 - 3 hours. During the same
time, she was given another 2.5mg of amlodipine (for a total of
5mg). Her blood pressure began to decline but then rose to 180s
again. Her affect was notably anxious with period of
hyperventilation and sobbing. Serial blood pressure checks were
likely contributing to her hypertension and anxiety. The
decision was made to reinsert a peripheral IV and administer
10mg of hydralazine x 1. She was also given 12.5 of HCTZ (total
of 25mg for the day). After 1 - 2 hours, her blood pressure was
in the 140s with a heart rate in the ___. Throughout these
periods mentioned above, the patient was never symptomatic, but
again, was severely anxious. When offered a low-dose
benzodiazepine, she refused.
At the time of discharge, Mrs. ___ was afebrile,
hemodynamically stable and in no acute distress. Her SBP was
148. She will follow-up with ACS in approximately two weeks.
She has an appointment with her PCP, ___, on ___,
___. She was instructed to take 5mg of Norvasc daily and 25mg
of HCTZ until she follows up with Dr. ___. Mrs. ___ was
discharged in the care of her son, ___, and is going back to
her home where she has nursing assistance there.
Medications on Admission:
1. ALPRAZolam 1 mg PO QHS
2. Artificial Tears ___ DROP BOTH EYES PRN dry eye
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 60 mg PO DAILY
5. Carvedilol 6.25 mg PO BID
6. Citalopram 10 mg PO DAILY
7. Hydrochlorothiazide 12.5 mg PO DAILY
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Omeprazole 20 mg PO BID
10. Acetaminophen 650 mg PO TID
11. Docusate Sodium 100 mg PO BID
12. Senna 1 TAB PO BID:PRN constipation
13. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
14. Amlodipine 2.5 mg PO DAILY
15. Ascorbic Acid ___ mg PO Frequency is Unknown
16. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit Oral daily
17. Cyanocobalamin 0 mcg PO Frequency is Unknown
18. Fish Oil (Omega 3) 1000 mg PO DAILY
19. Furosemide 10 mg PO BID
20. Glucosamine-Chondr-D3 (C & Mn) *NF*
(gluc-chondr-colgencomp-D3-C-Mn) 0 mg ORAL Frequency is Unknown
21. Nitroglycerin SL 0.3 mg SL PRN chest pain
22. Psyllium 1 PKT PO BID
23. Ibuprofen 600 mg PO Q8H:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. ALPRAZolam 1 mg PO QHS PRN insomnia
3. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 60 mg PO DAILY
6. Calcium Carbonate 500 mg PO DAILY
7. Carvedilol 6.25 mg PO BID
8. Citalopram 10 mg PO DAILY
9. Omeprazole 20 mg PO BID
10. Amlodipine 5 mg PO DAILY
11. Hydrochlorothiazide 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute-on-chronic abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ on
___ with complaints of nausea and vomiting. You had a CT scan
of your abdomen/pelvis which showed no concerning acute process.
You were admitted to the inpatient ward for furthe observation.
You were initially given bowel rest and IV fluids until your
pain subsided. As you improved clinically, your diet was
advanced and you tolerated oral intake well. Your laboratory
values were within normal limits. You are now being discharged
home with a follow-up appointment in the ___ clinic (see below).
Please continue to take all medications you were taking prior to
this admission. You are not being discharged on any new
medications otherwise.
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim DS
Attending: ___.
Chief Complaint:
Left shoulder pain
Major Surgical or Invasive Procedure:
___ - Left shoulder joint aspiration for synovial fluid
analysis
History of Present Illness:
Ms. ___ is an ___ w/ a PMHx of of osteoarthritis and CAD,
who presents w/ L shoulder pain.
.
Pt has been experiencing mild, chronic, intermittent Left
shoulder pain for many years. 1 day prior to admission, she
developed a new-onset pain, severe, ___, sharp and burning in
nature, located on the anterior/lateral aspect of ___ shoulder.
The pain radiated down ___ arm to ___ fingers. She denied neck
pain.
.
Pain was so severe/limiting that it caused pt to get into a
minor MVA (no airbag deployment, no head/neck strike, no arm
strike). She was using Tylenol #3 q6 hr with intermittent relief
of pain.
.
10 point review of system otherwise negative. All pertinent
positives noted as above in HPI.
.
Past Medical History:
CAD, s/p PCI (___)
peripheral vascular disease
hypertension
dyslipidemia
chronic back pain,
Raynaud's
.
Past Surgical History:
Lap cholecystectomy (___)
Right shoulder surgery
Back surgery
Bilateral Cataracts ___ and ___
hysterectomy
Social History:
___
Family History:
Father died of heart disease when he was ___. Mother died at ___
from CVA. No hx of cancer in the family.
Physical Exam:
Admission Physical Exam:
Vitals: 98, 190/60, 75, 20, 100%RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
JVD; + firm mass on L aspect of neck
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: L shoulder slightly warm and ttp. Severe pain on
passive motion. No overlying erythema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes
.
Discharge Physical Exam - unchanged from above, except as below
Vitals: 97.9, 149/60, 51, 18, 99 RA
EXTREMITIES: No warmth, erythema, or swelling in L shoulder.
Mild pain with passive motion of L shoulder joint, but much
improved from admission. Can abduct arm to 90 degrees with
minimal pain.
.
Pertinent Results:
Admission labs:
___ 06:00PM BLOOD WBC-9.4 RBC-3.16* Hgb-8.9* Hct-27.4*
MCV-87 MCH-28.3 MCHC-32.7 RDW-16.1* Plt ___
___ 06:00PM BLOOD Neuts-69.2 ___ Monos-7.7 Eos-1.2
Baso-0.5
___ 06:00PM BLOOD ESR-69*
___ 06:00PM BLOOD Glucose-97 UreaN-36* Creat-1.3* Na-137
K-4.3 Cl-107 HCO3-17* AnGap-17
___ 06:00PM BLOOD Calcium-9.2 Phos-2.9 Mg-1.6
___ 06:00PM BLOOD CRP-53.4*
___ 06:00PM BLOOD TSH-1.5
.
Discharge labs:
___ 06:15AM BLOOD WBC-7.2 RBC-3.02* Hgb-8.8* Hct-27.1*
MCV-90 MCH-29.2 MCHC-32.6 RDW-16.3* Plt ___
___ 06:50AM BLOOD Glucose-107* UreaN-35* Creat-1.2* Na-138
K-4.7 Cl-105 HCO3-17* AnGap-21*
___ 06:50AM BLOOD Calcium-9.9 Phos-4.1 Mg-2.0
.
Micro:
-L shoulder synovial fluid ___ 07:42PM JOINT FLUID ___ RBC-56* Polys-78*
___ Macro-21
___ 07:42PM JOINT FLUID Crystal-FEW Shape-RHOMBOID
Locatio-INTRAC Birefri-POS Comment-c/w calciu
.
___ 7:42 pm JOINT FLUID JOINT TEST.
Note: Culture results may be compromised by the limited
volume (less
than 1ml) of specimen received.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
-Blooc cultures (___): No growth to date
.
Imaging:
-L shoulder pain film ___: Degenerative disease at the
glenohumeral and acromioclavicular joint. No fracture or
dislocation.
.
Brief Hospital Course:
Ms. ___ is an ___ yo F w/ a PMHx of of osteoarthritis and CAD,
who presents w/ L shoulder pain.
.
# Left shoulder pain / Pseudogout: Pt had acute onset of severe
joint pain in L shoulder. Synovial fluid studies showed
positively birefringent crystals consistent with CPPD. CRP/ESR
elevated, but no other signs of infection (aspirate Gram Stain
negative for organisms, Aspirate culture negative x 48 hours,
exam reassuring, no systemic symptoms). She was started on
prednisone on ___ along with PRN acetaminophen with codeine for
pain. Both ___ pain and active/passive range of motion improved
with prednisone. Should continue prednisone for a total of 7 day
course (last dose on ___. Would minimize NSAID use if
possible given ___. Has follow-up with Rheumatology after
discharge. Given ___ left shoulder pain, she was seen by OT and
rehab was recommended. She is being discharged to rehab.
.
# ___: Creatinine on admission was 1.3 and remained elevated up
to 1.4. Patient appeared volume depleted on admission. FENa was
0.6%, and urine sediment was bland, so likely pre-renal in
etiology. After 3 liters of IVF, creatinine improved to 1.2 on
discharge. Should have creatinine repeated in ___ days after
discharge to ensure it continued to improve
# Code status: FULL
# Emergency contact: ___ (son) ___
# Transitional issues:
- Follow-up Blood Cx, synovial fluid culture
- Consider adding colchicine if no resolution of symtpoms and
___ resolves
- Repeat creatinine ___ days after discharge to ensure
resolution ___
- Reschedule surgery for neck mass - ___ ENT MD, Dr.
___, was contacted prior to discharge
- f/u with Rheumatology
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen w/Codeine 1 TAB PO Q6H:PRN pain
2. ALPRAZolam 1 mg PO QHS
3. ALPRAZolam 0.5 mg PO DAILY:PRN anxiety
4. Amlodipine 5 mg PO DAILY
5. Atorvastatin 60 mg PO DAILY
6. Carvedilol 6.25 mg PO BID
7. Cholestyramine 4 gm PO TID
8. Citalopram 10 mg PO DAILY
9. Hydrochlorothiazide 25 mg PO DAILY
10. Lidocaine 5% Patch 1 PTCH TD QAM
11. Omeprazole 20 mg PO DAILY
12. Ranitidine 300 mg PO DAILY
13. Aspirin 81 mg PO DAILY
14. Ibuprofen 400 mg PO Q6H:PRN pain
15. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen w/Codeine ___ TAB PO Q4H:PRN pain
RX *acetaminophen-codeine [Tylenol-Codeine #3] 300 mg-30 mg ___
tablet(s) by mouth Every 4 hours Disp #*0.3 Tablet Refills:*0
2. ALPRAZolam 0.5 mg PO DAILY:PRN anxiety
3. Amlodipine 5 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 60 mg PO DAILY
6. Carvedilol 6.25 mg PO BID
7. Hydrochlorothiazide 25 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Ranitidine 300 mg PO DAILY
11. PredniSONE 40 mg PO DAILY Duration: 5 Days
Last dose to be given on ___
12. Cholestyramine 4 gm PO TID
13. Citalopram 10 mg PO DAILY
14. Lidocaine 5% Patch 1 PTCH TD QAM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
-Calcium pyrophosphate deposition disease of the L shoulder
-Acute kidney injury
Secondary diagnoses:
-Hypertension
-Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Greetings Mrs. ___,
___ were admitted ___ for severe left shoulder pain as a
result of calcium pyrophosphate dihydrate deposition disease
(CPPD), also known as pseudogout, in your left shoulder joint.
Treatment for this condition was begun during ___ inpatient stay
and involved pain control with Tylenol with codeine (Tylenol
#3), and anti-inflammatory therapy with the steroid medication
prednisone. Your kidneys also showed signs of dyhydration, so
___ were treated with IV fluids throughout your hospitalization.
On discharge, ___ will continue medication therapy with both the
Tylenol with codeine as needed for pain control, as well as
prednisone for anti-inflammatory therapy. ___ has recommended
discharge to a rehabilitation facility for a few days while your
shoulder continues to recover and to help ___ regain full
function. We have also arranged for ___ to see a rheumatologist
after discharge.
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Bactrim DS / ace inhibitors / Vesicare / Lyrica
Attending: ___.
Chief Complaint:
s/p fall with L ___ rib fractures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ s/p fall with L ___ rib fractures
Past Medical History:
- CAD s/p ___, LCx
- PVD with lower extremity claudication
- Hyperlipidemia
- Anemia
- Back pain
- Knee pain
- Osteoarthritis
- GERD
- Insomnia with component of anxiety
- Raynaud's
- Sialadenitis
- SCC s/p excision
- Choledocholithiasis s/p laparascopic cholecystectomy
- s/p rectopexy and low anterior resection
- s/p hysterectomy
Social History:
___
Family History:
Father died of heart disease when he was ___. Mother died at ___
from CVA. No hx of cancer in the family.
Physical Exam:
Discharge Physical Exam:
Vitals - T 98.3 / HR 61 / BP 152/68 / RR 17 / O2sat 98%RA
General - comfortable, NAD
HEENT - normocephalic/atraumatic, PERRLA, EOMI, moist mucous
membranes
Cardiac - RRR, no M/R/G
Chest - CTAB, TTP right chest wall mild
Abdomen - soft, NT, ND, normoactive bowel sounds
Extremities - warm and well-perfused, no edema
Neuro - A&OX3, sensorimotor function intact in all 4 extremities
Pertinent Results:
Lab Results:
___ 05:12AM BLOOD WBC-6.0 RBC-3.36* Hgb-10.5* Hct-32.0*
MCV-95 MCH-31.3 MCHC-32.8 RDW-14.6 RDWSD-50.8* Plt ___
___ 05:12AM BLOOD Glucose-101* UreaN-52* Creat-1.2* Na-135
K-4.8 Cl-100 HCO3-24 AnGap-16
Imaging Results:
CT C-SPINE W/O CONTRAST Study Date of ___ 9:39 ___
IMPRESSION:
1. No traumatic malalignment or acute fracture.
2. No significant interval change in severe cervical spondylosis
with marked
degenerative changes at C1-2 and moderate spinal canal narrowing
as well as
associated neural foraminal narrowing at C5-6.
CT HEAD W/O CONTRAST Study Date of ___ 9:38 ___
IMPRESSION:
No acute intracranial abnormalities.
Brief Hospital Course:
___ s/p mechanical fall with Left ___ rib fractures. She had
no other injuries noted on clinical exam or imaging. Her pain
was controlled and she tolerated a regular diet. She remained
hemodynamically stable throughout her hospital course. She was
breathing well on room air and ready for discharge home with
follow-up in ___ weeks.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 1 mg PO QHS
2. Carvedilol 3.125 mg PO BID
3. amLODIPine 2.5 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Atorvastatin 20 mg PO QPM
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
8. Omeprazole 20 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Citalopram 10 mg PO DAILY
11. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 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
#*30 Tablet Refills:*0
3. OxyCODONE (Immediate Release) 2.5-5 mg PO Q6H:PRN Pain -
Severe
RX *oxycodone 5 mg Half tablet(s) by mouth every ___ hours Disp
#*20 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
5. Atorvastatin 60 mg PO QPM
6. ALPRAZolam 1 mg PO QHS
7. amLODIPine 2.5 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Carvedilol 3.125 mg PO BID
10. Citalopram 10 mg PO DAILY
11. Hydrochlorothiazide 25 mg PO DAILY
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
14. Omeprazole 20 mg PO DAILY
15. HELD- Atorvastatin 20 mg PO QPM This medication was held.
Do not restart Atorvastatin until atorvastatin 60
Discharge Disposition:
Home
Discharge Diagnosis:
Left ___ rib fractures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you here at ___. You were
admitted after a mechanical fall with Left ___ rib fractures.
You had no other injuries noted on clinical exam or imaging.
Your pain was controlled and you tolerated a regular diet. You
were breathing well on room air and are now ready for discharge
home.
Please follow the below instructions for a safe and speedy
recovery:
Rib Fractures:
* Your injury caused left ___ rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
Followup Instructions:
___
|
10692799-DS-19
| 10,692,799 | 29,959,668 |
DS
| 19 |
2166-02-14 00:00:00
|
2166-02-14 17:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
bloody diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ h/o Crohn's disease on humira who presents wwith 3d of
frequently bloody stools. Approximately 2 weeks ago stool
became less formed and then he developed ___ per day bowel
movements each time with blood up from his usual frequency of
___ per day of formed stools. He developed accompanying mid
abdominal discomfort/sharp pains that were constant and non
radiating. He developed chills and lightheadedness/dizziness
with activity. He did not have vomiting or nausea. He
presented to ED where he was anemic and tachycardic and had a
grossly bloody rectal exam. He received one unit of RBC
transfusion.
I spoke with his GI MD from ___ ME, Dr. ___
shared that the patient had not had the best medical follow up
earlier this year and that the patient may have been requesting
sample of humira and he wondered if the patient missed a dose or
more.
ROS: 13pt ROS includes pertinent positives above and is
otherwise negative
Past Medical History:
Crohn's disease: Diagnosed in ___ with ileo colitis and TI
ulcers and pan colitis with skipped lesions and ulcers up to
dentate line.
Started on ___ soon after diagnosis in ___.
Required transfusion in the past for anemia.
Dr. ___ ___ ___ GI Associates
Epilepsy, controlled for past ___ years, had partial complex
seizures in childhood
no past surgical history
Social History:
___
Family History:
no ___ malignancy or IBD
Physical Exam:
98.2 140/86 90
does not appear in any acute distress
facial features symmetric
no rashes or skin lesions to face or extremities
clear breath sounds
regular s1 and s2
___ tenderness to palpation without guarding or
rebound
no peripheral edema
neuro exam grossly intact
calm and attentive
Discharge Physical:
======================
Vitals stable, afebrile
General: Well appearing, comfortable, eating
HEENT: MMM, OP clear
CV: RRR, no murmurs
Lungs: CTAB, good air movement
Abdomen: Soft, nontender, nondistended with normoactive BS
No peripheral e
Pertinent Results:
___ 10:43PM BLOOD WBC-7.3 RBC-4.52* Hgb-10.0*# Hct-34.0*
MCV-75*# MCH-22.1*# MCHC-29.4*# RDW-13.2 RDWSD-35.4 Plt ___
___ 01:15PM BLOOD WBC-5.1 RBC-4.36* Hgb-10.1* Hct-32.9*
MCV-76* MCH-23.2* MCHC-30.7* RDW-13.4 RDWSD-35.9 Plt ___
___ 01:15PM BLOOD Glucose-88 UreaN-6 Creat-0.7 Na-139 K-3.9
Cl-104 HCO3-25 AnGap-14
___ 01:15PM BLOOD CRP-41.4*
___ 10:55PM BLOOD Lactate-1.2
___ 07:36AM BLOOD WBC-4.5 RBC-4.25* Hgb-9.6* Hct-32.0*
MCV-75* MCH-22.6* MCHC-30.0* RDW-13.7 RDWSD-36.3 Plt ___
___ 07:36AM BLOOD Glucose-84 UreaN-5* Creat-0.6 Na-137
K-4.1 Cl-102 HCO3-27 AnGap-12
___ 07:30AM BLOOD calTIBC-402 VitB12-985* Folate-9.9
Ferritn-19* TRF-309
___ 07:30AM BLOOD Iron-30*
___ 07:30AM BLOOD 25VitD-13*
___ 07:36AM BLOOD CRP-38.3*
___ 01:15PM BLOOD CRP-41.4*
___ 07:30AM BLOOD IgA-402*
___ 07:30AM BLOOD tTG-IgA-10
___ 10:55PM BLOOD Lactate-1.2
MRE
Final Report
EXAMINATION: MR enterography
INDICATION: 3 days of loose and bloody bowel movements
TECHNIQUE: T1 and T2 weighted images of the abdomen were
obtained
Intravenous contrast: 7 cc of Gadavist
Oral contrast: 900 cc of VoLumen
1 mg of IM glucagon was administered
COMPARISON: None
FINDINGS:
MR ENTEROGRAPHY:
There is bowel wall thickening and edema of approximately 10 cm
of terminal
ileum as well as noncontignous portions of the ascending colon
to the hepatic
flexure. Exam is not tailored for evaluation of the colon but
the remainder
of the colon wall is relatively normal. Terminal ileum
mesentery has slight
edema.
The affected terminal ileum and at least half of the ascending
colon shows
abnormal early phase mucosal hyperenhancement with some areas of
transmural
involvement.
No collection. No obstruction. No stricture. No fistula.
Appendix is not definitely identified.
MRI OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST:
Lower Thorax: Visualized lung bases are clear. Cardiomediastinal
structures are normal.
Liver: Normal in size. Visualized liver is normal in signal and
enhancement. No solid mass.
Biliary: Intrahepatic and extrahepatic bile ducts are not
dilated. Gallbladder is normal. No gallstone.
Pancreas: Normal in size. Parenchyma is normal in signal and
enhancement. Main pancreatic duct is not dilated.
Spleen: Normal in size, signal, and enhancement, limited
visualization.
Adrenal Glands: Normal in size, signal, and enhancement. No
nodularity.
Kidneys: No hydronephrosis. Normal in size, signal, and
enhancement. No solid mass.
Lymph Nodes: No enlarged pelvic or retroperitoneal lymph node.
Multiple
enlarged right lower quadrant mesenteric lymph nodes, likely
reactive.
Solitary prominent 10 mm lymph node is seen adjacent to the
involved bowel.
Vasculature: Aorta and iliac arteries are of normal caliber.
Origin of
superior mesenteric artery is patent. Flow artifact in the
proximal celiac artery may be related to mild stenosis or
impression from the crossing median arcuate ligament. Portal
veins and hepatic veins are patent.
Osseous and Soft Tissue Structures: No mass. Normal bone marrow
signal
MRI OF THE PELVIS WITH AND WITHOUT IV CONTRAST:
No pelvic mass. Normal bladder.
Grossly normal prostate and seminal vesicles.
IMPRESSION:
Findings are consistent with active inflammatory process
involving the
terminal ileum and ascending colon consistent with a Crohn's
flare. No
complication such as collection, obstruction, stricture, or
fistula.
Discharge labs:
==================
___ 07:36AM BLOOD WBC-4.5 RBC-4.25* Hgb-9.6* Hct-32.0*
MCV-75* MCH-22.6* MCHC-30.0* RDW-13.7 RDWSD-36.3 Plt ___
___ 07:36AM BLOOD CRP-38.3*
Brief Hospital Course:
___ with crohn's disease presenting bloody diarrhea.
#Crohn's disease
#Cdiff Colitis
The patient was seen by the GI consult service. Infectious
stool studies showed cdiff colitis and he was started on oral
vancomycin 125mg q6h. He received his usual dose of humira 40mg
on ___. He had moderate frequency of soft formed stools with
some blood by late in the week, approx. ___ times per day.
Repeat CRP value did not decline substantially and remained at
38, so GI advised initiation of steroids with solumedrol 20mg IV
q8h on the afternoon of ___. On ___, patient was adamant about
discharge and thus was transitioned to PO prednisone 40mg daily
through ___ then 30mg daily until GI follow-up. GI was emailed
to arrange for follow-up prior to ___ given high dose
prednisone until that time. Given prednisone taper, patient was
started on PO omeprazole at discharge for GI ppx. Unfortunately,
given patient's discharge on ___, we were unable to obtain a
prior authorization for vancomycin. On discussion with the on
call GI fellow, decision was made to discharge on oral flagyl
for 14 day course with plan for vancomycin if fails flagyl.
Patient in agreement with this plan. Of note, patient having ___
loose stools daily prior to discharge.
#Iron deficiency Anemia: likely chronic blood loss and Fe
deficiency anemia. He received one unit of RBC in ED and hgb
remained in the mid 9 to 10 range. Fe studies showed Fe
deficiency. He received iron dextran 1000mg IV on ___. Consider
repeat iron studies as outpatient and initiation of oral iron
supplementation if remains low.
#Vitamin D deficiency: start oral vitamin D 50,000 every
___ x 8 weeks
#Epilepsy: Patient was continued on his home lamictal and
carbamezipine for seizure prophylaxis.
Transitional Issues:
====================
[]continue flagyl for total of 14 days (___)
[]Continue prednisone taper as above, if unable to arrange GI
follow-up prior to ___, will need additional prednisone script
from ___. If remaining on high dose prednisone, consider
need for Bactrim ppx for PCP
[]continue omeprazole while on high dose steroids
[]will need f/u CRP at GI follow-up to ensure improvement on
steroids
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LamoTRIgine 300 mg PO DAILY
2. LamoTRIgine 200 mg PO QPM
3. CarBAMazepine 600 mg PO QAM
4. CarBAMazepine 800 mg PO QPM
5. Humira (adalimumab) 40 mg/0.8 mL subcutaneous every other
week
Discharge Medications:
1. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*33 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. PredniSONE 40 mg PO DAILY Duration: 14 Doses
Start: Today - ___, First Dose: Next Routine Administration
Time
This is dose # 1 of 2 tapered doses
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*28 Tablet
Refills:*0
4. PredniSONE 30 mg PO DAILY Duration: 7 Doses
Start: After 40 mg DAILY tapered dose
This is dose # 2 of 2 tapered doses
RX *prednisone 20 mg 1.5 tablet(s) by mouth Daily Disp #*11
Tablet Refills:*0
5. Vitamin D ___ UNIT PO 1X/WEEK (SA)
RX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by
mouth Every week on ___ Disp #*8 Capsule Refills:*0
6. CarBAMazepine 600 mg PO QAM
7. CarBAMazepine 800 mg PO QPM
8. Humira (adalimumab) 40 mg/0.8 mL subcutaneous every other
week
9. LamoTRIgine 300 mg PO DAILY
10. LamoTRIgine 200 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
clostridium difficile colitis
crohns disease complicated by acute colitis
Iron deficiency anemia
Vitamin D deficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized for evaluation of abdominal pain and
bloody stools. You were diagnosed with cdiff colitis, an
infection of the colon. You were started on a medication called
vancomycin. Unfortunately, this medication was not covered by
your insurance and so you were transitioned to metronidazole (or
flagyl) an antibiotic, which you will continue for a total of 2
weeks. It is very important that you take all of your
medications as prescribed. If you experience worsening in your
diarrhea, please call your gastroenterologist, Dr. ___ at
___ to discuss whether you need to restart vancomycin.
Your symptoms were also felt to be due to active inflammation
related to crohn's disease that is best treated with a
combination of steroids and continuing your humira. you
received iv steroids during the hospitalization and were
transitioned to prednisone at discharge. Please take prednisone
as follows:
40mg daily (2 pills) ___
30mg daily (1.5 pills) ___ until you follow-up with your
gastroenterologist.
Because you are on high dose steroids, you should take
omeprazole 20mg daily while you are on steroids. Additionally,
while you were in the hospital, you were noted to have iron
deficiency and vitamin D deficiency. You were given IV iron and
started on a weekly vitamin D supplement for 8 weeks.
It was a pleasure taking care of you,
Your ___ Team
Followup Instructions:
___
|
10692860-DS-12
| 10,692,860 | 26,362,019 |
DS
| 12 |
2152-12-15 00:00:00
|
2152-12-16 07:22:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old woman with history of asthma brought in by ambulance
after episode of loss of conciousness. Patient was eating a
vegetarian meal (asparagus and cauliflower) and two Martini's by
herself at ___ in ___ after completing her
meal and calling a taxi she was seated and does not recollect
what happens. She was told that she lost conciousness and
vomited. The first thing she remembers is being the emergency
department at ___. Prior to this episode the patient reports
being in good health.
Upon arrival to the ED she was noted to be drowsy and
hypotensive to ___ systolic. She was given 3L of IVF and
continued to be hypotensive. Heart rate was noted to be in the
___. She was started on levophed at 0.06. Her mentation started
to improve. Denied any complaints other than feeling light
headed. She was noted to be hypoglycemic to ___ and was given
half an amp of D5. The rest of her exam was unremarkable.
Labs notable for: WBC 6.9, Hgb 11.8/ HCT 35.4 Plt 311,
Neutrophils 71.9, Na 139 K 4.4 (moderately hemolyzed), Cl 104
HCO3 20, BUN 0.9 Cr 0.9, Glucose 63. INR 0.9. LFT within normal
limits. Lipase 31. Troponin T 0.01. ETOH level 182. Serum and
urine tox screen otherwise negative. Lactate 2.8. Infectious
work up was performed with negative UA and no evidence of
infection on CXR. Blood cultures are pending. Patient was
started on vancomycin and cefepime for broad coverage. Patient
had a negative troponins, lateral TWI were noted on EKG. CTA was
performed to rule out PE and was negative. ED was concerned
that the patient my have had a vasovagal episode and admitted
her for work up and monitoring of her hypotension. Right IJ was
placed in the ED for access and levophed.
On arrival to the MICU, pt was feeling well. She denies any
lightheadedness or dizziness. Not complaining of pain. No
nausea, vomiting, diarrhea or constipation. Denies any recent
illness. No fevers or chills. Levophed was shut off with
pressures ___.
Review of systems:
(+) Per HPI
Past Medical History:
Cataract, right eye s/p removal
Asthma- not on inhalers
Carotid atherosclerosis- found to have a "mild" carotid plaque
on a screening study
Left ankle fracture, s/p mechanical fall and ORIF on ___
Social History:
___
Family History:
Father died at age ___ due to heart problem
Mother died at age ___
Physical Exam:
Admission Physical Exam:
Vitals: T:97.6 BP:121/76 P:78 R: 18 O2: 97%RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP difficult to asses
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. Left ankle has erythema no drainage above medial
malleolus. Slight asymmetrical deformity of ankle/foot post ORIF
SKIN: warm, no evidence of rash
NEURO: AOx3, CN ___ intact, strength and sensation intact in
upper and lower extremities.
Discharge Physical Exam:
Pertinent Results:
Admission Labs:
___ 06:10PM BLOOD WBC-6.9 RBC-3.85* Hgb-11.8* Hct-35.4*
MCV-92 MCH-30.6 MCHC-33.3 RDW-15.1 Plt ___
___ 06:10PM BLOOD Neuts-71.9* ___ Monos-6.1 Eos-2.4
Baso-0.5
___ 06:10PM BLOOD ___ PTT-26.6 ___
___ 06:10PM BLOOD Glucose-63* UreaN-9 Creat-0.9 Na-139
K-4.4 Cl-104 HCO3-20* AnGap-19
___ 06:10PM BLOOD ALT-24 AST-30 AlkPhos-56 TotBili-0.2
___ 06:10PM BLOOD Lipase-31
___ 06:10PM BLOOD cTropnT-<0.01
___ 02:59AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.9
___ 06:10PM BLOOD Albumin-3.9
___ 06:10PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:09PM BLOOD Lactate-2.8*
___ 06:00AM BLOOD Cortsol-PND
___ 07:20PM URINE Color-Yellow Appear-Clear Sp ___
___ 07:20PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 07:20PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE
Epi-<1
___ 07:20PM URINE CastHy-85*
___ 07:20PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
Discharge Labs:
Imaging/Reports:
CXR
No evidence of pneumonia.
CTA
1. No evidence of pulmonary embolism or aortic abnormality.
2. Mildly enlarged left axillary lymph nodes.
3. An approximate 1 cm soft tissue lesion within right breast
pelvis could represent a lymph node. If clinically warranted,
additional mammographic/breast ultrasonography imaging could be
performed
EKG: NSR, low voltages in limb leads, VR 68, normal intervals,
TWI v3-v6
Micro:
- blood cx x 2:
Brief Hospital Course:
___ year old woman with history asthma brought in by ambulance
after episode of loss of conciousness and prolonged hypotension
requiring pressor support.
#Hypotension/Shock- patient was notably hypotensive with EMS and
in the ED requring pressors. The patient was given 3L of IVF and
weaned off pressors. Etiolgoy for her hypotension is unclear.
The patient does have new TWI in precordial leads over denies
any chest pain, SOB and no evidence of elevated troponins. Her
hypotension has also resolved, so it is less likely that she has
suffered an ACS event as one causing hypotension would not
resolve so quickly. Unlikely that the patient is suffering from
cardiogenic shock. Pulmonary embolism was ruled out via CT scan.
Infectious work up has been performed and no sign of urinary or
pulmonary infection. Allergic reaction seems unlikely as the
patient has not had any other sequale of an allergic response,
further more given her age and lack of new exposures makes this
unlikely.
Concern for vagal episode causing syncope and hypotension is
possible but it is unclear why she required pressors for so
long. It is possible that she may have been hypovolemic which
has now improved with fluid resuscitation. Pressors were weaned
quickly on the floor. IVF discontinued with PO intake. No
antibiotics continued. Repeat echo showed no LV dysfunction
#Syncope/AMS?- Infectious work up has been negative. Patient
does have notable hx of mild carotid plaque on screening
carotid u/s as per PCP note however no radiographic report in
OMR. Unknown when this was performed, however CVA event would
not present with transient hypotension. Furthermore she has no
other focal defecits. Seizure is a possiblity. No hx of
seizures, unclear why they would present at this age.
Hypoglycemia could have caused change in her mental status
however the patient had just consumed food/beverage. She was
also notably drinking alcohol during this incident with a high
ETOH level, it is possible that she may just have been
intoxicated. Vomiting and ETOH use lead to dehydration causing
her to be hypovolemic leading to syncopal episode.
#Hypoglycemia with blood sugar in the ___, given half an AMP of
D5W, blood sugars checked here to be in the ___. Patient is not
a diabetic. Unclear why she was hypoglycemic. Glucose improved,
AM cortisol elevated.
#Alcohol Use- ED was concerned about heavy alchol use. Patient
denies daily ETOH use
#Asthma- on home epinephrine inhaler (over the counter).
albuterol prn ordered while in house
TRANSITIONAL ISSUES:
=====================
# An approximate 1 cm soft tissue lesion within right breast
pelvis could represent a lymph node. If clinically warranted,
additional mammographic/breast ultrasonography imaging could be
performed
# Pt reports life long problem with SOB. Never been evaluated.
Should establish care with pulmonologist for PFTs.
Medications on Admission:
over the counter primatine asthma inhaler
no prescription medications
Discharge Medications:
1. Cane
ICD: ___
Length of need>13months
Prognosis good
Discharge Disposition:
Home
Discharge Diagnosis:
Syncope
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted after an episode of passing out. Your blood
pressure was low and you were monitored in the ICU overnight.
Your blood pressure improved with fluids. There were no signs of
infection.
Followup Instructions:
___
|
10693266-DS-17
| 10,693,266 | 27,958,742 |
DS
| 17 |
2167-04-17 00:00:00
|
2167-04-21 09:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Allergies/ADRs on File
Attending: ___
Chief Complaint:
Assault
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ found down in ___ s/p assault, intubated in ED as
he was extremely combative on arrival and subsequently
pan-scanned ___ patient's inability to participate in exam. Head
CT revealed bilateral zygomatic arch deformity and left-sided
nasal bone fracture; pan scanning revealed no other injuries.
Presently denying headaches or nausea. Endorses blurry vision
out
of the left eye ___ swelling. Of note the patient reports
history
of facial fractures in the past from playing football.
Past Medical History:
PMH: none
PSH: none
NKDA
Social History:
___
Family History:
Noncontributory
Physical Exam:
VS: 97.8 62 120/72 18 100%ra
Gen: awake, alert, in no acute distress
HEENT: Swelling/ecchymosis about left > right orbit, moderate
ecchymoses. Slight right deviation of nose Able to open right
eye, left eye more difficult to open due to swelling. Left eye
with subconjunctival hemorrhage. No weakness of muscles of
facial expression noted. EOMI without pain. No rhinorrhea. Able
to open mouth fully without pain or impingement. No pain to
palpation over zygoma.
CV: RRR
Pulm: CTAB
GI: Soft, NTND
Neurp: CN II-XII intact bilaterally, ___ strength in all
extremities bilaterally, sensation intact throughout
Pertinent Results:
___ 07:30AM BLOOD WBC-7.5 RBC-4.89 Hgb-14.0 Hct-42.5 MCV-87
MCH-28.6 MCHC-32.9 RDW-13.6 RDWSD-43.6 Plt ___
___ 07:30AM BLOOD Glucose-95 UreaN-17 Creat-1.1 Na-142
K-3.9 Cl-106 HCO3-26 AnGap-14
___ 02:30AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
CT Max/face (___)
IMPRESSION
IMPRESSION:
1. Soft tissue swelling over left orbit. Intact globes and bony
orbits.
2. No change in nondisplaced left nasal bone fracture.
3. Irregular buckling of the left greater than right bilateral
zygomatic
arches, may represent posttraumatic deformation without a
discrete fracture
line.
Brief Hospital Course:
Mr. ___ presented after an assault and suffered a left nasal
bone fracture and bilateraly zygomatic arch deformation without
fracture. He was seen by plastic surgery who determined his
injuries to be nonoperative and asked him to followup as an
outpatient. He was also seen by opthalmology due to significant
eye swelling and was found to have no discrete injuries so was
asked to follow up as an outpatient with them as well. He was
discharged home with these followup instructions as well as on
sinus precautions.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral Zygomatic arch deformation without discrete fracture
line
Left nasal bone fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___
___ were admitted to ___ after suffering bone fractures in
your left nose and bone deformations in your cheek area due to
assault. ___ were seen by the Plastic Surgery Team who said
there is nothing operative to do for these fractures. ___ will
follow up with them as an outpatient in 1 week. ___ were also
seen by the Opthalmology Team who recommend that ___ follow up
in ___ weeks as an outpatient to ensure that your vision remains
intact.
In the meantime, it is important that ___:
Do not blow your noseuse nasal saline spray as needed.
Sneeze with your mouth open, do not hold your sneeze in.
Do not lift heavy objects or bend over.
Use sinus decongestants as directed by your physician
___ to take pain medications as prescribed.
Followup Instructions:
___
|
10693837-DS-2
| 10,693,837 | 21,762,331 |
DS
| 2 |
2180-01-03 00:00:00
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2180-01-04 10:59:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dysarthria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Neurology at bedside for evaluation after code stroke
activation/consult within: 5 minutes
Time (and date) the patient was last known well: 12:30pm
___
___ Stroke Scale Score: 5
t-PA given: No Reason t-PA was not given or considered: on
coumadin with elevated INR, resolving symptoms
Thrombectomy performed: [] Yes [x] No
--- If no, reason thrombectomy was not performed or considered:
no acute LVO
I was present during the CT scanning and reviewed the images
instantly within 20 minutes of their completion.
The NIHSS was performed:
Date: ___
Time: 13:35
(within 6 hours of patient presentation or neurology consult)
___ Stroke Scale score was : 5
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 1
4. Facial palsy: 2
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 1
9. Language: 1
10. Dysarthria: 0
11. Extinction and Neglect: 0
REASON FOR CONSULTATION: Code stroke
HPI:
___ is a ___ year old man with a past medical history of
non-Hodgkin's diffuse large B-cell lymphoma with involvement of
the right atrium and central nervous system status post prior
chemotherapy including R-CHOP, multiple prior strokes of
uncertain etiology with residual left-sided weakness and
postopagnosia currently on low-dose aspirin and anticoagulated
with warfarin, seizures of unclear etiology on Keppra once
daily,
HIV infection on highly active antiretroviral therapy, history
of
multiple prior opportunistic infections, chronic kidney disease,
reduced EF with prior clinical CHF who presents with acute onset
L facial droop and slurred speech.
Patient was at his PCP's office today talking to the physician
when PCP noted acute onset of left facial droop associated with
slurred speech. Patient himself agreed speech seemed slurred,
but
he is not sure about his face as he couldn't see his face. His
health aid, who spends every day with ___, was not in the room
at
the time but saw him shortly after when EMS was being called. At
that time, home health aid thought that ___ face looked
slightly more asymmetric than usual, but he did not appreciate
significant dysarthria. He said that otherwise, ___ seemed to be
fairly normal to him. EMS was called and patient was brought to
___. En route, patient feels his speech improved somewhat,
though he cannot say if he was back to baseline.
On initial evaluation in the ED, exam notable for left facial
droop, visual field cut in the upper left VF, and decreased
sensation to light touch in the left hemibody. Based on prior
documentation, this is similar to previous neurological exams.
Patient is currently on coumadin and endorses compliance. INR
resulted at 2.9, and thus patient was not a tPA candidate. The
left vertebral artery is stenotic and chronically occluded,
confirmed on comparison to prior CTA. No acute LVO and therefore
patient not a thrombectomy candidate.
After code stroke, home health aid in room corroborated that
patient was at neurological baseline. Patient had a difficult
time deciding if he felt back to his usual self, but notably he
does have cognitive issues at baseline. Patient endorses smoking
marijuana this morning, which is something he does regularly
(either he takes a few hits of a joint or he eats an edible). On
other days when he does this it does not cause a facial droop
and
slurred speech so he didn't think that would be the cause today.
He did not use any other substances today.
Regarding his past neurological history, patient and home health
aid are not able to give me details regarding what kind of
cancer
went to the brain, what he was treated with, or when this
occurred. ___ does report following up regularly with oncology
at
___ and says he is currently cancer free.
On neuro ROS, the patient endorses decreased sensation in the
left hemibody, and has a difficult time saying if this is
chronic
or not. He denies headache, loss of vision, blurred vision,
diplopia, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness. No bowel or
bladder
incontinence or retention. Denies difficulty with gait different
from his baseline in which he walks with a cane.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies arthralgias or myalgias.
Denies rash.
Past Medical History:
- non-Hodgkin's diffuse large B-cell lymphoma with involvement
of
the right atrium and central nervous system status post prior
chemotherapy including R-CHOP
- multiple prior strokes of uncertain etiology with residual
left-sided weakness and postopagnosia currently on low-dose
aspirin and anticoagulated with warfarin
- seizures of unclear etiology on Keppra once daily
- HIV infection on highly active antiretroviral therapy, history
of multiple prior opportunistic infections
- chronic kidney disease
- mildly reduced left ventricular ejection fraction with prior
clinical congestive heart failure.
Social History:
___
Family History:
No family history of seizure or stroke that patient is aware of.
Physical Exam:
ADMISSION PHYSICAL EXAM
Physical Exam:
Vitals: T: 98.1 HR 85 BP 125/74 RR 18 SaO2 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple. 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. Language is fluent
with intact repetition and comprehension. Normal prosody. There
were a few paraphasic errors when describing stroke card. Pt.
was
able to name both high and low frequency objects. Able to read
without difficulty. Speech was not dysarthric. Able to follow
both midline and appendicular commands. There was no evidence of
apraxia or neglect.
CN
I: not tested
II,III: L upper quadrant VF cut. Pupils 4mm->2mm bilaterally
III,IV,VI: EOMI, no ptosis. No nystagmus
V: sensation intact V1-V3 to LT
VII: L facial droop, symmetric eyebrow raise bilaterally.
VIII: hears finger rub bilaterally
IX,X: palate elevates symmetrically, uvula midline
XI: SCM/trapezeii ___ bilaterally
XII: tongue protrudes midline, no dysarthria
Motor: Normal bulk and tone, no rigidity; no asterixis or
myoclonus. No pronator drift. Left arm postural tremor.
Delt Bi Tri WE FE Grip IO
C5 C6 C7 C6 C7 C8/T1 T1
L 5 ___ 5 5 5
R 5 ___ 5 5 5
IP Quad ___ PF
L2 L3 L4-S1 L4 L5 S1/S2
L 5 5 5- ___
R 5 5 5 ___
Reflex: No clonus
Bi Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 2+ 2 2+ 2+ ___ Flexor
R ___ 2 ___ Flexor
-Sensory: Decreased sensation to light touch left arm and leg.
Decreased pinprick left arm and leg in all distributions.
Proprioception intact. No extinction to DSS.
-Coordination: No intention tremor, dysdiadochokinesia noted. No
dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Circumducts left leg, walks with cane.
Narrow-based.
DISCHARGE PHYSICAL EXAM
======================
Vitals:24 HR Data (last updated ___ @ 723)
Temp: 97.8 (Tm 97.9), BP: 121/75 (104-121/57-75), HR: 70
(62-92), RR: 18 (___), O2 sat: 99% (97-99), O2 delivery: Ra
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple. No nuchal rigidity. Full ROM. Pain which he
describes as stiffness on neck extension not reproducible with
palpation.
Pulmonary: Lungs CTA bilaterally in posterior fields without
R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
-Mental Status: Alert, oriented. Language is fluent
with intact repetition and comprehension. Normal prosody. There
were a few paraphasic errors when describing stroke card. Pt.
was
able to name both high and low frequency objects. Able to read
without difficulty. Speech was not dysarthric. Able to follow
both midline and appendicular commands. There was no evidence of
apraxia or neglect.
CN
I: not tested
II,III: L upper quadrant VF cut. Pupils 4mm->2mm bilaterally
III,IV,VI: EOMI, no ptosis. No nystagmus
V: sensation intact V1-V3 to LT
VII: L facial droop, symmetric eyebrow raise bilaterally.
VIII: hears finger rub bilaterally
IX,X: palate elevates symmetrically, uvula midline
XI: SCM/trapezeii ___ bilaterally
XII: tongue protrudes midline, no dysarthria
Motor: Normal bulk and tone, no rigidity; no asterixis or
myoclonus. No pronator drift. Left arm postural tremor.
Decreased rapid movements on the left
Delt Bi Tri WE FE Grip IO
C5 C6 C7 C6 C7 C8/T1 T1
L 5 ___ 4+ 5 5
R 5 ___ 5 5 5
IP Quad ___ PF
L2 L3 L4-S1 L4 L5 S1/S2
L 5 4+ ___ 5
R 5- 5 ___ 5
Reflex: No clonus
Bi Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 2+ 2 2+ 3 ___ Flexor
R ___ 2 ___ Flexor
Crossed adductors w/ patellar on the right
-Sensory: Decreased sensation to light touch left arm and leg.
Decreased pinprick left arm and leg in all distributions.
Proprioception intact. No extinction to DSS.
-Coordination: No intention tremor, dysdiadochokinesia noted. No
dysmetria on FNF or HKS bilaterally.
-Gait:
Deferred but previously...
Good initiation. Circumducts left leg, walks with cane.
Narrow-based.
Pertinent Results:
ADMISSION LABS
==============
___ 01:30PM BLOOD WBC-7.4 RBC-3.56* Hgb-13.0* Hct-39.3*
MCV-110* MCH-36.5* MCHC-33.1 RDW-11.8 RDWSD-48.2* Plt ___
___ 01:30PM BLOOD Neuts-67.9 ___ Monos-7.7 Eos-2.9
Baso-0.3 Im ___ AbsNeut-5.00 AbsLymp-1.54 AbsMono-0.57
AbsEos-0.21 AbsBaso-0.02
___ 05:30AM BLOOD Glucose-79 UreaN-16 Creat-1.2 Na-144
K-4.7 Cl-106 HCO3-26 AnGap-12
___ 01:30PM BLOOD ALT-20 AST-26 AlkPhos-86 TotBili-0.3
DISCHARGE LABS
==============
___ 05:30AM BLOOD WBC-5.9 RBC-3.83* Hgb-14.1 Hct-42.1
MCV-110* MCH-36.8* MCHC-33.5 RDW-11.9 RDWSD-48.2* Plt ___
___ 05:30AM BLOOD ___ PTT-37.1* ___
IMAGING/REPORTS
===============
here is no evidence of hemorrhage, edema, masses, mass effect,
midline shift
or acute infarction.
Redemonstration of is in multifocal areas of cystic
encephalomalacia bilateral
occipital, right parietal and right posterior and anterior
frontal regions.
There is generalized parenchymal volume loss out of proportion
of patient's
age evidenced by enlargement of subarachnoid spaces and severely
expected
dilatation of lateral ventricles. Redemonstration of right
frontal
hyperintensity on FLAIR around previously placed ventricular
shunt.
Redemonstration of bilateral centrum semiovale and corona
radiata lacunar
infarcts.
There is no abnormal enhancement.
Both orbits and globes are unremarkable. Minimal mucosal
thickening at
ethmoid air cells and right mastoid air cells. Otherwise; other
paranasal
sinuses and left mastoid air cells are unremarkable.
IMPRESSION:
1. No evidence of mass, hemorrhage or recent infarction.
2. No imaging signs to suggest disease recurrence or new mass
lesion.
3. Redemonstration of bilateral cerebral hemisphere multifocal
encephalomalacia
4. Generalized parenchymal volume loss out portion of patient's
age.
EEG - Final report pending
Brief Hospital Course:
___ is a ___ year old man with a pmhx of non-Hodgkin's
DLBCL s/p R-CHOP, multiple prior strokes of uncertain etiology
with residual left-sided weakness on ASA and apixiban, seizures,
HIV on ART, CKD, and HFrEF presents with worsening L. facial
droop and dysarthria.
Neurological exam appears to largely be at baseline with L
facial droop, L upper quadrant VF cut, decreased sensation on
the left hemibody, and a subtle left hemiparesis. CTA notable
for chronic L mid-vertebral stenosis, no acute process. MRI
brain w/wo contrast did not reveal an acute stroke. No obvious
enhancement, though possibly some gliosis around old lesion in
corona radiata not seen on comparison study from ___.
At this point not entirely clear whether patient has had a new
clinical event, in which case consideration could be given to a
TIA, seizure, or recrudescence of prior deficits. Although no
particular trigger for the latter given negative infectious
workup and normal laboratory studies. At this time patient
appears to have returned largely
to his baseline, and is on maximal medical therapy for his
cryptogenic strokes (ASA, warfarin, statin, retroviral therapy
for his HIV). We monitored him on EEG, he did have rare right
temporal discharges. Thus we continued him on a increased dose
of Keppra (was only taking 1000mg daily) of 1000mg BID. We
contacted his outpatient neurologist to make him aware of this
admission and discharged him home w/plans for outpatient
follow-up.
Transitional Issues
=====================
[ ] Pt is on both ASA and warfarin, unclear indication for
aspirin, but if not indicated for cardiac purposes would
consider consolidation to warfarin
[ ] Increased Keppra to 1000mg BID, while we do not clinically
think that his presentation was likely due to seizures, his EEG
does have some right temporal discharges suggestive of a
possible epileptogenic focus - and thus we increased Keppra to a
therapeutic dose of 1000mg BID
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Raltegravir 400 mg PO BID
3. Epzicom (abacavir-lamivudine) 600-300 mg oral DAILY
4. LevETIRAcetam 1000 mg PO DAILY
5. Warfarin 5 mg PO DAILY16
6. Lisinopril 2.5 mg PO DAILY
7. rivastigmine tartrate 1.5 mg oral BID
8. LamiVUDine 300 mg PO DAILY
9. ClonazePAM 0.5 mg PO QHS:PRN insomnia
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. ClonazePAM 0.5 mg PO QHS:PRN insomnia
3. Epzicom (abacavir-lamivudine) 600-300 mg oral DAILY
4. LamiVUDine 300 mg PO DAILY
5. LevETIRAcetam 1000 mg PO BID
6. Lisinopril 2.5 mg PO DAILY
7. Raltegravir 400 mg PO BID
8. rivastigmine tartrate 1.5 mg oral BID
9. Warfarin 5 mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
Transient speech disturbance
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 there was concern you
were having a new facial droop and trouble speaking.
By time you came to the hospital you seemed to have returned to
your baseline. You had an MRI which did not demonstrate any new
strokes. You were monitored on EEG for seizures. We didn't see
any seizures on EEG, but we did increase your Keppra to a more
therapeutic dose to cover for the possibility of a small
seizure.
We communicated with your outpatient neurologist who will follow
up with you.
-Your ___ Care team
Followup Instructions:
___
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